Event Desc|En No|Site Name|Licensee Name|Region No|City Name|State Cd|County Name|License No|Agreement State Ind|Docket No|Unit Ind1|Unit Ind2|Unit Ind3|Reactor Type|Nrc Notified By|Ops Officer|Notification Dt|Notification Time|Event Dt|Event Time|Time Zone|Last Updated Dt|Emergency Class|Cfr Cd1|Cfr Descr1|Cfr Cd2|Cfr Descr2|Cfr Cd3|Cfr Descr3|Cfr Cd4|Cfr Descr4|Staff Name1|Org Abbrev1|Staff Name2|Org Abbrev2|Staff Name3|Org Abbrev3|Staff Name4|Org Abbrev4|Staff Name5|Org Abbrev5|Staff Name6|Org Abbrev6|Staff Name7|Org Abbrev7|Staff Name8|Org Abbrev8|Staff Name9|Org Abbrev9|Staff Name10|Org Abbrev10|Scram Code 1|RX CRIT 1|Initial PWR 1|Initial RX Mode1|Current PWR 1|Current RX Mode 1|Scram Code 2|RX CRIT 2|Initial PWR 2|Initial RX Mode 2|Current PWR 2|Current RX Mode 2|Scram Code 3|RX CRIT 3|Initial PWR 3|Initial RX Mode 3|Current PWR 3|Current RX Mode 3|Event Text|
Power Reactor|57163|Columbia Generating Station|Energy Northwest|4|Richland|WA|Benton||Y|05000397|2|||[2] GE-5|Chase Williams|Kerby Scales|06/05/2024|19:27:00|06/04/2024|21:41:00|PDT|8/1/2024 7:37:00 PM|Non Emergency|50.72(b)(3)(xiii)|Loss Comm/Asmt/Response|||||||Gaddy, Vincent|R4DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||EN Revision Imported Date: 8/2/2024<br><br>EN Revision Text: PRIMARY CONTAINMENT ISOLATION DUE TO LOSS OF RPS POWER SUPPLY    The following information was provided by the licensee via fax or email:    "On June 4, 2024, at 2141 PDT, with the unit in Mode 1 at 100 percent power, the reactor protection system (RPS) 'B' power supply unexpectedly de-energized which caused containment isolations to occur in reactor water clean up, equipment drains radioactive, floor drains radioactive, reactor recirculation, and traversing in-core probe systems. All actuations occurred as designed upon the partial loss of RPS power.     "This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) as a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates. Emergency assessment capability was restored at 2204."    The NRC Senior Resident has been notified.    * * * UPDATE ON 8/1/24 AT 1925 EDT FROM CHASE WILLIAMS TO ADAM KOZIOL * * *    "A clarification for reactor recirculation valve isolation above - the flow path was administratively isolated prior to the event.     "After further evaluation it has been confirmed that the containment isolations were not caused due to any actual plant conditions or system parameters that satisfied the requirements for isolation. The isolations were a result of loss of power to the RPS 'B' bus and therefore are not considered valid actuations.    "As indicated in 10 CFR 50.73(a)(1), in the case of an invalid actuation reported under 10 CFR 50.73(a)(2)(iv)(A), the licensee may, at its option, provide a telephonic notification to the NRC Operations Center within 60 days of discovery of the event instead of submitting a written licensee event report. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73(a)(2)(iv)(A)."    Notified R4DO (Werner)|
Agreement State|57165|SC Dept of Health & Env Control|Medical University - South Carolina|1|Charleston|SC| |SC-RML-081|Y||||||Adam Gause|Adam Koziol|06/06/2024|8:25:00|05/27/2024|0:00:00|EDT|8/13/2024 9:15:00 AM|Non Emergency| |Agreement State|||||||Bickett, Carey|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 8/14/2024<br><br>EN Revision Text: AGREEMENT STATE REPORT - BRACHYTHERAPY MISADMINISTRATION    The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:    "The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024. The licensee is reporting that the total source strength administered differed by 20 percent or more from the total source strength documented in the post-implantation portion of the written directive."    SC Event Number: 240003      * * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *    The following information was provided by the South Carolina Department of Health and Environmental Control via email:    "For the medical event, the licensee is reporting that the total source strength documented in the post-implantation portion of the written directive is 5.54 millicuries per seed, and 221.6 millicuries total (forty seeds implanted). At the conclusion of the initial procedure on May 16, 2024, the licensee is reporting that all seeds as documented in the post-implantation portion of the written directive were administered. As of May 30, 2024, all seeds had been removed from the patient due to medical complications."    Notified R1DO (Bickett), NMSS Events Notification (email).    * * * UPDATE ON 8/13/24 AT 0901 EDT FROM ADAM GAUSE TO TENISHA MEADOWS * * *    The following information was provided by the South Carolina Department of Health and Environmental Control via email:    On June 20, 2024, the licensee submitted a 15-day written report regarding the medical event. Department inspectors conducted an on-site visit between July 24 and July 31, 2024. Interviews with the licensee's representatives were consistent with the details outlined in the written report. The licensee has provided additional training to neurosurgery department staff. The investigation is considered closed.    Notified R1DO (Ford), NMSS Events Notification (email)    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.  |
Agreement State|57166|SC Dept of Health & Env Control|Medical University - South Carolina|1|Charleston|SC| |SC-RML-081|Y||||||Adam Gause|Adam Koziol|06/06/2024|8:25:00|05/27/2024|0:00:00|EDT|8/13/2024 9:28:00 AM|Non Emergency| |Agreement State|||||||Bickett, Carey|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 8/14/2024<br><br>EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEEDS    The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:    "The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024.     "The licensee is reporting that on May 27, 2024, the seven (7) Cs-131 seeds that were removed from the patient are lost or missing. The other thirty three (33) seeds are accounted for."    SC Event Number: 240003    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    The exact source strength of the lost seeds was not provided, however, the licensee reported that the quantity was greater than 10 times but less than 1000 times the 10CFR20 Appendix C value for Cs-131.      * * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *    The following information was provided by the South Carolina Department of Health and Environmental Control via email:    "For the seven (7) Cs-131 seeds that were lost on May 27, 2024, the licensee is reporting the estimated activity at the time of removal and loss was approximately 2.5 millicuries per seed and approximately 17.5 millicuries total."    Notified R1DO (Bickett), NMSS Events Notification (email), ILTAB (email).    * * * UPDATE ON 8/13/24 AT 0901 EDT FROM ADAM GAUSE TO TENISHA MEADOWS * * *    The following information was provided by the South Carolina Department of Health and Environmental Control via email:    On June 20, 2024, the licensee submitted a 30-day written report regarding the loss of seven (7) Cs-131 seeds. Department inspectors conducted an on-site visit between July 24 and July 31, 2024. Interviews with the licensee's representatives were consistent with the details outlined in the written report. The licensee has provided additional training to neurosurgery department staff. The investigation is considered closed.    Notified R1DO (Ford), NMSS Events Notification (email), ILTAB (email).    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf    |
Power Reactor|57181|Perry|Firstenergy Nuclear Operating Company|3|Perry|OH|Lake||Y|05000440|1|||[1] GE-6|Robert McClary|Tenisha Meadows|06/19/2024|15:07:00|06/18/2024|16:40:00|EDT|8/15/2024 10:41:00 AM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||Havertape, Joshua|R3DO|||||||||||||||||||N|Y|88|Power Operation|88|Power Operation| |N|0||0|| |N|0||0||EN Revision Imported Date: 8/16/2024<br><br>EN Revision Text: INOPERABILITY OF DIVISION 3 DIESEL GENERATOR SUPPORTING HIGH PRESSURE CORE SPRAY    The following information was provided by the licensee via phone and email:    "At 1640 EDT on 06/18/2024, the division 3 diesel generator was declared inoperable. This condition could prevent the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). All other emergency core cooling systems were operable during this time.    "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.     "The division 3 diesel generator was declared inoperable due to potential water intrusion into the electrical generator. Inspection of the generator is in progress."      The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    This event resulted in Perry Unit 1 entering a 72 hour limiting condition for operation (LCO) in accordance with Technical Specification 3.8.1. condition 'B'.    * * * RETRACTION ON 8/15/2024 AT 0943 EDT FROM TONY MCGOWAN TO ERNEST WEST * * *    "Investigation and assessment of the division 3 diesel generator exciter and generator as-found condition revealed that no water intrusion occurred and, therefore, would not have impacted the diesel generator's ability to start, run, and produce the required electrical power to perform its required safety function. Therefore, EN 57181 is being retracted.    "The NRC resident inspector has been notified of the Event Notification retraction."    Notified R3DO (Feliz-Adorno)  |
Non-Power Reactor|57191|U. S. Geological Survey (USGS)|U. S. Dept. Of Interior|0|Denver|CO|Denver|R-113|Y|05000274||||1000 Kw Triga Mark I|Johnathan Wallick|Sam Colvard|06/25/2024|16:57:00|06/25/2024|9:00:00|MDT|8/8/2024 10:44:00 AM|Non Emergency||Non-Power Reactor Event|||||||Andrew Waugh|NPR EVEN|Michelle Sutherland|USGS PM|Patrick Boyle|USGS PM|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 8/9/2024<br><br>EN Revision Text: TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE    The following information was provided by the licensee via phone and email:    "In accordance with Technical Specification (TS) 6.7.2.1, a report is required to be made within 24 hours by telephone, confirmed by digital submission or fax to the NRC Operations Center if requested, and followed by a report in writing to the NRC, Document Control Desk, Washington, D.C. within 14 days that describes the circumstances associated with eight different specifications, one of which, (h), is abnormal and significant degradation in reactor fuel, cladding, or coolant boundary.    "At approximately 0900 MDT this morning, abnormal and significant degradation in reactor cladding was observed on fuel element 681E, an aluminum-clad element being inspected for removal from service. The degradation was in the form of an L-shaped hole, approximately 0.25 inches long in the upper section of the fuel element body approximately one inch from the top edge, where the upper aluminum pin and upper graphite section meet internally. It is unknown how long this damage has existed, as there is no visual record of any of this fuel since first inspected in 2003 at the VA Omaha TRIGA reactor before USGS took possession. At that point, it did not have this damage. According to the records, it was dropped during handling in 2003 when it was being unloaded from the shipping cask here at the GSTR [Geological Survey TRIGA Reactor], but no record of further inspection appears to exist. Therefore, this element may have been in the operating core for as long as 18 years in this condition, as USGS was first licensed to use it in 2006."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    No fission products were detected in the primary, pool, or on an air particulate detector. The damaged element remains in its storage location in the pool with no other mitigating measures planned in the near term.    * * * UPDATE ON 07/03/2024 AT 0927 EDT FROM JONATHAN WALLICK TO JORDAN WINGATE * * *    The following is a summary of information provided by the licensee via phone and email:    After continued fuel inspections, four additional damaged fuel elements were identified (Fuel Element 3007, Fuel Element 5952, Fuel Follower Control Rod 5767, and Fuel Follower Control Rod 5768). The damaged elements will be moved to dry storage and will not be considered for further use.     The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    Inspections are approximately one third complete.    Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).    * * * UPDATE ON 7/15/2024 AT 1005 EDT FROM JONATHAN WALLICK TO ERNEST WEST * * *    "[The licensee has] additional elements to report, under license technical specification 6.7.2.1 (h):    "Fuel element 3361, stainless-steel clad: Substantial cladding damage, but not an apparent breach. It has a severe scratch approximately one eighth of an inch wide along most of the element, and two other substantial scratches. The top of the main scratch terminates in what appears to be a cracking pattern, though likely not fully through the cladding, as no fission product release was detected. The element also exhibits apparent rust on the triangular spacer, covering approximately 10 percent of the serial number face surface. It will not be used in the future. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was transferred to our facility after previous use at Michigan State University in 1989, also having been previously used at General Atomics in San Diego. Estimated manufacture [date] in 1964.    "Fuel element 7932, stainless-steel clad: Substantial cladding damage, but not an apparent breach. It has multiple deep scratches, disconnected at the ends, though running in parallel for lengths down a side of the element for nearly the entire length. [The element] gives the appearance of potential separation, but no fission product release was detected. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was purchased directly from General Atomics new in 1974.    "Fuel element 9473, stainless-steel clad: Multiple deep scratches on several sides with little to no light reflection. Scratches are typical on elements, however, the appear to threaten the integrity of the cladding and further use may result in release, though none has been detected yet. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was purchased directly from General Atomics new in 1980.    "Fuel element 5888, stainless-steel clad: Several concerning scratches and a large, repeatedly damaged scratch, indicating improper handling and threatening cladding integrity. No fission product release detected, but further handling may result in even minor damage sufficient enough to enable a release. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. Inspection records show small amounts of damage; however, [the records were] not fully indicative of the degree [of damage] observed during this inspection. The element has not been in service at this facility. It was obtained from the fuel repository at Idaho National Lab in 2016, which transferred the element from General Atomics, originally used starting in 1970.     "Fuel element 5671, stainless-steel clad: Appears to have oddly spaced and shaped bands of rust around the fuel section of the element. Coloration and lack of light reflection strongly suggest an abnormal corrosion, prominent on all sides of the element in varying degrees. Gently rubbing with a soft cloth resulted in minimal transfer of material, only some coloration but no discernable particulate, indicating the defects are integrated into the cladding and not freely releasable. No obvious mechanism exists to explain the features, though other elements on site have a similar pattern, none exhibit the degree of discoloration or loss of luster. The element was in storage at the facility but had been previously used. It will not be used in the future. It was originally purchased new from General Atomics in 1968.    "[The licensee is] still working through fuel inspections. There will likely be future updates."    Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).    * * * UPDATE ON 7/25/2024 AT 0903 EDT FROM JONATHAN WALLICK TO SAMUEL COLVARD * * *    "[The licensee has] an additional element to report, under license technical specification 6.7.2.1 (h):    "Fuel element 6551 (stainless-steel clad): Corrosion of top fitting and upper canister weld, but not an apparent breach as no fission product release was detected. It will not be used in the future. This is the first close inspection that the element has undergone at our facility other than briefly viewing upon its arrival. It was in storage prior to this inspection. This element was transferred to our facility after previous use at the VTT FiR-1 reactor in Finland in 1/2021. Estimated manufactured in 9/1970, and delivered to the Finland reactor in 11/1970.    "[The licensee is] still working through fuel inspections. There will likely be future updates."    Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).    * * * UPDATE ON 08/08/2024 AT 0918 EDT FROM JONATHAN WALLICK TO ROBERT THOMPSON * * *    "[The licensee has] an additional element to report, under license technical specification 6.7.2.1 (h):    "Fuel element 5708, stainless-steel clad: Was found to have a small bolt bonded to the top of the element, approximately 1/2" long, machine size 10. The bolt appears to have galvanically corroded to the top of the element and cannot be removed, suggesting it has been in place for decades. Top-down views show significant corrosion that is spreading to the upper weld of the element, but not an apparent breach, as no fission product release was detected. It will not be used in the future. Previous inspections did not note any problems with the element. It was in storage prior to this inspection, last in core in 2007. This element was procured new from General Atomics in 1969 by our facility.    "[The licensee is] still working through fuel inspections. There will likely be future updates."    Notified USGS PM (Sutherland), NPR Event Coordinator (Waugh).  |
Agreement State|57242|Illinois Emergency Mgmt. Agency|Ingalls Hospital|3|Harvey|IL| |IL-01342-01|Y||||||Gary Forsee|Sam Colvard|07/25/2024|9:49:00|07/16/2024|0:00:00|CDT|7/25/2024 10:05:00 AM|Non Emergency| |Agreement State|||||||Feliz-Adorno, Nestor|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - FOUND SOURCE    The following was provided by the Illinois Emergency Management Agency (the Agency) via email:    "On 7/16/2024, the Agency was notified that the licensee found a box with seven calibration rod sources stored in the previous radiation safety officer's desk. The licensee had previously been cited for poor source accountability. The replacement of the radiation safety officer (RSO) and the use of a consultant were implemented as corrective actions. Locating and reporting these sources is a result of those efforts. The New England Nuclear gamma reference rod source set (Catalog No. NES-100T) contains a Co-57, Co-60, Cd-109, Ba-133, Cs-137, Mn-54, and Na-22 source - each with a nominal activity of 7 microcuries. While the sources were labeled as exempt when distributed in 1977, the Co-60 and Cd-109 sources appear to no longer be exempt under current regulations (10 CFR 30.71 Schedule B), nor does any exemption exist that grandfathers these sources. Wipe tests were performed and indicated no leakage.    "In accordance with SA-300, section 5.6.2, 'found sources' are to be reported when they exceed 10 times the value specified in Appendix C to 10 CFR Part 20. The Cd-109 source contained 12.9 microcuries when assayed 9/6/77, so, it remains reportable. The sources were placed on the licensee's sealed source inventory. Corrective action is adequate, and this matter is now considered closed."    IL Event Number: IL240016    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf|
Part 21|57245|Browns Ferry|Browns Ferry|2|Decatur|AL|Limestone||Y||||||Mark Moebes|Ernest West|07/25/2024|20:48:00|07/23/2024|13:00:00|CDT|8/22/2024 3:43:00 PM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||Coovert, Nicole|R2DO|Part 21/50.55 Reactors, -|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 8/23/2024<br><br>EN Revision Text: PART 21 - HPCI RUPTURE DISC NOT WITHIN TECHNICAL REQUIREMENTS    The following information was provided by the licensee via phone and email:    "Tennessee Valley Authority (TVA) completed an engineering evaluation for a Fike Metal Products 16-inch rupture disc, part number 16-CPV-C, which had failed in March 2024 during an event previously reported to the NRC as Event Notification 57036 and Licensee Event Report 260/2024-002-00.    "The evaluation determined that the failure of the rupture disc constituted a failure to comply by a basic component which resulted in a substantial safety hazard.    "The rupture disc was procured as a non-safety related item from Fike Corporation and commercially dedicated by Paragon Energy Solutions. The disc was supplied to TVA in a satisfactory condition meeting all acceptance criteria. During a routine flowrate surveillance test, the high-pressure coolant injection (HPCI) inner rupture disc developed a hole which caused the Unit 2 HPCI turbine to trip. This resulted in [Browns Ferry Unit 2] entering Technical Specification (TS) Limiting Condition for Operation (LCO) 3.5.1 Condition `C', which is a 14-day shutdown LCO. Per HPCI system design criteria, turbine casing protection disc rupture pressure shall be at 175 psig plus 1 or minus 10 psig and the rupture discs shall be sized for a flow capacity of 600,000 pounds per hour at 200 psig, minimum. The failed HPCI inner rupture disc did not experience pressures above 45 psig since being installed; therefore, the HPCI turbine inner rupture disc did not meet its technical requirements.    "On July 23, 2024, the Browns Ferry Nuclear Plant Site Vice President was notified of the requirement to report this event under 10 CFR 21.21. This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    Both Fike Corporation and Paragon Energy Solutions have been informed of the HPCI inner rupture disc not meeting technical requirements. Known potentially affected plants include Browns Ferry Units 1, 2, and 3.    * * * RETRACTION ON 08/22/24 AT 1522 EDT FROM CHASE HENSLEY TO JOSUE RAMIREZ * * *    The following information was provided by the licensee via phone and email:    "The purpose of this notification is to retract a previous event notification, EN 57245, reported on 7/25/24.  "Continued evaluation has concluded that the failure of the disc was not the result of a failure to comply by a basic component, therefore, the NRC non-emergency 10 CFR 21.21 (d) report was not required and the NRC EN 57245 can be retracted.  "The licensee has notified the NRC Resident Inspector."    Notified R2DO (Masters) and Part 21/50.55 Reactors group (Email).    |
Agreement State|57247|Virginia Rad Materials Program|Molecular Imaging Services, Inc|1|Woodbridge|VA|Prince William|059-144-1|Y||||||Sheila Nelson|Ian Howard|07/26/2024|16:35:00|07/26/2024|14:44:00|EDT|7/26/2024 7:07:00 PM|Non Emergency| |Agreement State|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - LOST SOURCE    The following information was provided by the Virginia Radioactive Materials Program (the Department) via email:    "On July 26, 2024, at approximately 1440 EDT, the VDH [Virginia Department of Health] Office of Radiological Health was contacted by the radiation safety officer (by phone) from Molecular Imaging Services, Inc. to report a missing Co-57 reference source of 5.257 mCi. On July 25, the licensee discovered that a package that had contained the source was delivered on July 3, and was inadvertently disposed of in the trash. It was not known by the nuclear medicine staff until July 25, that the source had been delivered on July 3 and that their investigation determined that the unopened package was placed in the dumpster by the facility janitor. The licensee has confirmed that the dumpster was picked up on July 6 and has been disposed of in the Prince William County Sanitary Landfill.    "The Department will follow up with an investigation."    Virginia Event Report ID No.: VA240003    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf|
Agreement State|57250|Colorado Dept of Public Health|Rose Medical Center|4|Denver|CO||CO 229-03|Y||||||Phillip Peterson|Josue Ramirez|07/29/2024|9:44:00|05/13/2024|15:24:00|MDT|7/29/2024 10:09:00 AM|Non Emergency| |Agreement State|||||||Werner, Greg|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|Brenneman, Kevin|NMSS|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION     The following information was provided by the Colorado Department of Public Health and Environment via email:    "This event in Colorado was originally sent to the wrong NRC email address and it is now being provided to the NRC. This event is being tracked as NMED number 240183.    "A patient was administered a measured dose of 0.613 GBq Y-90 TheraSpheres on 5/13/2024, at 1524 MDT. The desired administration location in the liver received a dose of 0.582 Gbq. Post administration imaging analysis conducted on 5/15/2024, showed an uptake to the stomach wall of 1.5 Sievert."    Notification made per: 10 CFR 35.3045(a)(1)(iii)    Colorado event report ID No.: CO240013    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.  |
Fuel Cycle Facility|57251|BWX Technologies Inc.|BWX Technologies, Inc.|2|Lynchburg|VA|Campbell|SNM-42|N|070-27||||Uranium Fuel Fabrication|Daniel Ashworth|Karen Cotton-Gross|07/30/2024|9:24:00|07/29/2024|10:25:00|EDT|7/30/2024 10:25:00 AM|Non Emergency|20.2202(b)(1)|Pers Overexposure/TEDE >= 5 Rem|||||||Coovert, Nicole|R2DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|POSSIBLE OVEREXPOSURE DUE TO LOSS OF CONTROL    The following information was provided by the BWXT Nuclear Operations Group, Inc. (BWXT NOG-L) via email:    "At approximately 1025 EDT on Monday, July 29, 2024, a BWXT NOG-L recycle vendor notified the licensee that a shipment of scrap aluminum machining chips was identified as being potentially radioactive and/or contaminated.  The shipment of material activated the recycle vendor's portal detectors.  BWXT NOG-L responded to the vendor's facility and performed a preliminary assessment, exterior smears of the shipping container and inside the transport vehicle confirmed no contamination.  The recycle vendor obtained a special permit, from the Commonwealth of Virginia, to return the container back to BWXT NOG-L for evaluation of uranium contamination.  Upon return of the container, the contents were re-packaged into drums, values established through non-destructive assay (NDA), and stored within a radiation-controlled area.    "No one was exposed and the material did not pose a risk to the public or the environment during its transportation to and from the recycle vendor.  BWXT NOG-L recognizes the potential exposure implications had this material processed through the recycler's facility and is reporting accordingly under 10 CFR 20.2202(b).  BWXT NOG-L also recognizes the failure to properly ship radioactive material in accordance with 10 CFR 71.5.     "The resident inspector has been notified. "    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    As a corrected action the licensee has suspended shipments until an evaluation is completed.  |
Power Reactor|57252|River Bend|Entergy Nuclear|4|St Francisville|LA|West Feliciana||Y|05000458|1|||[1] GE-6|Terry Blanchard|Adam Koziol|07/30/2024|15:10:00|06/07/2024|1:46:00|CDT|8/5/2024 3:20:00 PM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||Werner, Greg|R4DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||EN Revision Imported Date: 8/6/2024<br><br>EN Revision Text: CONTROL ROOM ENVELOPE FAILED SURVEILLANCE    The following information was provided by the licensee via email:    "At 0146 CDT on June 7, 2024, River Bend Station (RBS) was operating at 100 percent power when a loss of control room envelope (CRE) was declared due to failing to meet Technical Specification (TS) 3.7.2, Surveillance Requirement (SR) 3.7.2.4, during surveillance testing. Mitigating actions were established which included the ability to issue potassium iodide to control room staff. With mitigating actions in place, the dose consequence to control room staff continued to be less than the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event.    "The CRE is considered a single train system at RBS, therefore, this event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function.    "The NRC resident inspector has been notified."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    The failed surveillance (SR 3.7.2.4) was for unfiltered air in-leakage greater than 300 cubic feet per minute.    * * * RETRACTION ON 08/05/2024 AT 1456 EDT FROM DARREN FARTHING TO ROBERT THOMPSON * * *    "This event was initially reported under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function. The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that there was no adverse impact on the control room emergency ventilation system or the control room envelope (CRE) boundary's ability to perform its safety function. The CRE would not have been challenged to meet the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event. Consequently, this condition is not reportable as an event or condition that could have prevented the fulfillment of a safety function.    "The NRC resident inspector has been notified."    Notified R4DO (Vossmar).  |
Agreement State|57255|WA Office of Radiation Protection|Dermatology of Seattle and Bellevue|4|Burien|WA| |WN-M0327-1|Y||||||Boris Tsenov|Adam Koziol|07/31/2024|20:30:00|11/15/2023|0:00:00|PDT|7/31/2024 10:05:00 PM|Non Emergency| |Agreement State|||||||Werner, Greg|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - POTENTIAL LEAKAGE FROM MEDICAL SOURCE    The following is a summary of information received from the Washington State Department of Health via email:     An inspection was conducted on July 25, 2024 at the licensee facility for the use of Alpha DaRT. The inspection team noted that on November 15, 2023, records indicated that two of the applicators had alpha contamination inside of the sterile packaging with readings of 10,000 counts per minute (cpm) and 6000 cpm, with average background of 23 cpm using an alpha meter.    Washington Incident No.: WA-24-018  |
Agreement State|57256|Illinois Emergency Mgmt. Agency|Wood River Refinery|3|Roxana|IL| |IL-01282-01|Y||||||Whitney Cox|Jordan Wingate|08/01/2024|10:05:00|07/30/2024|0:00:00|CDT|8/1/2024 10:22:00 AM|Non Emergency| |Agreement State|||||||Feliz-Adorno, Nestor|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - STUCK OPEN SHUTTER    The following information was provided by the Illinois Emergency Management Agency (the Agency) via email and phone:    "On July 30, 2024, the licensee, WRB Refining, LP - Wood River Refinery (IL-01282-01) in Roxana, IL, discovered a stuck open shutter on a fixed gauge. They reported this to the Agency on July 31, 2024. The Vega Americas level indicator gauge is located on the 'Coker North Drum 8 Top Gauge' and contains 5000 mCi of Cs-137 (assay date 11/10/2008) with serial number 8626CM, source holder model number SHLG-2-30, source holder serial number 13541754, and tag number LX0544CK. The gauge will be serviced soon. Updates will be provided as available."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    This poses no safety hazard to the public.    Illinois Item No. IL240017|
Agreement State|57257|Texas Dept of State Health Services|Gulf Coast Growth Ventures|4|Gregory|TX| |L07102|Y||||||Art Tucker|Adam Koziol|08/01/2024|15:57:00|08/01/2024|0:00:00|CDT|8/1/2024 4:07:00 PM|Non Emergency| |Agreement State|||||||Werner, Greg|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE - STUCK OPEN SHUTTER    The following information was provided by the Texas Department of State Health Services (the Department) via email:    "On August 1, 2024, the Department was notified by the licensee that the shutter of a Vega model SH-F2B gauge containing 200 millicuries (original activity) of cesium - 137 was stuck in the open position. Open is the normal operating position. The problem was discovered during routine testing. The licensee reported there was no risk of additional radiation exposure to any individual.    "Additional information will be provided as it is received in accordance with SA-300."    Texas incident number: 10117  NMED number: TX240020  |
Agreement State|57258|Florida Bureau of Radiation Control|Jacksonville Cardiovascular Center|1|Lake Butler|FL| |3725-2|Y||||||John Williamson|Adam Koziol|08/01/2024|16:25:00|08/01/2024|0:00:00|EDT|8/1/2024 4:37:00 PM|Non Emergency| |Agreement State|||||||Young, Matt|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - LOST CALIBRATION SOURCE    The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via email:    On August 1, 2024, the BRC received a notification from the Jacksonville Cardiovascular Center mobile trailer that a 174 microcurie Cs-137 Evial calibration source was missing. The source was last inventoried at the end of June, 2024.    Device: Evial  Manufacturer: EZAG  Model Number: 3350  Serial Number: 1792-20-18     Florida Incident Number: FL24-068    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf|
Agreement State|57259|Texas Dept of State Health Services|Univ of Texas Anderson Cancer Ctr|4|Houston|TX| |L 00466|Y||||||Arthur L Tucker|Robert A. Thompson|08/02/2024|12:58:00|08/02/2024|0:00:00|CDT|8/2/2024 1:24:00 PM|Non Emergency| |Agreement State|||||||Werner, Greg|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|CNSNS (Mexico), -   (EMAIL)|FAX|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE - MISSING SHIPMENT    The following information was provided by the Texas Department of State Health Services (the Department) via email:    "On August 2, 2024, the Department was notified by a Texas licensee that they had shipped 118 millicuries of iodine-125 seeds to a vendor in the state of Florida on July 26, 2024. The package was shipped standard overnight shipping. The Texas licensee reported that on August 2, 2024 the vendor contacted them and requested a status update of the shipment. The Texas licensee looked up the shipping information on the shipper's web site and it only showed that the material had been picked up by the shipper at the Texas licensee's location. The Texas licensee has not been able to get any additional information from the shipper. The Texas licensee has opened a case with the shipper. Additional information will be provided as it is received in accordance with SA-300.    "The licensee reported the iodine-125 seeds involved in this event are not an exposure risk to any individuals."    Texas incident number: I-10118    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdfThe following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:  |
Agreement State|57260|NC Dept of Health and Human Serv|Volkert|1|Charlotte|NC||065-1551-1|Y||||||Travis Cartoski|Robert A. Thompson|08/02/2024|13:17:00|08/01/2024|8:00:00|EDT|9/16/2024 10:56:00 AM|Non Emergency| |Agreement State|||||||Young, Matt|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 9/17/2024<br><br>EN Revision Text: AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE    The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:    "The licensee reported that around 0800 EDT on August 1, 2024, it was discovered that a break-in had occurred at a construction site. Their portable nuclear gauge (PNG) containing 8 mCi Cs-137 and 40 mCi of Am-241/Be was stolen. The construction site is a locked and secured fenced area with the licensee's Conex box inside that secured area. The PNG was located inside the Conex box, locked inside its own secured steel storage box, secured via chains and locks to the inside of the Conex box. The steel box containing the PNG was also locked with chains and locks.    "The fenced area was broken into and the doors to the Conex box were forced open with a large sheepsfoot roller, allowing the thieves' access to the steel box containing the PNG.    "RMB's investigation is ongoing. A follow-up report will be made to close and complete the record."    NC event number: NC240004  NMED Number 240271    * * * UPDATE ON 9/16/2024 AT 0951 EDT FROM TRAVIS CARTOSKI to SAMUEL COLVARD * * *    The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:    "RMB have completed the investigation and consider the case closed given the following information."    "No additional party was involved. Corrective action is not needed as the licensee was not found in violation and adhered to all security requirements as required by the rule. Device info: Portable nuclear gauge, Troxler model 3440, serial number 14357."    Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email).    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdfThe following information was provided by the licensee via fax or email:  |
Agreement State|57261|California Dept of Public Health|Regents of the University of California- Los Angeles|4|Los Angeles|CA||1335-19|Y||||||Robert Greger|Robert A. Thompson|08/02/2024|15:21:00|07/26/2024|0:00:00|PDT|8/2/2024 4:01:00 PM|Non Emergency| |Agreement State|||||||Werner, Greg|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|Williams, Kevin|NMSS|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - DOSE TO UNINTENDED ORGAN    The following information was obtained from the California Department of Public Health, Radiologic Health Branch, via email:    "University of California at Los Angeles (UCLA) reported a medical event had occurred on Friday, July 26, 2024, during a Y-90 Therasphere liver cancer treatment. Patient SPECT imaging performed on August 1, 2024, showed that all of the Y-90 activity was in the patient's stomach tissue rather than in the intended left lobe of the liver. The licensee reported that the dosage of Y-90 administered was in conformance with the written directive. UCLA is continuing to investigate to determine how the Y-90 Theraspheres ended up in the stomach tissue and will address the cause in their 15-day written report to the Radiologic Health Branch.    "Per the licensee's documentation, a dosage of 0.77 GBq was delivered to the patient, with 0.74 GBq expected to go to the treatment site to result in a dose of 178.9 Gy to the treatment site."    California event number: 5010-080124    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.  |
Agreement State|57262|Illinois Emergency Mgmt. Agency|Eastern Illinois University|3|Charleston|IL| |IL-01021-01|Y||||||Gary Forsee|Robert A. Thompson|08/02/2024|16:41:00|08/01/2024|0:00:00|CDT|8/2/2024 4:45:00 PM|Non Emergency| |Agreement State|||||||Feliz-Adorno, Nestor|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE - LOST STRONTIUM-90 SOURCES    The following information was provided by the Illinois Emergency Management Agency (the Agency) via email and phone:    "On August 1, 2024, the Agency was advised by the radiation safety officer (RSO) for Eastern Illinois University that twelve strontium-90 button sources were missing from inventory. As the sources had been secured in a locked cabinet, they were likely mistakenly included in a low-level radioactive waste pickup that occurred on July 8, 2024. The RSO was not present for the shipment, nor was the waste pickup coordinated with relevant radiation safety program staff. The sources were identified as missing when the RSO did a sealed source inventory on August 1, 2024. The sources were not itemized on the waste manifest and while this is the most likely disposition, it cannot be verified at this time.     "The twelve sources were 0.5 microcurie Sr-90 button sources when assayed in 1970. All were manufactured by The Nucleus, Inc. as model Sr-90-S-5, with serial numbers 6/2/70-1 through 6/2/70-12. They are now decayed to approximately 0.14 microcuries each and do not represent a radiation safety concern. The Agency has already conducted a reactive inspection. The licensee is assessing the availability of documentation through the waste broker (NAC Philotechnics). Pending that documentation and a response to the Notice of Violation, this matter is considered closed."    Illinois item number: IL240018    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf|
Agreement State|57263|California Radiation Control Prgm|Regents of the UCLA|4|Los Angeles|CA| |1335-19|Y||||||Donald Oesterle|Ian Howard|08/06/2024|21:30:00|08/05/2024|15:15:00|PDT|8/6/2024 10:13:00 PM|Non Emergency| |Agreement State|||||||Vossmar, Patricia|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - MEDICAL UNDERDOSE    The following report was received by the California Department of Public Health, Radiation Health Branch (RHB) via email:    "The University of California, Los Angeles (UCLA) reported a medical event that had occurred on Monday, August 5, 2024, during a Y-90 Sirtex SIR-Sphere liver cancer treatment.     "The target organ was the patient's left liver lobe. The authorized user prescribed an activity of 0.71 GBq (19.14 mCi).     "Unfortunately, the target organ only received 7.72 mCi or 40.33 percent of the prescribed dose.     "The interventional radiologist reported that the cause of the under-delivery was a leak in the SIR-Sphere tubing system (delivery box and covered table). All contaminated equipment is being held for decay by UCLA.     "UCLA will submit a 15-day written report to the RHB."    California Event Number: 080524    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.  |
Agreement State|57264|Texas Dept of State Health Services|Alliance Laboratories Inc|4|Missouri City|TX| |L 05586|Y||||||Arthur Tucker|Josue Ramirez|08/07/2024|23:04:00|08/07/2024|0:00:00|CDT|8/9/2024 8:47:00 PM|Non Emergency| |Agreement State|||||||Vossmar, Patricia|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB, |EMAIL|CNSNS (Mexico), -   (EMAIL)|EMAIL|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - LOST SOURCE    The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:    "On August 7, 2024, the Department was notified by the licensee that they had lost a Humboldt model 5001 EZ moisture density gauge. The gauge contains a 40 millicurie americium - 241 source and an 8 millicurie cesium - 137 source. The gauge was used at a temporary job site and had been placed in the back of a pickup truck to transport back to its storage location. The technician failed to secure the gauge in the truck and did not raise and secure the tailgate. When the technician arrived at the office, they found the gauge was missing. The technician drove the route they had taken looking for the gauge but did not find it. They then notified their radiation safety officer (RSO). The licensee has contacted the Houston Police Department and notified them of the loss. The licensee stated the cesium source rod was locked in the fully shielded position. The RSO stated that the technician and a district RSO are still out looking for the gauge at the time of this report. The RSO stated the gauge would not create an exposure risk to any individual. Additional information will be provided in accordance with SA 300."    Texas Incident #: I-10119      * * * UPDATE ON 08/09/24 AT 2019 EDT FROM ARTHUR TUCKER TO JOSUE RAMIREZ * * *    The following information was provided by the Texas Department of State Health Services (the Department) via email:    "On August 9, 2024, the licensee reported that they had recovered the gauge. An individual was driving on the road where the gauge had fallen out of the truck and recognized what it was and picked it up. He found the contact information on the gauge container and called the licensee. The licensee has the gauge in its storage location. The licensee inspected the gauge and stated that the gauge was in good condition."    Notified R4DO (Vossmar), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email.      THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf  |
Agreement State|57265|Colorado Dept of Health|BAE Systems|4|Boulder|CO||GL000246|Y||||||Kathryn Kirk|Robert A. Thompson|08/08/2024|11:08:00|08/07/2024|0:00:00|MDT|8/8/2024 11:12:00 AM|Non Emergency| |Agreement State|||||||Vossmar, Patricia|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,    (EMAIL)|EMAIL|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE - LOST STATIC ELIMINATOR    The following is a summary of information provided by the Colorado Department of Public Health and Environment (the Department) via email:    The Department reported that on August 7, 2024, the licensee notified them of a lost NRD model P-2021 static eliminator containing 0.7 mCi of polonium 210. The licensee continues to search for the device.    Colorado event ID:  CO240020    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf  |
Agreement State|57266|New York State Dept. of Health|Kleinfelder, Inc.|1|Syracuse|NY| |MD-05-248-01|Y||||||Nate Kishbaugh|Robert A. Thompson|08/08/2024|13:29:00|08/07/2024|0:00:00|EDT|9/16/2024 5:35:00 PM|Non Emergency| |Agreement State|||||||Bickett, Brice|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 9/17/2024<br><br>EN Revision Text: AGREEMENT STATE - DAMAGED MOISTURE DENSITY GAUGE    The following information was provided by the New York State Department of Health (NYSDOH) via email:    "NYSDOH received a phone call from the radiation safety officer (RSO) on August 7, 2024, to report a damaged moisture density gauge. The gauge was struck by a passing skid steer.    "Device Make: Instrotek  "Device Model: 3500  "Isotopes: Am-241/Be (44mCi), Cs-137 (11mCi)    "The area was cordoned off. The gauge base plate appeared damaged. The source rod was not exposed. Measurements taken with a survey meter were 0.2 mR/hr at 3ft, which appears consistent with the radiation dose profile for this instrument per the sealed source and device registry.     "The RSO reports that the device was removed from the site at the request of the client and transported to the Kleinfelder Scranton, PA, location for leak testing. A leak test was performed and sent out for analysis, however, at this time is not believed that the source would be leaking. It is not believed that this event led to any degradation of the source, source housing, or shielding. NYSDOH is monitoring this incident and has assigned incident number 1496 to track this event.     "As this company was performing work under reciprocity, the State of Maryland and the Commonwealth of Pennsylvania have also been notified of this event for their awareness. Additional information will be provided to NMED once available."    New York event report ID: NY-24-07    * * * UPDATE ON 8/09/2024 AT 1643 EDT FROM ATNATIWOS MESHESHA TO JOSUE RAMIREZ * * *    This event was also reported by the State of Maryland under EN 57267.    Notified R1DO (Bickett), NMSS Events Notifications (Email).    * * * UPDATE ON 9/16/2024 AT 1643 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *    The following information was provided by the New York State Department of Health (NYSDOH) via email:    "Following the original notification of this event, it was confirmed via leak testing of both the Cs-137 source and Am-241/Be source that neither source was breached, damaged, or leaking from this event. Furthermore, an additional radiation protection survey indicated that there were no breaches to the shielding or integrity of this device and no essential safety functions were damaged. The extent of damage to the baseplate was cosmetic.    "As a corrective action, the licensee retrained the responsible authorized user of the device, including manufacturer's operation training, licensee specific policies and procedure, and a demonstration of proper use of the device with the radiation safety officer (RSO). On August 8, 2024, all authorized users were retrained in constant surveillance and immediate control of the gauges when not secured in permanent storage. Additionally, the licensee placed highly visible stickers affixed to their gauges to remind authorized users to maintain constant surveillance and immediate control over gauges.    "NYSDOH has accepted the findings from this investigation and have accepted the licensee's proposed corrective actions. As a result, NYSDOH has closed this incident."    Notified R1DO (Werkheiser), NMSS Events Notifications (Email).  |
Agreement State|57267|Maryland Dept of the Environment|Kleinfelder|1|Syracuse|NY| |MD-05-248-01|Y||||||Atnatiwos Meshesha|Josue Ramirez|08/09/2024|16:43:00|08/07/2024|10:45:00|EDT|8/9/2024 5:21:00 PM|Non Emergency| |Agreement State|||||||Bickett, Brice|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE - DAMAGED MOISTURE DENSITY GAUGE    The following information was provided by the Maryland Department of the Environment (MDE) via email:    "This report is made in accordance with 10 CFR 30.50 (b)(2).    "At 1045 EDT on 8/7/2024, an Instrotek 3500 nuclear density gauge (serial number 566), containing a 10 mCi Cs-137 source and a 40 mCi Am-241 source, was struck by site equipment (skid steer) during asphalt placement operations in Syracuse, NY. The gauge was licensed to, and being operated by, Kleinfelder, a Maryland licensee (MD-05-248-01) and used in New York under reciprocity arrangement. The base plate of the gauge was damaged, but there was no observable damage to the source rod and it was retracted to the safe position at the time of the accident. Kleinfelder contracted a third party to complete a survey and no elevated levels of radiation were detected. The gauge was then transported to the Kleinfelder office, located in Mechanicsburg, PA, and tested for source leakage. MDE was notified on 8/8/2024 at 1258 EDT and requested that the gauge be tested for leakage. Leak tests later showed no leakage of radioactive material. At this time, the gauge is returned to the licensee storage in Maryland and [placed] out-of-service."    The State of New York also reported this event on August 8, 2024, under EN 57266.    |
Agreement State|57268|New York State Dept. of Health|NY Dept. of Health Wadsworth Center|1|Albany|NY| |0448|Y||||||Nathaniel Kishbaugh |Josue Ramirez|08/12/2024|16:38:00|08/06/2024|0:00:00|EDT|9/17/2024 2:12:00 PM|Non Emergency| |Agreement State|||||||Ford, Monica|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 9/18/2024<br><br>EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE    The following information was provided by the New York State Department of Health (NYSDOH) via  email:    "NYSDOH Bureau of Environmental Radiation Protection (BERP) received an email from the radiation safety officer (RSO) of NYSDOH Wadsworth Laboratories on August 12, 2024, to report a leaking Ni-63 electron capture device (ECD) contained within a decommissioned gas chromatograph. This sample was collected on August 6, 2024, and was analyzed (and quality control tested) following collection.    "Device Make: Agilent Technologies, Inc.  "Device Model: 19233  "Device Serial Number: L2075  "Isotopes: Ni-63 (18 mCi at time of manufacture)    "NYSDOH Wadsworth Laboratory staff were conducting a leak test and wipe of a decommissioned gas chromatography unit that had not been used for over 20 years. The ECD housing within the unit did have removable contamination detected at 30,000 disintegrations per minute (approximately 0.015 micro Ci) when analyzed using a liquid scintillation counter. The gas chromatograph was isolated, and an enhanced survey showed that the gas chromatograph chamber (which sits below the ECD housing) had removable contamination consistent with the ECD housing. Other areas of the gas chromatograph were surveyed and showed levels indistinguishable from background. Furthermore, checks of areas around the gas chromatograph were surveyed as well as personnel and personal protective equipment and no levels exceeding background were discovered. The extent of contamination appears to be isolated to the open port of the ECD, which has been sealed.    "The entire gas chromatograph is isolated pending disposal. NYSDOH Wadsworth staff contacted the RSO for Agilent [Technologies] and confirmed that the device may be sent to them for disposal."    "The cause of this leaking source is unknown as the device had been removed from service for several decades. Routine surveys have indicated that the extent of contamination was localized to areas of the chromatograph that would not be touched or in contact with any laboratory equipment or personnel.    "NYSDOH BERP is actively monitoring this event under Incident No. 1497. Additional information will be provided to the Nuclear Material Events Database (NMED) once available."    Event Report ID No. NY-24-08  NYSDOH Incident Number: 1497    * * * UPDATE ON 9/17/2024 AT 1355 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *    The following information was provided by the New York State Department of Health (NYSDOH) via email:    "The leaking source and affected device in question were returned to the vendor in Wilmington, DE. On September 3, 2024, NYSDOH received an acknowledgement of receipt of the device. The exact cause of the leaking source is unknown, however, NYSDOH will focus on this aspect during the next routine inspection to inquire if any contributing or primary causes for this leaking source maybe attributed to the use, maintenance, or storage of these types of devices. Any additional follow-up will occur under the scope of the inspection; therefore, NYSDOH has closed out this incident."    Notified R1DO (Werkheiser), NMSS Events Notification (email).  |
Agreement State|57269|California Radiation Control Prgm|Giles Engineering Associates, Inc.|4|Palm Springs|CA||4592-30|Y||||||Donald Oesterle|Josue Ramirez|08/12/2024|18:44:00|08/09/2024|0:00:00|PDT|8/12/2024 6:56:00 PM|Non Emergency| |Agreement State|||||||Agrawal, Ami|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB,  (EMAIL)|EMAIL|CNSNS (Mexico),  (EMAIL)|EMAIL|||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - LOST/STOLEN PORTABLE GAUGE    The following information was provided by the California Department of Public Health, Radiologic Health Branch (RHB) via email:    "The radiation safety officer for Giles Engineering contacted the RHB in Sacramento to report a lost/stolen CPN portable nuclear gauge, model MC-1, serial number MD71003961. This gauge contains two radioactive sealed sources: 370 MBq (10 mCi) of Cs-137 and 1.9 GBq (50 mCi) of Am-241.    "The loss / theft occurred about on Friday August 9, 2024, while in Palm Springs at a job project. The CPN [brand] gauge was secured in the rear of the company pickup truck, locked inside the locked case. The gauge operator got stuck in deep sand at the job site, so he removed the security chain to get pulled out. He failed to re-secure the portable gauge to the pick-up truck and noticed it was missing while he was stopped at a local gas station. A police report was filed with Palm Springs police department. Maurer Technical Services and Instrotek were also notified."    California 5010 Number: 081224    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf    |
Power Reactor|57270|Vogtle 1/2|Southern Nuclear Operating Company|2|Waynesboro|GA|Burke||Y||2|||[1] W-4-LP,[2] W-4-LP|Jamaal Merriweather|Karen Cotton-Gross|08/13/2024|12:22:00|08/13/2024|11:49:00|EDT|8/13/2024 1:50:00 PM|Alert|50.72(a) (1) (i)|Emergency Declared|||||||Lopez-Santiago, Omar|R2DO|Laura Dudes|R2 RA|Andrea Kock|NRR|Jeff Grant|IR MOC|Dave Gasperson|RII PAO|Russell Felts|NRR EO|Mike Franovich|NRR|||||||N|Y|100|Power Operation|100|Power Operation| |N|0||0|| |N|0||0||EN Revision Imported Date: 8/14/2024<br><br>EN Revision Text: ALERT - FIRE IN SAFETY-RELATED TRANSFORMER    The following information was provided by the licensee via phone:    "At 1200 EDT on August 13, 2024, with Unit 2 in Mode 1 at 100 percent power, Vogtle Unit 2 declared an ALERT per emergency action level (EAL) SA9 due to a fire that caused visible damage to a safety system component needed for the current operating mode. At 1151 EDT, the fire was extinguished. The equipment affected was the safety-related regulating 480V transformer which supplies power to the Unit 2 'B' engineered safety features chiller.    "There was no impact to the safety and health of the public or plant personnel.     "Units 1, 3, and 4 are unaffected.    "State and local officials were notified. The NRC resident inspector was notified."    The NRC decided to remain in the Normal mode of operation at 1234 EDT.    Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, EPA Emergency Ops Center, USDA Watch Officer, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC THD Desk (email), FEMA NRCC SASC (email), FERC RMC (email), CWMD Watch Desk (email).    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    The fire alarm was received at 1145 EDT. A fire was confirmed at 1149 EDT. The switchgear was de-energized and a fire extinguisher was used to put out the fire.    * * * UPDATE ON 8/14/2024 AT 1448 EDT FROM JEFF COX TO BRIAN SMITH  * * *    The licensee terminated the ALERT emergency action level at 1436 EDT.    Notified R2DO (Lopez-Santiago), IR MOC (Grant), NRR EO (Felts), DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, EPA Emergency Ops Center, USDA Watch Officer, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC THD Desk (email), FEMA NRCC SASC (email), FERC RMC (email), CWMD Watch Desk (email).  |
Part 21|57271|Diablo Canyon|Diablo Canyon|4|Avila Beach|CA|San Luis Obispo||Y||||||Jim Morris|Sam Colvard|08/15/2024|13:25:00|08/13/2024|0:00:00|PDT|8/15/2024 1:52:00 PM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||Agrawal, Ami|R4DO|Part 21/50.55 Reactors, -|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|PART 21 - COMMERCIALLY SOURCED PART NOT PROPERLY HEAT TREATED    The following information was provided by the licensee via phone and email:    "On August 13, 2024, Diablo Canyon Power Plant (DCPP) determined that a manufacturing non-conformance associated with snubber valve assemblies identified with ALCO part number 2402466 is reportable under 10 CFR Part 21.    "Pacific Gas and Electric Company's (PGE) evaluation has determined the upper body of these valves did not meet material and heat treatment requirements (AISI 1117 resulfurized carbon steel vs. AISI 8620/8630 low alloy steel). Similar Part 21 reports regarding issues associated with the material and heat treatment requirements of ALCO snubber valves have been previously reported by others. The subject parts were procured as commercial grade items and dedicated by PGE solely for use at DCPP. Therefore, although previously reported, and potentially not required per the provisions of Part 21.21 (d)(2), DCPP is conservatively making this notification.    "There is no impact to the operability of any safety related systems or impact to the health and safety of the public. All spare valve assemblies have been removed from PGE's warehouse. The NRC senior resident inspector has been notified, and a written report will be submitted within 30 days."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    No other nuclear power plants were affected.  |
Agreement State|57272|PA Bureau of Radiation Protection|Nondestructive & Visual Inspection|1|Eighty-Four|PA| |PA-1413|Y||||||John Chippo|Natalie Starfish|08/16/2024|7:15:00|07/31/2024|0:00:00|EDT|8/16/2024 7:27:00 AM|Non Emergency| |Agreement State|||||||Ford, Monica|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA    The following was received from the Pennsylvania Bureau of Radiation Protection (the Department) via email:    "On August 15, 2024, the licensee notified the Department of a disabled device. It is reportable per 10 CFR 34.101(a)(2) and 30.50(b)(2).    "On July 31, 2024, the licensee reported damage to a QSA 880D (serial number D14778, source serial number FC2203), camera containing 38 curies of Ir-192. The licensee was on site performing weld inspections for a client. After the second exposure, the source did not return to the shielded position. The technicians on site called the radiation safety officer (RSO) and established a restricted area around the source. They also notified the client to keep their personnel away from the area. The RSO arrived on site and was able to retrieve the source. The licensee staff determined that the technicians on site did not receive any overexposure. The RSO received 451 mR during the source retrieval. The badges have been sent to Landauer for verification. The equipment was taken out of service for repair."    PA Event Report Identification Number: PA240017|
Agreement State|57273|Virginia Rad Materials Program|ECS Mid Atlantic LLC|1|Fairfax|VA|Fairfax|107-314-1|Y||||||Sheila Nelson|Sam Colvard|08/16/2024|16:37:00|08/16/2024|9:00:00|EDT|8/23/2024 2:28:00 PM|Non Emergency| |Agreement State|||||||Ford, Monica|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|EN Revision Imported Date: 8/26/2024<br><br>EN Revision Text: AGREEMENT STATE REPORT - POSSIBLE DAMAGED PORTABLE GAUGE    The following information was provided by the Virginia Department of Health, Office of Radiologic Health (RMP) via email:    "At approximately 1100 EDT on 8/16/2024, RMP was notified of an incident involving a portable nuclear gauge. At approximately 0900, at a deep trench construction site in Fairfax, a CPN International gauge model MC-1, containing 10 mCi Cs-137 and 50 mCi Am-241, was dropped approximately 15 feet when a rope pulley system slipped. The authorized user notified the radiation safety officer (RSO) who arrived on site and then they notified the RMP.    "Per the RSO, the gauge fell onto dirt at the bottom of a trench. The device landed flat onto the base of the gauge. The gauge functions and is operational. The rod handle was retracted and locked at the time, and the source remained retracted in the shielded position. The RSO obtained survey readings of 0.4 mR/h at 1 meter from the gauge. The gauge was placed in its transportation box, secured in the back of a pickup truck, and transported back to the licensee's office for secure storage. A leak test was obtained and analysis indicates there is no leakage. The gauge will be sent for assessment by an authorized dealer.    "RMP will follow up with an investigation."    Event Report ID No.: VA240004    THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL    Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
Power Reactor|57274|Callaway|Ameren Ue|4|Fulton|MO|Callaway||N|05000483|1|||[1] W-4-LP|Ali Syed|Ian Howard|08/19/2024|15:55:00|08/19/2024|12:21:00|CDT|8/19/2024 4:25:00 PM|Non Emergency|26.719|Fitness For Duty|||||||Vossmar, Patricia|R4DO|FFD Group, |EMAIL|||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||FITNESS-FOR-DUTY REPORT    The following information was provided by the licensee via phone call and email:    "A non-licensed supervisory employee had a confirmed positive test during a random fitness-for-duty test. The employee's access to the plant has been terminated."    The NRC Senior Resident Inspector has been notified.  |
Agreement State|57275|Kentucky Dept of Radiation Control|Leonard Lawson Cancer Center|1|Pikeville|KY| |202-375-27|Y||||||Russell Hestand|Josue Ramirez|08/20/2024|17:55:00|08/20/2024|13:30:00|CDT|8/20/2024 6:16:00 PM|Non Emergency| |Agreement State|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - MEDICAL UNDERDOSE    The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:    "KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center [of the following:]  "The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.  "The authorized user physician and the patient have been notified of the medical events.  "The first dose was administered on July 9, 2024, with a prescribed dose of 91.2 micro Ci and an administered dose of 72.46 micro Ci with a difference of 20.5 percent.  [The second dose is being tracked under a different NRC Event number. See EN 57276]  "The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:  "Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).  "The concentration provided in the formula is different than the concentration for each dose. The concentration for the first dose was 19.17 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.  "Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).  "The problem is the document does not instruct one to use an actual concentration for the patient specific dose.  "The two reasons for the medical events are:  "1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.  "2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.  "The incident remains under evaluation and investigation for corrective actions."      A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.      |
Agreement State|57276|Kentucky Dept of Radiation Control|	Leonard Lawson Cancer Center|1|Pikeville|KY| | |Y||||||Russell Hestand|Josue Ramirez|08/20/2024|17:55:00|08/20/2024|13:30:00|CDT|8/20/2024 6:53:00 PM|Non Emergency| |Agreement State|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - MEDICAL UNDERDOSE    The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:    "KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center [of the following:]  "The date of discovery is August 20, 2024 at 13:30 EDT.  "There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.  "The authorized user physician and the patient have been notified of the medical events.  [The first dose is being tracked under a different NRC Event number. See EN 57275]  "The second dose was administered on August 7, 2024, with a prescribed dose of 89.2 micro Ci and an administered dose of 45.53 micro Ci with a difference of 53.9 percent.  "The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:  "Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).  "The concentration provided in the formula is different than the concentration for each dose. The concentration for the second dose was 18.12 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.  "Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).  "The problem is the document does not instruct one to use an actual concentration for the patient specific dose.  "The two reasons for the medical events are:  "1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.  "2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.  "The incident remains under evaluation and investigation for corrective actions."    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.    |
Agreement State|57277|Tennessee Div of Rad Health|3M Corporation|1|Clinton|TN| |R-M5003-G29|Y||||||Andrew Holcomb|Josue Ramirez|08/20/2024|18:05:00|08/19/2024|0:00:00|EDT|8/20/2024 7:15:00 PM|Non Emergency| |Agreement State|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - GAUGE SHUTTERS FOUND OPEN WITHOUT COMMAND    The following information was provided by the Tennessee Division of Radiological Health via email:    "It was discovered on August 19, 2024, that three (3) fixed gauges had shutters that were open without commands to open from the PLC terminal. The area was unoccupied at the time. The facility radiation safety officer (RSO) did not indicate any physical damage to the devices. The event occurred again on the morning of August 20, 2024. No exposure was noted since the gauges were operating in a normal capacity. The RSO had the shutters closed and took the gauges out of service. The gauges were also locked out to prevent reoccurrence. The gauge manufacturer has been contacted for troubleshooting the occurrence. The available device information is as follows:  "Manufacturer: Mahlo America, Inc.  "Model: 11-200933 (source holder)  "Isotope: Kr-85, 260 mCi (as of March 28, 2019)  "Source SN#: AN-3035, AN-3036, AN-3037  "Corrective actions will be updated with a report within 30 days."      Tennessee Event Report Number: TN-24-060    |
Power Reactor|57278|Summer|South Carolina Electric & Gas Co.|2|Jenkinsville|SC|Fairfield||Y|05000395|1|||[1] W-3-LP,[2] W-AP1000,[3] W-AP1000|Jason Pawlak|Jordan Wingate|08/20/2024|23:32:00|08/20/2024|20:01:00|EDT|8/21/2024 5:57:00 PM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|50.72(b)(3)(xiii)|Loss Comm/Asmt/Response|||||Masters, Anthony|R2DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||CONTROL ROOM VENTILATION INOPERABLE    The following information was provided by the licensee via email and phone:    "At 2001 EDT on 8/20/2024, it was discovered that both trains of the control room ventilation system were simultaneously inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour notification per 10 CFR 50.72(b)(3)(v).    "There is no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified.    "One train of control room ventilation was restored to operable status at 2107 EDT on 8/20/2024."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    While performing canister maintenance on train B, it was discovered that the dampener for train A failed to close. Train B was restored at the conclusion of maintenance.      * * * UPDATE ON 08/21/24 AT 1648 EDT FROM LAUREN ANDERSON TO JOSUE RAMIREZ * * *    The following information was provided by the licensee via email and phone:    "This event is also reportable per 10 CFR 50.72(b)(3)(xiii), loss of emergency assessment capability, as the technical support center facility is located inside the control room envelope."    Notified R2DO (Masters)|
Power Reactor|57279|South Texas|Stp Nuclear Operating Company|4|Wadsworth|TX|Matagorda||Y||2|||[1] W-4-LP,[2] W-4-LP|Chris Van Fleet|Jordan Wingate|08/21/2024|1:34:00|08/20/2024|20:10:00|CDT|8/21/2024 1:50:00 AM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||Vossmar, Patricia|R4DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||CONTROL ROOM FILTRATION SYSTEMS INOPERABLE    The following information was provided by the licensee via fax or email:    "At 2010 CDT on 08/20/2024, with Unit 2 in Mode 1 at 100% power, Train B Essential Chiller was unable to maintain the Chilled Water Outlet Temperature in the required band. Train B Essential Chilled Water and the associated cooled components were declared inoperable. Train B Control Room Makeup and Cleanup Filtration System was declared inoperable due to the unavailability of cooling. Train C Control Room Makeup and Cleanup Filtration System was previously inoperable for planned maintenance for reasons other than loss of cooling. This resulted in the inoperability of two of the three 50-percent capacity safety trains required for accident mitigation.     "This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.    "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    Train C has been placed back in service and is awaiting testing to verify its ability to perform its safety function. Testing is expected to be completed by 1500 CDT on 08/21/2024. Plant is on a 72 hr S/D clock until restoration is verified.  |
Hospital|57280|VA Boston Healthcare System|VA Boston Healthcare System|3|Boston|MA||03-23853-01VA|N||||||Clinton Abell|Jordan Wingate|08/21/2024|11:01:00|08/20/2024|13:00:00|EDT|8/21/2024 11:20:00 AM|Non Emergency|35.3045(a)(1)|Dose <> Prescribed Dosage|||||||Skokowski, Richard|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|MEDICAL UNDERDOSE    The following information was provided by the Department of Veterans Affairs (VA) via email:    "VA Boston Healthcare System, Boston, Massachusetts, which holds Veterans Health Administration (VHA) Permit Number 20-00671-02 under the VA Master Materials License, reported discovery of a medical event to the National Health Physics Program (NHPP) at approximately 1410 CDT, August 20, 2024. A therapeutic administration of Y-90 microspheres (TheraSphere) to the right lobe of a patient's liver was conducted at approximately 1300 EDT on August 20, 2024. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity. The prescribed activity was 42.9 mCi; the administered activity was estimated at 27 mCi. A causal analysis of the medical event is being performed by the medical center.     "The patient and the referring physician have been notified. Short term harm to the patient is not expected. NHPP plans to perform a reactive inspection to assess causes and regulatory compliance. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified the NRC Region III Project Manager, Bryan Parker."    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.|
Agreement State|57281|Utah Division of Radiation Control|IGES INGENIEROS DBA Geostrata|4|Magna|UT| |UT 1800434|Y||||||Tim Butler|Josue Ramirez|08/21/2024|11:48:00|08/20/2024|14:30:00|MDT|8/21/2024 12:20:00 PM|Non Emergency| |Agreement State|||||||Vossmar, Patricia|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - DAMAGED GAUGE    The following summary was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC) via phone and email:    The licensee (IGES INGENIEROS, L.L.C. DBA GEOSTRATA) contacted the DWMRC to report that a portable gauge, Troxler 3430 model, with a 8 mCi Cs-137 and a 40 mCi Am-241/Be source, fall off the back of a truck. Once the licensee noticed the gauge was missing, they returned to the scene and found the damaged gauge. Although the gauge was in pieces, the sources were intact and there was no apparent leakage identified. Swipe tests were taken and the results are pending.     Utah event report ID number: UT 240006  |
Power Reactor|57282|Millstone|Dominion Generation|1|Waterford|CT|New London||N||3|||[1] GE-3,[2] CE,[3] W-4-LP|Donald Haynes|Josue Ramirez|08/21/2024|19:30:00|08/21/2024|12:00:00|EDT|8/21/2024 8:07:00 PM|Non Emergency|50.72(b)(3)(v)(C)|Pot Uncntrl Rad Rel|50.72(b)(3)(v)(D)|Accident Mitigation|||||Lilliendahl, Jon|R1DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation||N|0||0|||N|0||0||SECONDARY CONTAINMENT BOUNDARY INOPERABLE    The following information was provided by the licensee via fax and phone:    "At 1200 EDT on 8/21/2024, with Millstone unit 3 in mode 1 at 100 percent power, it was discovered that the secondary containment boundary was inoperable while maintenance activities on the system were in progress. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C) and (D).  "There is no impact on the health and safety of the public and plant personnel. The NRC Resident Inspector has been notified.  "Unit 3 continues to operate in mode 1 at 100 percent power with actions in progress to restore the system to operable within the technical specification allowed outage time. There has been no impact to unit 2, which remains at 100 percent power.    "The state of Connecticut and local towns were notified."  |
Non-Agreement State|57283|Steel of West Virginia|SWVA, Inc.|1|Huntington|WV||47-16310-03|N||||||Michael Winarta|Brian P. Smith|08/22/2024|15:58:00|08/15/2024|0:00:00|EDT|8/22/2024 4:22:00 PM|Non Emergency|30.50(b)(1)|Unplanned Contamination|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|Skokowski, Richard|R3DO|||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|UNPLANNED CONTAMINATION INVOLVING MELTING OF SOURCE    The following summary was provided by via phone:    The facility Steel of West Virginia notified the NRC (see National Response Center report #1408695 for additional notifications) to inform them that they potentially melted a Cesium-137 (Cs-137) source during their melting process before shipping scrap metal to another facility in Chicago, Illinois. Radiation detectors indicated positive readings for Cs-137 in the atmosphere at this facility. The source of the material is unknown at this time. Investigation is underway.  The state of West Virginia were able to take radiation readings in the facility's bag house and readings were 550 microRem/hour.     The state of Illinois likewise notified the NRC during the discovery of the shipment of bag house dust from the West Virginia steel mill had tripped a portal alarm upon arrival in Chicago. The Cs-137 was identified in the load with the dust surveying approximately 1.7 mR/hour on contact with the truck. The shipment is planned to be returned to West Virginia under a Department of Transportation (US DOT) special permit. West Virginia program staff are on site at the steel mill and confirmed Cs-137 contamination. Early indications are that a load of scrap, received on or about August 15, 2024, contained a Cs-137 source and was melted in the mill's electric arc furnace. The mill staff surveyed QA samples from recent melts and believe that the Cs-137 volatilized as it wasn't identified in finished steel product.  |
Power Reactor|57284|Wolf Creek|Wolf Creek Nuclear Operating Corp.|4|Burlington|KS|Coffey||Y|05000482|1|||[1] W-4-LP|Alex Meyer|Sam Colvard|08/23/2024|9:02:00|08/23/2024|8:00:00|CDT|8/23/2024 9:45:00 AM|Non Emergency|50.72(b)(2)(i)|Plant S/D Reqd By TS|||||||Vossmar, Patricia|R4DO|||||||||||||||||||N|Y|98|Power Operation|98|Power Operation||N|0||0|||N|0||0||SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS    The following information was provided by the licensee via phone and email:    "At 0500 CDT on 8/23/24, Wolf Creek entered technical specification limiting condition for operation (LCO) 3.7.5 required action D.1 which requires shutdown to mode 3 within 6 hours. The turbine driven auxiliary feedwater pump discharge valve to the 'B' steam generator was not successfully restored to operable prior to expiration of the 72 hour completion time. At 0800 CDT, the shutdown to mode 3 was initiated, which is being reported in accordance with 10CFR50.72(b)(2)(i)."    The NRC Resident Inspector has been notified.  |
Power Reactor|57285|Sequoyah|Tennessee Valley Authority|2|Soddy-Daisy|TN|Hamilton||Y|05000327|1|||[1] W-4-LP,[2] W-4-LP|Timothy Wood|Josue Ramirez|08/23/2024|13:44:00|08/23/2024|12:19:00|EDT|8/23/2024 2:05:00 PM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||Masters, Anthony|R2DO|||||||||||||||||||A|Y|100|Power Operation|0|Hot Standby||N|0||0|||N|0||0||AUTOMATIC REACTOR TRIP    The following information was provided by the licensee via email:    "At 1219 EDT, with unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped due to a turbine trip. The trip was not complex, with all systems responding normally post-trip.  "Operations responded and stabilized the plant. Decay heat is being removed by the auxiliary feedwater (AFW) and steam dump systems. Unit 2 is currently in a refueling outage (U2R26) and was not affected.  "Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non- emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system. The AFW system started automatically and is operating as designed.  "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."    |
Agreement State|57286|Virginia Rad Materials Program|Virginia Commonwealth University|1|Richmond|VA| |760-215-1|Y||||||Karen Shelton|Brian P. Smith|08/23/2024|15:30:00|08/22/2024|13:30:00|EDT|8/23/2024 3:39:00 PM|Non Emergency| |Agreement State|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG SEGMENT OF LIVER    The following information was received via email from the Virginia Radiation Materials Program (VRMP):    "At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation."    A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.    |
Agreement State|57287|Florida Bureau of Radiation Control|University of Florida|1|Gainesville|FL| |031-3|Y||||||John Williamson|Josue Ramirez|08/23/2024|17:33:00|07/29/2024|0:00:00|EDT|8/23/2024 5:45:00 PM|Non Emergency| |Agreement State|||||||Lilliendahl, Jon|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|AGREEMENT STATE REPORT - LEAKING SEALED SOURCE    The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:    "On 3/27/24, the Cs-137 dose calibrator source was found to have 635 disintegrations per minutes (dpm) of contamination during the routine weekly swipe. Second set of swipes found 2346 dpm on the inside of the shielded container and 2559 dpm on the outside of the vial. The source was cleaned and swiped again, which brought counts to zero on the inside of the shielded container and 1018 dpm on the outside of the vial. On 4/1/2024, the swipes were counted again and found to be at the same level, showing the contamination to be a long-lived isotope. Since the area where the sealed source resides does not contain long-lived isotopes, it was assumed the source was leaking and was taken out of service and stored under the office of radiation safety's control. On 4/2/2024, Eckert and Ziegler [the manufacturer] was contacted to request instructions on returning the leaking source. Another swipe taken on 7/29/2024 found 17807 dpm and a small fracture was noticed on the vial. This swipe exceeded 5 nano Ci, and the report was made to BRC. Source will be returned to the manufacturer."    Source Information:  Manufacturer: Eckert and Ziegler.  Model: RV-137-200U.  Serial number: 1047-67-4.  Original activity: 197 micro Ci with a calibration date of 7/1/2004.    Florida Incident No.: FL24-076  |
Power Reactor|57291|Farley|Southern Nuclear Operating Company|2|Ashford|AL|Houston||Y|05000348|1|2||[1] W-3-LP,[2] W-3-LP|David Hershman|Karen Cotton-Gross|08/26/2024|16:54:00|08/26/2024|12:00:00|CDT|9/16/2024 12:23:00 PM|Non Emergency|26.719|Fitness For Duty|||||||Masters, Anthony|R2DO|FFD Group, |EMAIL|||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|Y|100|Power Operation|100|Power Operation||N|0||0||EN Revision Imported Date: 9/17/2024<br><br>EN Revision Text: FALSE NEGATIVE INDICATED ON A FITNESS FOR DUTY BLIND QUALITY ASSURANCE TEST     The following information was provided by the licensee via email:    "On 8/26/2024 at 1200 CDT, Farley Nuclear Plant Medical Services identified a false negative quality assurance test. [The contracted laboratory] was provided an adulterated sample of hydrocodone and hydromorphone that was part of a blind performance test. The results from the [contracted laboratory] returned a false negative. This false negative test result will be investigated, and the results reported as required.     "This event is being reported in accordance with 10 CFR 26.719(c)(3).     "The NRC resident inspector has been notified."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officer Report Guidance:    The contracted laboratory was a U.S. Department of Health and Human Service (HHS) certified laboratory.      * * * RETRACTION ON 09/16/24 AT 1014 EDT FROM RONNIE SUBER TO KERBY SCALES * * *    The following update was provided by the licensee via email:    "Following further review of the event, it has been determined that this issue is not reportable under 10CFR26.719(c)(3) as the unsatisfactory test was not for a validity screening test. This event is reportable for testing errors in accordance with 10CFR26.719(c)(1) and a 30 day report will be submitted."    Notified R2DO (Suber) and FFD Group (email).|
Power Reactor|57298|Browns Ferry|Tennessee Valley Authority|2|Decatur|AL|Limestone||Y|05000259|1|||[1] GE-4,[2] GE-4,[3] GE-4|Stewart Wetzel|Sam Colvard|08/30/2024|18:30:00|08/30/2024|10:51:00|CDT|8/30/2024 6:54:00 PM|Non Emergency|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||||Masters, Anthony|R2DO|||||||||||||||||||N|Y|75|Power Operation|40|Power Operation||N|0||0|||N|0||0||SPECIFIED SYSTEM ACTUATION - AUTOMATIC START OF DIESEL GENERATORS    The following information was provided by the licensee via phone and email:    "At 1051 CDT on 8/30/2024, during transfer of 4KV shutdown bus 1 to support Unit 1 shutdown activities, the alternate feeder breaker failed to close resulting in 4KV shutdown boards 'A' and 'B' experiencing an under voltage condition.  This resulted in 'A' and 'B' diesel generators automatically starting and tying to their respective boards.  This condition also caused a loss of reactor protection system (RPS) channel 'A' on Units 1 and 2, resulting in invalid actuation of primary containment isolation system Groups 2, 3, 6, and 8.  The failure of the board to transfer was identified during preparation for the evolution, contingency actions were prepared and implemented as planned.  The breaker failure to close has been corrected and 4KV shutdown bus 1 is energized on alternate.  4KV shutdown boards 'A' and 'B' have been restored to offsite power supplies and the diesel generators are secured.       "All systems responded as expected for the loss of voltage.  This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A).  There was no impact to the health and safety of the public or plant personnel.  The NRC resident has been notified."    The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:    The change in reactor power from 70 percent to 40 percent was not as a result of the failed breaker, rather Browns Ferry Unit 1's change in reactor power was due to a scheduled reactor shutdown which was in progress. In regards to the Unit 2 loss of channel 'A' RPS, this was not a specified system actuation. The actuation of the 'A' and 'B' diesel generators were the specified system actuation. Although the 'A' and 'B' diesels are common to both Units 1 and 2, only Unit 1 credits these specific diesel generators for accident mitigation. As such, this event is only reportable from Unit 1. Unit 2 did not experience a specified system actuation.  |