Current Event Notification Report for April 30, 2024

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."


* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.


PA Event Number: PA240008

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 REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."


* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.


PA Event Number: PA240009

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 REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."


* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.


PA Event Number: PA240010

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 REPORT - SHUTTER STUCK PARTIALLY OPEN

The following was received from the Iowa Department of Public Health - Bureau of Radiological Health (Iowa HHS) via email:

"Arconic Davenport possesses an IMS Measuring System (model 5221-02 profile thickness gauge) for measuring thickness of aluminum on the production line. The C-frame gauge contains five independent source housings, with each housing containing a 5 curie, americium-241, sealed source. The C-frame gauge is constructed from steel and is suspended from a monorail which allows the device to be moved offline to a restricted access calibration area. The shutter [on each source] is opened and closed by a pneumatic cylinder that is controlled from a remote location.

"On the morning of April 22, 2024, it was determined that shutter number 1 of the C-frame gauge B had failed to fully close. This was determined [during] an automated attempt to close all 5 shutters on the gauge, and the computer indicated that shutter number 1 was not fully closed. Per the licensee's procedures, the C-frame gauge was removed from the line using the monorail to the secured calibration house. Radiation surveys of the outside wall adjacent to the shutter 1 position were above background with a maximum dose rate of 0.1 mR/hr.

"The licensee has contacted their service provider to perform repair work (identify and fix the equipment problem) which is tentatively scheduled for same day or April 23, 2024. No reported overexposures have occurred because of this incident, no release or contamination of radioactive material occurred because of this incident (most recent negative leak test was November 2, 2023), and Iowa HHS will update this report once additional information is provided (cause, corrective actions, etc.)."

IA Event Number: IA240002

EN Revision Imported Date: 4/30/2024

EN Revision Text: PART 21 - FUEL ASSEMBLY SPACER RELOCATION

The following is a summary of information provided by the licensee via email:

Global Nuclear Fuel discovered instances of GNF3 fuel assembly spacers relocating within the fuel bundle. A safety communication was issued in 2022 following the discovery of a raised water rod (WR) at Grand Gulf Nuclear Station. Shutdown inspections in February 2024 at Lasalle identified five spacers out of position. Shutdown inspections at Limerick in April 2024 identified four spacers out of position. Those discoveries prompted this Part 21 report. An evaluation concluded that the relocated spacers could result in a degraded critical power margin, but the evaluation of this condition indicates it will not compromise or greatly reduce protection to public health and safety.

Plants with suspect bundles installed:
Grand Gulf Nuclear Station (Raised WR but no defective spacers)
Lasalle (1 bundle with 5 relocated spacers found)
Limerick (1 bundle with 4 relocated spacers found)
Nine Mile Point (No defects found)
Fermi (No defects found)
Peach Bottom (Shutdown scheduled in Fall 2024)
Fitzpatrick (Shutdown scheduled in Fall 2024)

* * * UPDATE ON 4/26/24 AT 1220 EDT FROM LISA SCHICHLEIN TO ADAM KOZIOL * * *

Updated to correct administrative errors in the summary of defects. Corrections were made above.

Notified R1DO (Werkheiser), R3DO (Betancourt-Roldan), R4DO (Warnick), Part 21/Reactor Group (email)

RADIOGRAPHY CAMERA SOURCE RETRIEVAL

The following report is a summary of the event provided via phone from the licensee's radiation safety officer:

At 0030 AKDT on April 23, 2024, a radiography crew utilizing a QSA Global 880D exposure device with a 50.9 Ci Ir-192 sealed source experienced an issue where the slide lock of the device actuated prior to the source being in the fully shielded position. The licensee's radiation safety personnel were notified. The source was properly secured in the device at 0440 AKDT by trained personnel using a U tool to reengage the slide lock. There were no overexposures during this incident.