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|
Part 21|52466|ENGINE SYSTEMS, INC|ENGINE SYSTEMS, INC|1|ROCKY MOUNT|NC|||Y||||||TOM HORNER|JEFF HERRERA|12/29/2016|16:54:00|12/21/2016|0:00:00|EST|12/4/2020 12:00:00 AM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||STEVE ROSE|R2DO|MARK JEFFERS|R3DO| PART 21/50.55 REACTORS|EMAIL|||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/7/2020<br><br>EN Revision Text: PART 21 - ISSUES IDENTIFIED WITH THE ENTERPRISE DIESEL ENGINE SUBCOVER    The following information is excerpted from a facsimile report submitted:    "Engine Systems Inc. (ESI) began a 10 CFR 21 evaluation on November 18, 2016 upon notification of an issue with a subcover assembly at Perry Nuclear Plant. Attempts to install the subcover on their Enterprise diesel engine revealed two issues that prevented successful installation. First, one of the bolt holes was not fully machined through the entire depth of the subcover. Though the bolt could be inserted into the top of its corresponding hole, it would not pass completely through. The second issue was an interference between the rocker arm shaft and its mating pedestal. It was found that incomplete machining of the pedestal prevented the shaft from sitting flat on the pedestal.    "The evaluation was concluded on 12/21/16 and it was determined that this issue is a reportable defect as defined by 10 CFR 21."    The affected facilities are:  First Energy - Perry  Georgia Power - Vogtle    Also listed was the following affected facility:  Korea - Yonggwang    Component:  Subcover Assembly, P/N 1A-7846    * * * UPDATE ON 12/4/20 AT 1435 EST FROM DAN ROBERTS TO THOMAS KENDZIA * * *    The following is the summary of a facsimile:    Engine Systems Inc. (ESI) determined that in addition part number 03-362-04-AH was affected by this defect.  Two of these parts were supplied to Commanche Peak with an ESI certification date of 8/6/2014.    Notified R4DO (Gepford) and Part 21 Reactors Group (email).|
Part 21|54520|AMETEK SOLIDSTATE CONTROLS|AMETEK SOLIDSTATE CONTROLS|3|COLUMBUS|OH|||Y||||||ETHAN SALSBURY|KERBY SCALES|02/11/2020|0:00:00|02/11/2020|0:00:00|EST|12/9/2020 12:00:00 AM|Non Emergency|21.21(a)(2)|Interim Eval Of Deviation|||||||BRICE BICKETT|R1DO|ERIC MICHEL|R2DO|ROBERT RUIZ|R3DO|RAY AZUA|R4DO|- PART 21/50.55 REACTORS|EMAIL|||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/10/2020<br><br>EN Revision Text: PART 21 REPORT - AMETEK 85-RP2675-01 POWER SUPPLY MOUNTING HARDWARE    The following is a synopsis of a Part 21 report received by email:    "SUMMARY - AMETEK Solidstate Controls recently discovered a concern with the structural integrity of the 85-RP2675-01 Rack Mounted Power supply.  While qualifying a replacement part for an obsolete breaker, the left panel of the power supply came loose after the hardware had sheared during the seismic simulation testing of the qualification.  The loss of structural integrity of the power supply led to internal shorting and a premature stoppage of the simulation testing.    "PROBLEM - During a seismic event, a structural failure of the power supply enclosure resulting in a loss of output could occur.  At this point, it is suspected that the failure is related to a variation in the components that increased strain on the power supply enclosure, and it is indeterminate if there is a widespread deviation.  It is also possible that the cause of the failure is attributed to inadequately sized hardware that supports the bottom panel of the power supply.  In the current design, there are 3 #10-32 machine screws through each of the side panels that fasten to the bottom panel to support the transformer.      "AMETEK is unable to identify the actual structural support of power supplies in the field.  In the recent testing performed, no support was provided under the power supply during the testing.  If there is support in the end application from the bottom of the power supply, there may not be a structural concern as the connection screws would not be exposed to the same forces.  In this instance, the power supply had been exposed to a peak acceleration of approximately 4.8 giga second.  It should also be noted that acceptable results have been obtained in previous seismic tests and changes have not been made to the structure of the power supply since its initial design in 1996.      "ACTION RECOMMENDED - At this time, there are no actions to take as the evaluation is ongoing.  The next step is to determine if the screws are likely to become overstrained with enough seismic force.  To do this, AMETEK is repeating the test with two new power supplies.  One power supply will not have any changes made to the structure while the second power supply will be enhanced to improve its seismic withstand capabilities.      "The enhancement is an increase in the size of the hardware to 1/4 inch bolts that connects the side panels to the bottom panel through 5/16 inch through holes with a nut and washers.  In combination, these changes will increase the force required to shear the hardware [and] reduce the force on the bolt itself by allowing some movement to dampen the forces during a seismic event.  While AMETEK believes this solution will be suitable, it has not been validated with a follow up seismic simulation test.  Additionally, AMETEK is unable to determine the criticality of the applications the power supplies are installed in and if the safety function is required to be maintained during a seismic event, which will determine the need to take corrective actions.      "A report of the next seismic test results will follow upon completion as a final evaluation.  The current expected date for completion is May, 2020.  For questions or clarifications in the meantime, please contact Ethan Salsbury, Quality Director, at 1-614-410-6293."    * * * UPDATE ON 12/09/2020 AT 0819 EST FROM ETHAN SALSBURY TO OSSY FONT * * *    The following is an update of a Part 21 report received by email:    "ACTION RECOMMENDED - AMETEK does not consider this to be a likely failure based on these test results. Additionally, AMETEK is unable to determine the criticality of the applications the power supplies are installed in and if the safety function is required to be maintained during a seismic event, which will determine the need to take corrective actions. The following enhancements can be applied to power supplies in operation:   - Add a #10-32 nut to each of the six (6) mounting screws to avoid any lateral movement of the sheet metal parts that would lead to potential elongation or striping of the fastener.   - Add support to the bottom of the transformer to prevent horizontal forces on the support screws     "Although recent testing did not result in a similar failure, AMETEK is taking actions to enhance the design of the power supply. On new power supplies, the mounting hardware will use ¬" bolts that connect the side panels to the bottom panel through 5/16" through holes with a nut and washers. In combination, these changes will increase the force required to shear the hardware reduce the force on the bolt itself by allowing some movement to dampen the forces during a seismic event."    Notified R1DO (Bower), R2DO (Miller), R3DO (Feliz-Adorno), and R4DO (Kellar) and Part 21/50.55 Reactors via email.|
Agreement State|54953|CALIFORNIA RADIATION CONTROL PRGM|The Board of Trustees of the Leland Stanford, Jr. University|4|Stanford|CA||0676-43|Y||||||K. Arunika Hewadikaram|Brian P. Smith|10/16/2020|20:37:00|10/16/2020|15:03:00|PDT|12/2/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||RAY AZUA|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|KEVIN WILLIAMS|NMSS|||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/3/2020<br><br>EN Revision Text: AGREEMENT STATE REPORT - GREATER THAN INTENDED DOSE TO LIVER LOBE    The following was received via email from the California Radiation Control Program:    "On October 16, 2020, the [Radiation Safety Officer] RSO of Stanford University emailed [the Radiation Health Branch] RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi).  The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi).  So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation."    California 5010 Number: 101620      * * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1816 EST ON 12/2/2020 * * *    The following information was received via E-mail:    "The authorized user prescribed 31.57 mCi (1.17GBq) Y-90 to the right lobe of the liver and 13.22 mCi (0.49GBq) to the left lobe of the liver.    "The higher dosage, 31.57 mCi (1.17GBq) Y-90 was delivered to the left lobe of the liver.    "The prescribed dosage of 13.22 mCi (0.49GBq) would result in a dose to the left lobe of 7,000 rad (70Gy), however the delivered dose was 17,500 rad (175 Gy).    "This is 10,500 rad (105 Gy) above the prescribed dose."    Notified R4DO (Gepford) and via E-mail, NMSS (Williams) and the NMSS Events Notification E-mail Group.    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|54960|VIRGINIA RAD MATERIALS PROGRAM|Hillis-Carnes Engineering Associates, Inc.|1|Sandston|VA||107-453-1|Y||||||Sheila Nelson|Brian Lin|10/20/2020|20:19:00|10/20/2020|0:00:00|EDT|12/8/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||MEL GRAY|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/8/2020<br><br>EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE    The following information was received from the Commonwealth of Virginia via email:    "On October 20, 2020, a representative of the Virginia Radioactive Materials Program (VRMP) received a report from a licensee via email that a portable nuclear moisture/density gauge was damaged in a vehicle accident at the intersection of Airport Road and Hwy 156 in Sandston, Virginia. The report indicated that a Troxler soil density gauge (Model 3430, Serial # 36803, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241/Beryllium) was being transported in its case in the bed of a truck. During the accident, the case was damaged and the gauge housing was cracked, but there appeared to be no significant damage to the baseplate, rod, shielding or sources. The licensee's survey of the gauge yielded readings of 8-10 mR/hr at a 6 inch distance from the gauge. The gauge was returned to the Ashland office then transferred to an intact case and transported to North East Technical Services [(NETS)] for further evaluation. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."    VA incident no.: VA20005    * * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *    The following retraction was received from the Commonwealth of Virginia via email:    "On November 4, 2020, VRMP performed a reactive inspection. The inspector noted that on October 20, 2020, the licensee sent the gauge to NETS for leak testing and evaluation. The record from NETS indicated that no removable contamination was detected. It also concluded that every component of the gauge is functioning as it should and the gauge was deemed serviceable for field use. The licensee, however, reported this initially as a damaged gauge because of the small crack observed on the plastic case of the gauge.  Since the gauge still functioned properly with no damage to any shielding components, the incident does not meet the reporting requirements of 12VAC5-481-1110 B. 2.(10 CFR 30.50 b.2). Thus, VRMP requests the NRC Operation Center retract this event report.  "    Notified R1DO  (Bower) and NMSS Event Notification via email.|
Non-Agreement State|54969|Spectrum Health|Spectrum Health|3|Grand Rapids|MI||210024306|N||||||Evan Boote|Ossy Font|10/28/2020|16:50:00|10/28/2020|12:00:00|EDT|12/2/2020 12:00:00 AM|Non Emergency|35.3045(a)(1)|Dose <> Prescribed Dosage|||||||HIRONORI PETERSON|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/3/2020<br><br>EN Revision Text: IODINE-125 SEED INADVERTENTLY LEFT IN PATIENT    The following is a summary of a call with the licensee:    On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion.    On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork.    An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more.    The patient was informed and no effects are expected.    The licensee will notify the NRC Region 3 Office.      * * * RETRACTION FROM EVAN BOOTE TO DONALD  NORWOOD AT 1620 EST ON 12/2/2020 * * *    The following information was received via E-mail:    "Following review of the images and discussion of this case with surgery [personnel], the linear metallic foreign body previously reported as a 'seed' has a high probability of being a vascular surgical clip."    Notified R3DO (Dickson) and NMSS Events Notification E-mail group.    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.|
Power Reactor|54983|Browns Ferry|Tennessee Valley Authority|2|Decatur|AL|Limestone||Y|05000259|1|||[1] GE-4,[2] GE-4,[3] GE-4|Michael Millsap|Bethany Cecere|11/05/2020|6:32:00|11/04/2020|21:50:00|CST|12/29/2020 12:00:00 AM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||MARK MILLER|R2DO|||||||||||||||||||N|Y|17|Power Operation|16|Power Operation|N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/30/2020<br><br>EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE    "At 2150 CST on 11/04/2020, it was discovered that Unit 1 High Pressure Coolant Injection System (HPCI) was INOPERABLE; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.    "During performance of 1-SR-3.5.1.7, HPCI Main and Booster Pump Set Developed Head and Flow Rate Test at Rated Reactor Pressure, Unit 1 HPCI was manually tripped by the control room operator due to local report of excessive shaking of the cooling water supply from the booster pump line.    "There was no impact to the safety of the public or plant personnel. The NRC Resident Inspector has been notified.    "CR 1650042 documents this condition in the Corrective Action Program."    The Unit is in a 14-day LCO 3.5.1(c). The RCIC System is operable.    * * * RETRACTION FROM MARK ACKER TO HOWIE CROUCH AT 1607 EST ON 12/29/2020 * * *     "ENS Event number 54983, made on 11/05/2020 is being retracted. NRC notification 54983 was made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72 were met when Unit 1 HPCI was manually tripped by the control room operator due to a local report for excessive shaking of the cooling water supply from the booster pump line.    "A subsequent engineering evaluation concluded on 11/06/2020 there was reasonable assurance of operability with no additional intrusive maintenance performed and that the condition was bounded by a previous evaluation documented in [Condition Report] CR 1347736. As such, the circumstances discussed in the report did not result in any condition that at the time of discovery could have prevented the fulfillment of the safety function of structures of the system that are needed to mitigate the consequences of an accident. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v).    "TVA's evaluation of this event is documented in the corrective action program.    "The licensee has notified the NRC Resident Inspector."    Notified R2DO (Miller). |
Agreement State|54984|TEXAS DEPT OF STATE HEALTH SERVICES|Basic Energy Services LP|4|Eastland|TX||L 06425|Y||||||Arthur Tucker|Andrew Waugh|11/05/2020|12:13:00|11/05/2020|0:00:00|CST|12/6/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||PROULX, DAVID|R4DO|NMSS_EVENTS_NOTIFICATION, |EMAIL|ILTAB|EMAIL|CNSNS (MEXICO)|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: 12/7/2020<br><br>EN Revision Text: AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGES     The following is a summary of information received from the Texas Department of State Health Services (the Agency) via email:    "On November 5, 2020, the Agency was notified by the licensee that three of their nuclear density/level measurements gauges had been stolen from one of their storage sites. The storage site had been vandalized and various pieces of equipment were damaged as well. The licensee has contacted local law enforcement about this incident.    "The gauges contain Cs-137 sources. The total activity of the missing sources is estimated to not exceed 200 mCi. The licensee does not have any additional information regarding the incident or gauges at this time."    Texas Incident Number: 9808    * * * UPDATE ON 11/10/20 AT 0813 EST FROM ART TUCKER TO BRIAN LIN * * *    "On November 9, 2020, the licensee provided additional information on the stolen gauges. All gauges contained cesium-137 sources. Two of the gauges were Thermo Fisher model 5192 gauges. One of the two gauges contained a 250 milliCurie (mCi) (original activity now 215 mCi) source and the other contained a 200 mCi (now 162 mCi) source. The third gauge was a Thermo Fisher model 5190 gauge containing a 200 mCi (now 166 mCi) source. The gauges had been stored in a locked cage on the licensee's site. The gauges were still installed on the pipes they were used on. The licensee stated the last time the gauges were seen was September 1, 2020. The Agency instructed the licensee to notify local scrap yards of the theft and provided them with a copy of the attached picture. The Agency has requested additional information from the licensee. Additional information will be provided as it is received in accordance with SA-300."    Notified R4DO (Dixon), ILTAB (email), NMSS Events Notification (email), and CNSNS-Mexico (email)    * * * UPDATE ON 12/6/20 AT 2301 EST FROM ART TUCKER TO THOMAS KENDZIA * * *    "On December 6, 2020 at 2033 [CST] hours the Agency was notified by the licensee that the three devices reported stolen in this event have been recovered. The gauges are in the possession of the licensee and are locked inside a secured location. Additional information will be provided through NMED as it is received.."    Notified R4DO (Gepford), ILTAB (email), NMSS Events Notification (email), and CNSNS-Mexico (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|
Non-Agreement State|55004|Baxter Healthcare of Puerto Rico|Baster Healthcare of Puerto Rico|1|Abonito|PR||52-21175-01|N|030-1988|||||Marco Torres|Brian Lin|11/19/2020|10:44:00|11/18/2020|15:00:00|EST|12/19/2020 12:00:00 AM|Non Emergency|36.83(a)(3)|Damaged Source Racks|21.21(d)(3)(i)|Defects And Noncompliance|||||JONATHAN GREIVES|R1DO|WILLIAM GOTT|IRD|NMSS_EVENTS_NOTIFICATION|EMAIL|- PART 21 MATERIALS|EMAIL|||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/21/2020<br><br>EN Revision Text: DAMAGED SOURCE RACK    The following was received from the licensee via email:    "Nordion personnel initiated cobalt reloading and source racks' cables replacement activities on November 18, 2020.  Irradiator source rack No. 1 was emptied in order to proceed with the source rack cable replacement process.  When the rack was lifted from the pool, it was noticed that multiple bars (cross taps) had welding points broken or separated from the rack main structure.  All of the radioactive materials are kept stored in safe position inside the pool.    "Two Nordion technicians are providing the guidance and recommendations for the damage observed.  As an immediate correction, re-welding has been initiated for all broken weldings and non-damage welding points for both source racks bars (cross taps).    "A report will be provided by Nordion personnel describing the findings, immediate corrective action implemented and long-term recommendations."    The licensee notified NRC Region I.      * * * UPDATE ON 12/19/20 AT 0945 EST FROM MARCO TORRES TO THOMAS HERRITY * * *    The following is a synopsis of the report received from Baxter Healthcare of Puerto Rico:     The racks were original to the irradiator, manufactured in 1982.  Both racks were re-welded and inspected by Nordion technicians.  Operations were resumed on November 20, 2020.   After analysis, new racks with different shaped tubes allowing increased weld surface area were designed and ordered.  Expected installation is 1st Quarter 2021.   Nordion will inspect source racks every 5 years while servicing the cables and sheaves.  An update report will be sent when new racks are confirmed for installation.    Notified R1DO (Ambrosini), IRD (Gott), NMSS Events Notification and Part 21 Group via email.|
Agreement State|55006|NEW YORK STATE DEPT. OF HEALTH|Not Provided|1||NY||Not Provided|Y||||||Daniel J. Samson|Solomon Sahle|11/24/2020|12:20:00|11/23/2020|0:00:00|EDT|11/24/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||MARK HENRION|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|GRETCHEN RIVERA-CAPELLA|NMSS DAY|||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - DOSED INCORRECT ORGAN    The following information was received from the state of New York via fax:     "A medical licensee reported on 11/23/2020 that a Y90 microsphere procedure performed on Friday 11/20/2020 was later discovered to have had the catheter connected to the gallbladder instead of the liver as prescribed in the written directive.  More information will be forthcoming but preliminary information shows that the microspheres were Sirtex SIR-Spheres."    New York Incident Number: NYDOH-20-07.      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|55007|LOUISIANA RADIATION PROTECTION DIV|Marathon Petroleum Company, LLC|4|Garyville|LA||LA-3239-L01A|Y||||||James Pate|Solomon Sahle|11/24/2020|14:25:00|11/23/2020|0:00:00|CDT|11/24/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||JASON KOZAL|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - STUCK SHUTTER    The following was received from the State of Louisiana via email:     "Marathon Petroleum Company contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on November 24, 2020, concerning a stuck shutter.  The fixed gauge is stuck open and determined on November 23, 2020 to be in this condition.  The fixed gauge is an Ohmart/Vega Model Number SHGL-2, s/n for housing and source is 9853 CN.  The source is Cs-137 with an activity of 5000 mR (185 GBq).  There were no radiation exposures.  A technician from BBP will be out at the facility on December 1, 2020 for repair."    Louisiana Incident No.: LA20200009|
Agreement State|55008|TEXAS DEPT OF STATE HEALTH SERVICES|University of Houston|4|Houston|TX|||Y||||||Matthew Kennington|Solomon Sahle|11/24/2020|18:58:00|11/24/2020|0:00:00|CDT|11/24/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||JASON KOZAL|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB|EMAIL|||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT -  LOSS TRITIUM EXIT SIGNS    The following information was received from the Texas Department of State Health Services (the Agency) via email:    "On November 24, 2020, the Agency was contacted by the radiation safety officer (RSO) of a Texas licensee reporting that two self-luminescent tritium exit signs were not able to be located.  The signs are Sealed Source Inc. Isolite signs each containing 7.5 curies (original activity) of tritium manufactured in April of 2015.  The RSO stated that the area they were in had some work done and that he believes the signs may have been thrown into construction dumpsters after being replaced.  The signs were first discovered missing on November 11, 2020.  The RSO has been actively searching for the signs but as of today he has determined that they are no longer at the facility.  The RSO stated that he will attempt to determine the final disposition of the construction dumpsters believed to have contained the devices.  Additional information will be provided as it is received."      Texas Incident Number: 9814    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|55009|NJ RAD PROT AND REL PREVENTION PGM|Phillips 66 Co.|1|Linden|NJ||506897|Y||||||Sarah Adkisson|Solomon Sahle|11/25/2020|13:34:00|11/24/2020|0:00:00|EDT|11/25/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||MARK HENRION|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT -  FIXED GAUGE SHUTTER MALFUNCTION    The following information was received from State of New Jersey via email:    "The licensee reported on 11/24/20 that during a 6-month shutter check, one Cs-137 (50 mCi) fixed gauge shutter was found to be not closing completely.  The gauge manufacturer was contacted and came on site to fix the shutter.  Leak tests were taken before and after and found to be under 0.005 æCi.  More information will be provided by the licensee."    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|55010|MA RADIATION CONTROL PROGRAM|McArdle Gannon Associates|1|Tewksbury|MA||48-0518|Y||||||Charma Waring|Kerby Scales|11/25/2020|16:34:00|11/25/2020|0:00:00|EDT|11/25/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||MARK HENRION|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE    The following information was received from the state of Massachusetts via email:    "MA RCP [Radiation Control Program]  Officer received notification from the licensee Radiation Safety Officer (RSO) that one of their portable gauges was damaged by construction equipment at a temporary job site of the licensee.    "The portable gauge is a Troxler Electronics Laboratories Model 3400 Series moisture-density gauge containing up to 9 milliCurie of Cesium-137 in one sealed source and up to 44 milliCurie of Americium-241 in another sealed source.    "The RSO reported that they were in route to the site with a survey instrument and that, based on information received by his technician at the site, the damage is expected to be minor.  The RSO indicated the portable gauge was in use at the time of the incident.  The gauge and rod were pushed into the sand when the damage occurred.  The RSO indicated his technician told him the shielding was intact, however, the source and shielding separated from the plastic portion of the gauge.  He also indicated the source was able to be retracted into the gauge's shielding.  Additionally, RCP dispatched personnel to the site to perform surveys and evaluation of the gauge.    "RCP staff evaluated NRC reporting requirements. Equipment was secured on-site. No loose contamination identified and maximum dose rate was 20 mR per hour at contact on the shielded source holder.  No personnel exposure and there was no immediate threat to public health. No additional emergency response was required.  RCP personnel assisted in boxing the damaged gauge and the licensee will return the gauge securely to their office and will then arrange for transport back to the manufacturer.  RCP will follow up with additional information."    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|
Non-Agreement State|55011|ALLWEST Engineering|ALLWEST Testing & Engineering, Inc.|4|Hayden|ID||11-27637-01|N||||||Chris C. Beck|Howie Crouch|11/30/2020|10:19:00|10/29/2020|11:15:00|MDT|12/8/2020 12:00:00 AM|Non Emergency|30.50(b)(2)|Safety Equipment Failure|||||||HEATHER GEPFORD|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|EN Revision Imported Date: 12/8/2020<br><br>EN Revision Text: DAMAGED MOISTURE DENSITY GAUGE    The following information was received from ALLWEST Testing & Engineering, Inc. via email:     "On October 29, 2020, an ALLWEST employee [the authorized user] was testing the density of freshly placed asphalt on Painted Sky Street in the Spring Hollow Ranch subdivision in Nampa, Idaho using a CPN MC-1 portable nuclear densometer (SN 9216). At approximately 1115 Mountain Daylight time, the gauge was damaged by a Cat CCS9 combination roller under the direction of Nampa Paving.    "[The authorized user] was in the process of running a density test in AC mode when the roller backed up and impacted the gauge. The roller moved off of the gauge after impact. After impact, the handle was oriented at a 45-degree angle from the base of the gauge and the case was detached from the base. [The authorized user] moved away from the damaged gauge and cordoned off the area to prevent anyone from approaching the damaged gauge.    "[The authorized user] immediately contacted the Meridian office assistant RSO [radiation safety officer] who contacted the Corporate RS. [The assistant RSO] and another ALLWEST employee [the employee] responded to the accident and initiated ALLWEST's emergency protocol. [The assistant RSO] used a survey meter to obtain readings around the damaged gauge. The readings indicated the nuclear sources were not exposed and the shielding was intact. The handle was placed back in the case, and the handle, case and base were placed in the transport box. The  transport box was then placed in an overpak barrel and transported back to the ALLWEST office.    "Additional readings were taken using the survey meter around the gauge at the ALLWEST office. All readings were consistent with the sources being in a shielded condition.    "[The assistant RSO] contacted lnstrotek and discussed the condition of the gauge and the readings obtained from the survey meter. lnstrotek representatives indicated it was acceptable to ship the damaged gauge to them for disposal in the transport box. As an additional precaution, [the assistant RSO] and [the employee] wrapped the damaged gauge in lead sheeting and placed the wrapped gauge in the transport box. The transport box with the damaged gauge was then shipped to lnstrotek for disposal.    "ALLWEST sent the personal dosimetry badges for [the authorized user], [the assistant RSO], and [the employee] to Landaeur for immediate evaluation. The radiation dosimetry report from Landauer indicated minimal exposure to all three individuals."    The gauge contained 10 mCi Cs-137 source and a 50 mCi Am-241 source.|
Agreement State|55013|KANSAS DEPT OF HEALTH & ENVIRONMENT|ELI Wireline Services LLC|4|Hays|KS||27-B1008|Y||||||Aaron Short|Solomon Sahle|11/30/2020|15:58:00|10/16/2020|0:00:00|CST|11/30/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||HEATHER GEPFORD|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT -  WELL LOGGING, STUCK SOURCE     The following information was received from the State of Kansas, Department of Health & Environment via email:    "On 10/16/2020 Kansas licensee #27-B1008  ELI Wireline Services LLC  was logging a gas storage well when the tool became stuck in 2 3/8"  tubing at approximately 2100 feet from surface. Attempts to free the tool while still attached to the wireline were unsuccessful and the wireline was pulled resulting in the rope socket leaving the cable head, two weight bars, gamma ray neutron tool, and a 3 Curie AmBe-241 sealed source lodged inside the tubing. The licensee's attempts to retrieve the source have so far been unsuccessful, partly due to windy weather conditions and 1500 pounds of gas pressure on the well. The licensee contacted the state of Kansas on 10/21/2020 to report a stuck radioactive source downhole. The licensee made the decision to wait until spring when the field had less pressure and the weather was better to clean out the tubing to enable the fishing tool to reach the stuck logging tool. Kansas agreed with the delay on source recovery for better weather and required that a sign matching the requirements of K.A.R. 28-35-362 [with the exception of (2)(C) and (2)(H)(i)]  be placed at the wellhead no later than December 24, 2020. At this time this incident is not considered an abandoned source, however, The state of Kansas determined that it was appropriate to go ahead and report to the HOO out of an abundance of caution in the event that the source is unable to be retrieved in the spring of 2021."|
Agreement State|55014|UTAH DIVISION OF RADIATION CONTROL|Utah State University|4|Logan|UT||UT 0300159|Y||||||Spencer Wickham|Jeffrey Whited|11/30/2020|18:13:00|11/25/2020|0:00:00|MST|11/30/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||HEATHER GEPFORD|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB|EMAIL|||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - LOST STATIC CONTROL DEVICE     The following was received from the state of Utah via email:    "The licensee indicated that while conducting an inventory of their radioactive devices it was discovered that a small Static Control Device (SCD) was missing containing an estimated 16.27 mCi, Po-210 source, manufacturer: NRD, model: 1U400. The source was licensed and distributed under a general license. The licensee believes the SCD may have been disposed of as lab waste, been moved to a different location within the building, or was inadvertently added to a field project kit that has not been located. The current location of the device is unknown."    Event Report ID No.: UT 200002    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|55015|IOWA DEPARTMENT OF PUBLIC HEALTH|3M|3|Knoxville|IA||0042163FG|Y||||||Randal Dahlin|Howie Crouch|12/01/2020|9:55:00|11/16/2020|0:00:00|CST|12/8/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||DICKSON, BILLY|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|EN Revision Imported Date: 12/8/2020<br><br>EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER    The following information was obtained from the State of Iowa via email:    "A maintenance technician at the 3M facility in Knoxville, Iowa discovered that a Thermo Fisher Scientific model SULP-77A fixed gauging device containing 661 milliCuries of Krypton-85 had a shutter that was stuck open and would not close. This discovery occurred when the production line was shutdown for routine maintenance. The RSO [Radiation Safety Officer] and backup RSO were notified and the gauge was isolated with caution tape to prevent personnel from getting close to the device. 3M maintenance personnel are authorized to perform shutter repair under the supervision of the RSO or backup RSO by Iowa radioactive materials license number 0042-1-63-FG. The licensee will provide a written follow-up report once repairs have been completed and the cause of the failure identified.    "The licensee had a service provider operating under reciprocity with Iowa onsite November 17, 2020 to troubleshoot and repair the gauge. The root cause of the stuck shutter was a broken shutter return spring. A new shutter operating cylinder with a new return spring was installed and the gauge shutter was tested and found to be operating correctly. To minimize the chance of future shutter closure failures, the shutter operating cylinders will be replaced for all beta gauges of the same model that are currently in use at the site. Cylinder replacement will occur during future planned maintenance activities. These failures are exceedingly rare. This is the first occurrence in more than 20 years of using these gauges. The site is considering implementing a preventative maintenance replacement of these cylinders every 10 years."    Iowa report number: IA200004|
Agreement State|55016|ILLINOIS EMERGENCY MGMT. AGENCY|Sterigenics U.S., LLC|3|Schuamburg|IL||IL-01220-01|Y||||||Robin Muzzalupo|Donald Norwood|12/01/2020|16:35:00|11/30/2020|0:00:00|CST|12/1/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||BILLY DICKSON|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - STUCK IRRADIATOR SOURCE RACK    The following information was received via E-mail:    "The Agency [Illinois Emergency Management Agency] was contacted on 12/1/20 by Sterigenics U.S., LLC to advise that one of their pool irradiator source racks at the Schaumburg location had become stuck in the unshielded position on 11/30/20. The source rack, containing approximately 1.3 MCi of Co-60, was successfully returned to the shielded position and no exposures to personnel or the public resulted. All safety interlocks functioned as designed. This event did not result in any compromises to source security or to any safety or security systems. There is no indication of intentional misuse, theft or diversion at this time.    "On 12/1/2020, the Agency was contacted by the Radiation Safety Officer for Sterigenics U.S., LLC, to advise that in the middle of performing scheduled routine safety checks on 11/30/2020, authorized engineers reported that the east source rack failed to return to the shielded position as designed upon completion of a check. The west source rack lowered as designed without incident. Sources contained in the east source rack remained unshielded from approximately 1400 CST until 1648 CST. The event was immediately reported to the Radiation Safety Officer by the two authorized engineers performing the safety checks that day. The Radiation Safety Officer immediately responded to the site to assist in assessment and formulation of an action plan. After consultation with the Corporate Radiation Safety Officer, the Radiation Safety Officer and staff engineers were able to use a hand winch to successfully lower the rack of sources into the shielded position within the pool. Safety and security systems remain operational and functioned as designed throughout the source lowering process. There is no immediate hazard to workers or members of the public as a result of this incident.    "This morning [12/1/2020], source modules were removed without incident from the east source rack and are currently shielded and in safe storage at the bottom of the pool. Sterigenics staff are continuing their investigation into the cause for the stuck rack. All interlocks and safety systems were reported as operational. An action plan was formulated in conjunction with Corporate staff to safely and slowly raise the empty east rack using a hand winch so that it can be adequately inspected. IEMA staff will follow up later this afternoon for an update.     "A reactive inspection by inspectors is planned for later this week."    Illinois Reference Number:  IL200024|
Power Reactor|55017|Harris|Carolina Power & Light Co.|2|Raleigh|NC|Wake & Chatham||Y|05000400|1|||[1] W-3-LP|Lonnie Hickerson|Donald Norwood|12/01/2020|17:00:00|12/01/2020|11:16:00|EST|12/1/2020 12:00:00 AM|Non Emergency|50.72(b)(3)(xiii)|Loss Comm/Asmt/Response|||||||MARK MILLER|R2DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|N|0||0||N|N|0||0||LOSS OF TECHNICAL SUPPORT CENTER FUNCTIONALITY    "On December 1, 2020 at 1116 EST, a condition impacting functionality of the Technical Support Center (TSC) Ventilation System was discovered during surveillance testing. The issue resulted in a loss of TSC functionality due to a high flow rate measured on outside air intake fans. The cause of the high flow rate is under investigation.    "This is an eight-hour, non-emergency notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the condition affects the functionality of an emergency response facility.    "If an emergency is declared requiring TSC activation during the non-functional period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions.  If relocation of the TSC becomes necessary, the Emergency Coordinator will relocate the TSC staff to an alternate location in accordance with site procedures. This condition does not affect the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."|
Agreement State|55018|WA OFFICE OF RADIATION PROTECTION|Hayre McElory & Associates|4|Redmond|WA||WN-I0566-1|Y||||||Steve Matthews|Solomon Sahle|12/02/2020|17:48:00|11/30/2020|0:00:00|PST|12/2/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||HEATHER GEPFORD|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - PORTABLE DENSITY GUAGE RUN OVER    The following was received from the State of Washington via email:    "On Monday, November 30, 2020, at a construction site at 2800 MLK Jr South, Seattle, WA, a density gauge was run over by a mini dozer. The source was extended and in use at the time. When the device was run over, the handle that is used to extend and retract the source rod broke off from the gauge completely, leading to concern that the source rod had also broken off. Personnel on site were evacuated and the area secured.       "Because of the concern that the source rod had broken off, it was necessary to wait until a licensed entity that had the ability to handle the unshielded source arrived on site to continue recovery operations. Also, shortly after the incident,  Northwest Technical Services (NTS), was hired for remedial action.      "When NTS personnel arrived, they were able to determine that the source rod had not detached as feared. A leak test to check the integrity of the source revealed no leakage and the source rod was able to be retracted back into the shielded gauge. Radiation readings and additional leak tests in the area were conducted to ensure there were no remaining safety concerns. There were none.    "The damaged source was taken to Northwest Technical Services in Snohomish, WA and has been secured while awaiting disposal."    Washington Incident Number: WA-20-026.|
Agreement State|55019|LOUISIANA RADIATION PROTECTION DIV|Acuren Inspection, Inc.|4|Laporte|TX||LA-7072-L01, Amd 119|Y||||||James Pate|Donald Norwood|12/03/2020|15:19:00|12/02/2020|16:40:00|CST|12/3/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||HEATHER GEPFORD|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT -  RADIOGRAPHY SOURCE STUCK WITHIN SOURCE GUIDE TUBE    The following information was received via E-mail:    "Acuren Inspection, Inc. contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on December 3, 2020, concerning an industrial radiography source that had been stuck within the source guide tube. The crew was using a QSA Global model - 880D, serial number - 14783, with an Ir-192 source, with source serial number - 11512M, with an activity of 41 Ci (1,517 GBq).    "On December 2, 2020, around 1640 CST, the source became stuck outside the camera in the source guide tube while performing radiography operations [when an equipment stand fell on the source guide tube leading it to become crimped]. There were no excessive radiation exposures. The industrial radiography crew's pocket dosimeters did not go off scale.     "A source retrieval team was sent out and had the source returned back into the camera by 2000 CST on December 2, 2020.    "The event occurred at Enbride Venice Facility in Venice, LA."    Louisiana Event Report ID No.:  LA20200010|
Power Reactor|55020|Calvert Cliffs|Constellation Nuclear|1|Lusby|MD|Calvert||Y|05000317|1|||[1] CE,[2] CE|Britain Foster|Donald Norwood|12/03/2020|17:10:00|12/03/2020|9:23:00|EST|12/3/2020 12:00:00 AM|Non Emergency|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||||CHRISTOPHER CAHILL|R1DO|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|N|0||0||N|N|0||0||VALID ACTUATION OF AN EMERGENCY DIESEL GENERATOR    "At 0923 EST on December 3, 2020, with Unit 1 in Mode 1 at 100 percent power, an actuation of the Emergency AC Electrical Power System (Emergency Diesel Generator 1A) occurred during normal plant operations. The reason for Emergency Diesel Generator 1A auto start was due to Class 1E 4KV Bus 11 feeder breaker opening.     "The Emergency Diesel Generator 1A automatically started as designed when the loss of voltage signal on 4KV Bus 11 was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Emergency AC Electrical Power System.    "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."    The cause of the 4KV Bus 11 Feeder Breaker opening is unknown at the present time and is under investigation.|
Agreement State|55021|VIRGINIA RAD MATERIALS PROGRAM|Inova Fairfax Medical Campus|1|Falls Church|VA||610-116-1|Y||||||Asfaw Fenta|Jeffrey Whited|12/04/2020|8:20:00|12/03/2020|0:00:00|EST|12/8/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||CHRISTOPHER CAHILL|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||EN Revision Imported Date: 12/8/2020<br><br>EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE     The following was received from the Virginia Radioactive Materials Program via email:    "On December 3, 2020, at 1540 EST, the Virginia Radioactive Materials Program (VRMP) received a report from the licensee via telephone that a medical event occurred on December 3, 2020, as a result of a therapy procedure using SIR-Spheres Yttrium-90 resin microspheres. The prescribed dosage to the tumor was 27.9 milliCuries. The actual delivered dosage to the tumor was 20.03 milliCuries, which resulted a difference of 28.3 percent (under-dosage). The preliminary report indicated that this difference was determined based on the measurement of the remaining residual activity in the delivery system.     "Referring physician was notified and an Authorized User was requested to contact the patient concerning the event. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."    Event Report ID No.: VA20006    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.    * * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *    The following retraction was received from the Commonwealth of Virginia via email:    "On 12/7/2020, VRMP received a report from the licensee re-investigation the event by two independent teams on 12/4/2020 for verification. Both teams found an error on the first measurement of the remaining residual radioactivity in the delivery system. Based on the teams' new measurements, the dosage left over after the procedure was now calculated to be 1.4 milliCuries of Yttrium-90 versus the original value of 8 milliCuries. Those measurements were corrected for the radioactive decay to the time of the procedure. The new value is within the allowed dose deviation of a normal procedure (new estimate 5 percent deviation of prescription). Thus, VRMP requests the NRC Operation Center retract this event report."    Notified R1DO (Bower) and NMSS Event Notification via email.|
Agreement State|55022|LOUISIANA RADIATION PROTECTION DIV|Alpha-Omega Services, Inc.|4|Vinton|LA||LA-10025-L01, Amendment 33, AI# 30898|Y||||||James Pate|Solomon Sahle|12/04/2020|15:44:00|12/04/2020|0:00:00|CST|12/4/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||HEATHER GEPFORD|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB|EMAIL|||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT -  LOST HIGH DOSE RATE SOURCE WHILE IN TRANSIT    The following was received from the state of Louisiana via email:    "On December 04, 2020, Alpha-Omega Services RSO contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was lost in transit with the commercial carrier.     "The source was being shipped to Stanford University Medical Center, 820 Quarry Road, Palo Alto, CA 94304.      "The source serial number is 02-01-2922-001-111120-11438-41.      "The activity of the Ir-192 source was 11.44 Ci (423.22 GBq) on November 13, 2020 when it was shipped. The source was last tracked in the commercial carrier Memphis, TN Hub on November 14, 2020 at 06:07 am CST."    Louisiana Incident Number: LA20200011    THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL    Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours.  It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging.  For additional information go to  http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf    Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)|
Agreement State|55023|ARIZONA DEPT OF HEALTH SERVICES|Northwest Medical Center, L.L.C.|4|Tucson|AZ||10-097|Y||||||Brian Goretzki|Solomon Sahle|12/04/2020|16:21:00|12/01/2020|0:00:00|MST|12/4/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||HEATHER GEPFORD|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB|EMAIL|- CNSNS (MEXICO)|EMAIL|||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - LOST IODINE-125 SEEDS    The following was received from the state of Arizona Department of Health Services (the Department) via email:     "The Department received notification from the licensee that seven approximately 0.4 milliCurie Iodine-125 seeds used for breast localization were discovered missing [during inventory on 12/1/2020].  The Department has requested additional information and continues to investigate the event."     Arizona Incident Number: 20-024.    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|55025|TEXAS DEPT OF STATE HEALTH SERVICES|VALERO REFINING TEXAS LP|4|Texas City|TX||L-02578|Y||||||Art Tucker|Solomon Sahle|12/09/2020|9:21:00|12/08/2020|0:00:00|CST|12/9/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||RAY KELLAR|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - SHUTTER MALFUNCTION    The following information was received from the Texas Department of State Health Services (the Agency) via email:    "On December 8, 2020, the Agency received an e-mail from the licensee stating that during routine testing the shutters on two nuclear gauges were found stuck in the open position. The gauges are Vega model SH-F1 both containing 20 milliCuries (original activity) cesium-137 sources. The licensee reported there is no risk of radiation exposure to members of the general public or workers at the facility due to the failures. The licensee stated they were working on a plan to repair the gauges and would provide that information once the plan is completed. Additional information will be provided as it is received in accordance with SA-300."    Texas Incident No: I-9815|
Power Reactor|55026|Millstone|Dominion Generation|1|Waterford|CT|New London||N||||3|[1] GE-3,[2] CE,[3] W-4-LP|Dan Beachy|Solomon Sahle|12/10/2020|10:58:00|11/06/2020|19:08:00|EST|12/10/2020 12:00:00 AM|Non Emergency|50.73(a)(1)|Invalid Specif System Actuation|||||||FRED BOWER|R1DO|||||||||||||||||||N|N|0||0||N|N|0||0||N|N|0|Hot Standby|0||60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION    "This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid actuation of the 'B' train High Head Safety Injection Pump (3SIH*P1B), the 'B' train Low Pressure Safety Injection Pump (3RHS*P1B) and four Steam Generator Blowdown Containment isolation valves at Millstone Nuclear Power Station Unit 3.     "At 1908 EST on November 6, 2020, with Unit 3 in Mode 3, a partial invalid actuation of 'B' train Emergency Core Cooling System (ECCS) components occurred. The 'B' train SIH pump and the 'B' train RHS pump had started, and ran successfully on recirculation. Four Steam Generator Blowdown Containment isolation valves also closed. Due to this condition the 'B' Emergency Diesel Generator and the 'B' Emergency Generator Load Sequencer (EGLS) were declared inoperable and the required Technical Specification action statements were entered. Troubleshooting determined that this actuation was caused by a failure of one of the circuit boards in the 'B' train EGLS that caused a partial 'B' train 'SIS only' signal. Other 'B' Train components received the 'SIS only' signal but did not start because they were already running or were a backup to an already running component. Troubleshooting discovered a failed NAND gate on the 'B' Train EGLS XA93 circuit card. The card was replaced, retested, and the Technical Specification action statements were exited.      "The pumps and valves responded in accordance with plant design. No other equipment was affected during this event.      "There were no safety consequences or impacts on the health and safety of the public. The event was entered into the station's corrective action program.      "The actuation was not due to actual plant conditions or parameters meeting design criteria for an ECCS actuation. Therefore, this is considered an invalid actuation.    "The NRC Resident Inspector was notified."|
Part 21|55027|ENGINE SYSTEMS, INC|Engine Systems Inc.|1|Rocky Mount|NC|||Y||||||Dan Roberts|Kerby Scales|12/10/2020|15:42:00|10/20/2020|0:00:00|EST|12/10/2020 12:00:00 AM|Non Emergency|21.21(d)(3)(i)|Defects And Noncompliance|||||||RAY KELLAR|R4DO|- PART 21/50.55 REACTORS|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||PART 21 REPORT - CAMSHAFT KEY WITH INCORRECT STAMPING    The following is a summary of the report provided by the supplier:    ESI supplied stepped camshaft keys with an incorrect stamping.  The keys are stamped "AFT" on one end to identify orientation during installation.  Keys supplied by ESI have ''AFT" stamped on the opposite end of where they should be stamped.  If installed incorrectly and the condition goes undetected during post-maintenance inspection activities, engine performance could suffer resulting in inability of the emergency diesel generator set to perform its safety-related function.  This issue is therefore considered to be a reportable defect as defined by 10CFR-part 21.      The key is used in early Cooper-Bessemer model KSV diesel engines to locate the fuel pump cam on the engine's camshaft.  This design has a stepped arrangement to provide 4-1/2 degree timing retard.  The key is stamped "AFT" to designate the end facing the generator end of the engine.  An additional "CAM" tamping designates the cam (up) surface.  In the event the key is stamped incorrectly, it is feasible the key could be installed backward which would advance the timing by 9 degree from the desired position.      Date which the information of the defect or failure was obtained is October 20, 2020.    The extent of condition is limited to the part number supplied on the following two orders:    Part Number (KSV-16-6E#1)  Customer (Nebraska Public Power District (NPPD) - Cooper Nuclear Station)  Purchase Orders:  1. NPPD Purchase Order Number (4500106009), ESI Sales Order Number (3006001), Quantity - 5  2. NPPD Purchase Order Number (4500106222), ESI Sales Order Number (3006017), Quantity - 5    Corrective Actions    For affected users:   Camshaft keys installed on engines:  No action is required provided post-maintenance injection timing was verified and subsequent engine performance was successful.  An incorrectly installed key would be evident by a shift in fuel injection timing.  If injection timing and/or engine performance has not been verified, then additional inspections should be performed to verify installed keys from the above referenced orders are oriented properly.    Camshaft keys in inventory (not-installed) on engines:  Cooper Nuclear may elect to correct the mislabeled condition or return to ESI for rework.  To correct the condition, surface grind to remove the existing "AFT" stamping.  Stamp opposite end with "AFT" designation.     For affected ESI:  The dedication report will be revised to add clarification of the correct end for the "AFT" stamping.  This will be completed by December 18, 2020.    Points of Contact: John Kriesel, Engineering Manager and Dan Roberts, Quality Manager at Engine Systems Inc. 175 Freight Rd. Rocky Mount, NC 27804. Office number: 252-977-2720|
Power Reactor|55028|Arkansas Nuclear|Entergy Nuclear|4|Russellville|AR|Pope||N|||2||[1] B&W-L-LP,[2] CE|Danny Watts|Kerby Scales|12/10/2020|20:43:00|12/10/2020|16:08:00|CST|12/11/2020 12:00:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||RAY KELLAR|R4DO|||||||||||||||||||N|N|0||0||A/R|Y|100|Power Operation|0|Hot Standby|N|N|0||0||EN Revision Imported Date: 12/14/2020<br><br>EN Revision Text: AUTOMATIC REACTOR SCRAM DUE TO LOW STEAM GENERATOR WATER LEVEL    "On December 10, 2020 at 1608 CST, Arkansas Nuclear One, Unit 2 (ANO-2) experienced an automatic reactor scram from 100 percent power due to Low Steam Generator Water Level in 2E-24A Steam Generator.  Emergency Feedwater actuated automatically due to low water level in the A Steam Generator.  Due to inadequate control of the B Main Feedwater Control System, water level in the B Steam generator rose to a level requiring manual trip of the B Main Feedwater pump.  Emergency Feedwater responded as designed to feed both steam generators automatically.    "All other systems responded as designed.  All electrical power is being supplied from offsite power and maintaining unit electrical loads as designed.    "Unit 2 is currently stable in Mode 3 (Hot Standby) maintaining pressure and temperature via Emergency Feedwater and secondary system steaming.    "There are no indications of a radiological release on either unit as a result of this event.    "This report satisfies the reporting criteria of both 10 CFR 50.72(b)(2)(iv)(6) for the Reactor Protection System actuation and 10 CFR 50.72(b)(3)(iv)(A) for the actuation of the Emergency Feedwater System.    "The Arkansas Nuclear One NRC Senior Resident Inspector has been notified."      * * * UPDATE FROM JOHN LINDSEY TO DONALD NORWOOD AT 1605 EST ON 12/11/2020 * * *    "The purpose of this [report] is to provide an update to NRC Event Number 55028.    "The cause of the inadequate control of the B Main Feedwater Control System to control B Steam Generator Level was verified to be associated with the failure that led to the A Steam Generator low level condition.    "After taking action to trip the B Main Feedwater Pump, Emergency Feedwater was manually actuated for the B Steam Generator and the Emergency Feedwater System was verified to maintain proper automatic control of both Steam Generator levels.    "At the time of the initial event notification, plant temperature and pressure control had been transferred from Emergency Feedwater to Auxiliary Feedwater along with secondary system steaming."    The licensee notified the NRC Resident Inspector.    Notified R4DO (Kellar).|
Agreement State|55029|ARIZONA DEPT OF HEALTH SERVICES|Banner University Medical Center - Tucson|4|Tucson|AZ||10-044|Y||||||Brian D. Goretzki|Thomas Herrity|12/11/2020|0:57:00|12/11/2020|0:00:00|MST|12/11/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||RAY KELLAR|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT- UNDER DOSAGE     The following was received from the state of Arizona via email:     "The Department (Arizona Department of Health Services) received notification from the licensee about a medical event involving Y-90 Theraspheres.  A patient was prescribed a dose of 120 Gy but was delivered 47.6 Gy, a percent dose delivered of 32.5%.  The Department has requested additional information and continues to investigate the event.        "The Licensee is:  Arizona License Number- 10-044,  Banner University Medical Center - Tucson, 1625 N. Campbell Ave, Tucson, Arizona 85719    "Additional information will be provided as it is received in accordance with SA-300.    Arizona Incident: 20-025    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.|
Power Reactor|55030|Grand Gulf|Entergy Nuclear|4|Port Gibson|MS|Claiborne||Y|05000416|1|||[1] GE-6|Gabriel Hargrove|Kerby Scales|12/11/2020|15:15:00|12/11/2020|12:04:00|CST|12/11/2020 12:00:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|||||||RAY KELLAR|R4DO|||||||||||||||||||A/R|Y|100|Power Operation|0|Hot Shutdown|N|N|0||0||N|N|0||0||AUTOMATIC REACTOR SCRAM DUE TO MAIN TURBINE / GENERATOR TRIP    "On December 11, 2020 at 1204 CST, Grand Gulf Nuclear Station (GGNS) experienced an Automatic Reactor Scram from 100 percent Reactor Power after a Main Turbine and Generator Trip.    "All Control Rods fully inserted and there were no complications.  All systems responded as designed.     "Reactor pressure is being maintained with Main Turbine Bypass Valves.  Reactor water level is being maintained in normal band with the condensate system.    "No radiological releases have occurred due to this event from the unit.    "The NRC Branch Chief has been notified."|
Non-Agreement State|55031|MGV-GES-Lab Inc.|MGV-GES-Lab Inc.|1|Dorado|PR||52-25470-01|N||||||David Rhoe|Kerby Scales|12/11/2020|15:57:00|12/11/2020|0:00:00|EST|12/11/2020 12:00:00 AM|Non Emergency|30.50(b)(2)|Safety Equipment Failure|||||||FRED BOWER|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||DAMAGE NUCLEAR MOISTURE DENSITY GAUGE - RUNOVER    The following is a synopsis of a report received via telephone:    On December 11, 2020, the licensee reported that a CPN moisture density gauge (model MC-1DR-P) had been run-over and damaged.  The gauge contained two sources (Americium-241 and Cesium-137).  The activity of the Americium-241 is 1.85 GBq.  The activity of Cesium-137 is 370 MBq.  The shielding around sources is intact.  Both sources are outside the gauge, but placed in lead containers.  The manufacturer has been notified and the sources will be leak tested before returning to the manufacturer.|
Power Reactor|55032|Palo Verde|Arizona Nuclear Power Project|4|Wintersburg|AZ|Maricopa||Y|05000528|1|||[1] CE,[2] CE,[3] CE|George Lester|Kerby Scales|12/11/2020|17:38:00|12/11/2020|0:00:00|MST|12/11/2020 12:00:00 AM|Non Emergency|50.73(a)(1)|Invalid Specif System Actuation|||||||RAY KELLAR|R4DO|||||||||||||||||||N|N|0|Cold Shutdown|0|Cold Shutdown|N|N|0||0||N|N|0||0||60-DAY OPTION TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION    "On October 13, 2020, at approximately 02:25 [MST], an automatic start of the Unit 1 'A' Train EDG and SP systems occurred following the restoration of power to the 'A' Train 4160 Volt Class Bus.  The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the EDG and the Engineered Safety Features Actuation Systems to simulated design basis events.  During the test, technicians installed a jumper across incorrect relay points that caused the running Unit 1 'A' Train EDG to trip, resulting in a loss of power to the 'A' Train 4160 Volt Class Bus.    "Following restoration of normal offsite power to the 'A' Train 4160 Volt Class Bus, the Loss of Power Actuation signal was reset, however, EDG start relay logic was not reset at the EDG Local Panel.  This resulted in the Unit 1 'A' Train EDG and SP system actuations with the EDG running unloaded.  The system actuations did not occur as a result of valid plant conditions or parameters and are therefore invalid.    "The Unit 1 'A' Train EDG and SP system actuations were complete and the systems started and functioned successfully.    "The event was attributed to a human performance error and entered into the corrective action program.  There was no adverse impact to public health and safety nor to plant employees.    "The NRC Resident Inspectors have been informed."|
Agreement State|55033|TEXAS DEPT OF STATE HEALTH SERVICES|The Methodist Hospital|4|Houston|TX||L00457|Y||||||Art Tucker|Kerby Scales|12/12/2020|17:06:00|12/11/2020|0:00:00|CST|12/12/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||RAY KELLAR|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - UNRETRACTABLE SOURCE    The following report was received from the Texas Department of State Health Services (the Agency) via email:    "On December 12, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that on December 11, 2020, they were unable to retract a source string composed of 16 strontium - 90 sources with a total activity of 36 milliCuries to the fully shielded position.  The RSO stated they had completed the treatment of a patient using a Best Vascular model A1000 brachytherapy device and Novoste Beta-Cath Delivery System and when they attempted to retract the source to the shielded position, the source stuck just outside the device.  The source did retract outside the patient.  The source and associated equipment were placed in a shield box and have been placed in storage.  The RSO stated neither the patient or individuals operating the device received any additional exposure from the event. The RSO stated the patient received the prescribed dose from the treatment.  Additional information will be provided as it is received in accordance with SA-300."    Texas Incident Number:  9816|
Non-Power Reactor|55034|National Inst Of Standards & Tech|U. S. Dept. Of Commerce|0|Gaithersburg|MD|Montgomery|TR-5|Y|05000184||||20000 Kw Test|Tom Newton|Brian Lin|12/14/2020|14:35:00|12/14/2020|3:36:00|EST|12/14/2020 12:00:00 AM|Unusual Event| |Other Unspec Reqmnt|||||||RUSS FELTS|NRR|GREG CASTO|NRR EO|BETH REED|NRR|WILLIAM GOTT|IRD|PAULETTE TORRES|NRR|||||||||||N|N|0||0||N|N|0||0||N|N|0||0||DISCOVERY OF AFTER-THE-FACT UNUSUAL EVENT - INADVERTENT RELEASE OF ARGON-41 GAS    At 0336 EST, operators declared an Unusual Event due to elevated radioactivity levels observed at the facility's ventilation stack. The elevated levels were due to a release of Argon-41 gas caused by a failure of the facility's fan system. This failure caused the Argon gas to be released to the ventilation stack into the atmosphere. The reactor was operating at 19.5 MW at the time of the incident and was shutdown when the ventilation stack set point was reached. Facility personnel secured the offsite gas release and verified no fission product release occurred. The Unusual Event was terminated at 0422 EST.|
Power Reactor|55035|Surry|Dominion Generation|2|Surry|VA|Surry||N|||2||[1] W-3-LP,[2] W-3-LP|Kenneth Wagar|Donald Norwood|12/14/2020|15:00:00|12/12/2020|22:14:00|EST|12/14/2020 12:00:00 AM|Non Emergency|50.72(b)(2)(xi)|Offsite Notification|||||||MARK MILLER|R2DO|||||||||||||||||||N|N|0||0||N|Y|100|Power Operation|100|Power Operation|N|N|0||0||OFFSITE NOTIFICATION DUE TO TRITIUM LEAKAGE TO THE GROUND    "At 2214 EST on 12/12/20, Surry Power Station personnel identified leakage from the Unit 2 Refueling Water Storage Tank (RWST) Cooling System to the ground. Leakage was estimated to be greater than 100 gallons and tritium concentration determined to be 4.5E07 picocuries per liter (pCi/L), requiring report in accordance with the industry voluntary groundwater protection program.    "As such, at 1450 EST on 12/14/2020, the Surry County Administrator, NRC Resident, Virginia Department of Health, Virginia Department of Emergency Management, and Virginia Department of Environmental Quality were notified of this release to the environment.    "Due to the offsite agency notifications, this 4-hour, non-emergency report is being made in accordance with 10 CFR 50.72(b)(2)(xi).     "There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."|
Power Reactor|55036|Turkey Point|Florida Power And Light|2|Miami|FL|Dade||Y|||4||[3] W-3-LP,[4] W-3-LP|Branden Nathe|Brian Lin|12/14/2020|20:21:00|12/14/2020|12:40:00|EST|12/14/2020 12:00:00 AM|Non Emergency|50.72(b)(3)(v)(A)|Pot Unable To Safe Sd|||||||MARK MILLER|R2DO|||||||||||||||||||N|N|0||0||N|Y|100|Power Operation|100|Power Operation|N|N|0||0||CHARGING PUMP AND BORATION FLOWPATHS SIMULTANEOUSLY INOPERABLE    "At 1240 EST on 12/14/20, it was determined that all Unit 4 Charging Pumps and Boration Flowpaths were simultaneously inoperable.     "This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v).    "The NRC Resident Inspector has been notified."|
Power Reactor|55037|Palo Verde|Arizona Nuclear Power Project|4|Wintersburg|AZ|Maricopa||Y|05000528|1|2|3|[1] CE,[2] CE,[3] CE|Lorraine Weaver|Howie Crouch|12/16/2020|12:09:00|12/15/2020|15:00:00|MST|12/16/2020 12:00:00 AM|Non Emergency|26.719|Fitness For Duty|||||||YOUNG, CALE|R4|FFD GROUP, |EMAIL|||||||||||||||||N|N|100|Power Operation|100|Power Operation|N|N|100|Power Operation|100|Power Operation|N|N|100|Power Operation|100|Power Operation|FITNESS FOR DUTY    A plant employee, after being selected for a random fitness-for-duty test, admitted to use of a controlled substance. The employee's unescorted access to the facility has been placed on hold pending an investigation.    The NRC Resident Inspector has been notified.|
Power Reactor|55038|Harris|Carolina Power & Light Co.|2|Raleigh|NC|Wake & Chatham||Y|05000400|1|||[1] W-3-LP|Chris Hayes|Howie Crouch|12/16/2020|12:19:00|12/16/2020|8:51:00|EST|12/16/2020 12:00:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|||||||MILLER, MARK|R2|||||||||||||||||||A/R|Y|80|Power Operation|0|Hot Standby|N|N|||||N|N|||||AUTOMATIC REACTOR TRIP DUE TO GENERATOR LOCKOUT    "On December 16, 2020 at 0851 EST, with Harris Nuclear Plant Unit 1 in Mode 1 at 80 percent power, an automatic reactor trip occurred due to lockout of the main generator. The trip was not complex, with all systems responding normally post-trip. The initial assessment of this event indicates that there was a ground fault on the 'B' train of the non-safety electrical distribution system that caused the main generator lockout. Steam generator levels are being maintained by normal feedwater through the feedwater regulator bypass valves. Decay heat is being removed by using the condenser steam dump flow path.      "Due to the unplanned 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).     "This condition does not affect the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."    All rods inserted into the core during the trip. The electrical grid is stable and all safe shutdown equipment is available for service. No reliefs lifted during the transient.|
Agreement State|55039|SC DEPT OF HEALTH & ENV CONTROL|Self Regional Health Care|1|Greenwood|SC||073|Y||||||Adam Gause|Howie Crouch|12/17/2020|17:25:00|12/14/2020|0:00:00|EST|12/17/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||AMBROSINI, JOSEPHINE|R1|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 - SOURCE ROOM DOOR INTERLOCKS FAILED TO FUNCTION    The following information was received from the South Carolina Department of Health and Environmental Control via email:    "The South Carolina Department of Health and Environmental Control was notified on 12/16/20 that a piece of equipment was disabled or failed to function as designed when the equipment is required by regulation or license condition to prevent exposures to radiation and radioactive materials exceeding regulatory limits, or to mitigate the consequences of an accident. The licensee reported that the electrical interlocks at the remote afterloader room entrance failed to function from 12/14/20 until 12/17/20. The source in the remote afterloader unit is a Varian Medical Systems, Inc. Model GammaMed 232, Ir-192 source, with a reported activity of 8.5 Curies. The remote afterloader unit is a Varian Medical Systems, Inc. Model GammaMedplus iX. As of 12/17/20, the licensee is reporting that the electrical interlocks at the remote afterloader room entrance is now operable and functioning as designed. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control."    No overexposures were reported as a result of the failed interlocks.|
Power Reactor|55040|Harris|Carolina Power & Light Co.|2|Raleigh|NC|Wake & Chatham||Y|05000400|1|||[1] W-3-LP|Paul Houseworth|Howie Crouch|12/17/2020|22:03:00|12/17/2020|15:39:00|EST|12/17/2020 12:00:00 AM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||MILLER, MARK|R2|||||||||||||||||||N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|N|N|0|Power Operation|0|Power Operation|ACCUMULATOR DISCHARGE VALVES ISOLATED WITH PLANT GREATER THAN 1000 PSIG    "On December 17, 2020 at 1539 EST, with Harris Nuclear Plant Unit 1 preparing for entry into Mode 4, the Reactor Coolant System was pressurized greater than 1000 psig for approximately 15 minutes with all three Cold Leg Injection Accumulator Discharge Valves closed. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). Both Low Head and High Head Safety Injection Systems were operable at this time.      "This condition does not affect the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."|
Agreement State|55041|CALIFORNIA RADIATION CONTROL PRGM|Sequoia Consultants, Inc.|4|Orange|CA||7597-30|Y||||||Robert Greger|Howie Crouch|12/18/2020|20:39:00|12/18/2020|8:30:00|PST|12/18/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||YOUNG, CALE|R4|NMSS_EVENTS_NOTIFICATION, |EMAIL|ILTAB, |EMAIL|CNSNS (MEXICO)|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 - STOLEN MOISTURE DENSITY GAUGE    The following information was obtained from California Department of Public Health Radiologic Health Branch Brea (RHB Brea) via email:    "On December 18, 2020, at approximately 1100 PST, [the] RSO [(Radiation Safety Officer)] of Sequoia Consultants, Inc., Radioactive Materials License #7597-30, contacted RHB Brea to report the theft of a moisture/density gauge: CPN, MC-3 Elite, serial #30582 (Cs-137  0.370 GBq, Am-241, 1.85 GBq). The gauge had been in a mobile storage unit at a temporary job site at approximate mile marker 20.07, Northbound State Route 99 (Golden State Highway) in Atwater, CA 95301.  The storage unit  had been broken into and the radioactive gauge was missing.  The Authorized User who discovered the missing radioactive gauge at approximately 0830 on December 18, 2020 notified the RSO and then notified the Atwater Police Department, who directed him to contact the California Highway Patrol.  A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report.  The RSO will contact local newspapers in an attempt to retrieve the stolen radioactive gauge, as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service.  The investigation will continue to determine if the radioactive gauge can be recovered."    California 5010 number: 121820    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|55042|NC DIV OF RADIATION PROTECTION|Froehling and Robertson, Inc.|1|Charlotte|NC||060-0353-4|Y||||||David Crowley|Andrew Waugh|12/21/2020|16:27:00|12/19/2020|11:41:00|EST|12/21/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||ELISE BURKET|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||DAMAGED NUCLEAR GAUGE    The following is a summary of information that was received via email:    At 1141 EST, on 12/19/20, an authorized user (AU) for the licensee determined that one of their portable nuclear gauges was damaged. The AU felt the index rod loosen and then break off when he went to retrieve the gauge from its transport case. The gauge had been used the day before at a jobsite and did not experience any accidents. The gauge had not been dropped and was in the possession of the AU at all times during this event. The source remained in the shielded position within the gauge throughout this event.     The AU contacted the radiation safety officer (RSO) and the gauge was transported to an authorized storage location. The RSO took measurements of the outer transport box surface (1 mR/hr) and the gauge surface (5 mR/hr). The gauge was placed into an authorized storage shed and readings at the surface of the shed were non-distinguishable from background.     The gauge was a Troxler 3440 (s/n: 16938) with an 8 mCi Cs-137 source and a 40 mCi Am-241/Be source.       NC event number: NC200023|
Agreement State|55043|PA BUREAU OF RADIATION PROTECTION|RSL (USA) Inc.|1|Wilkes-Barre|PA||PA-0892|Y||||||John Chippo|Andrew Waugh|12/23/2020|11:30:00|12/10/2020|11:50:00|EST|12/23/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||ELISE BURKET|R1DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - LOST AND RECOVERED RADIOACTIVE MATERIAL    The following information was received via email:    "On December 10, 2020, the licensee discovered a lost iodine-131 shipment. The shipper of the 475 mCi of iodine-131 Liquid (Yellow II label) delivered the package to the wrong address, a neighboring business. The package was delivered to the licensee by the recipient before the package was known to be 'lost', later on the scheduled delivery date. The surface reading of 12 mR/hr was obtained upon the licensee receiving the package. The package was estimated to be in the possession of the recipient for approximately 1 hour. The estimated dose was approximately 12 mrem if an individual had been in contact with the package for the entire time it was in the possession of the recipient. Since the material was delivered by the recipient within the time frame the shipper would normally deliver, and the facility had no reason to suspect the material was incorrectly delivered, the licensee will inform the shipper of the incident to handle training of their staff on proper delivery of radioactive packages."    PA Event Report ID No.: PA200024    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|55044|WISCONSIN RADIATION PROTECTION|Amcor|3|Madison|WI||GL 709058|Y||||||Megan Shober|Andrew Waugh|12/23/2020|11:49:00|12/22/2020|0:00:00|CST|12/23/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||JAMNES CAMERON|R3DO|NMSS_EVENTS_NOTIFICATION|EMAIL|ILTAB|EMAIL|- CNSC (CANADA)|EMAIL|||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS    The following information was received via email:    "The Department [Wisconsin Radiation Protection Section] was notified on December 22, 2020, of the loss of four Safety Light Corporation Model SLX-60 tritium exit signs. The signs each contained 7.5 Ci of tritium in December 2006. The licensee searched for the missing signs and was unable to locate them on the premises. The licensee believes that the signs were inadvertently disposed during construction in 2019. The Department will follow up with the licensee."    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|
Non-Agreement State|55045|Avera McKennan Nuclear Medicine|Avera McKennan Nuclear Medicine|4|Sioux Falls|SD||40-16571-02|N||||||Michelle White|Andrew Waugh|12/23/2020|12:12:00|12/15/2020|13:00:00|MST|12/23/2020 12:00:00 AM|Non Emergency|35.3045(a)(1)|Dose <> Prescribed Dosage|||||||JEREMY GROOM|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||PATIENT RECEIVED THE WRONG RADIONUCLIDE DURING TREATMENT    A patient was set to receive an I-123 scan and uptake procedure on 12/15/20. Due to an error in scheduling the patient incorrectly underwent an I-131 therapy procedure instead. The I-131 therapy procedure delivered 15.8 mCi to the patient's thyroid where an I-123 scan and uptake procedure would have only delivered microCuries to the patient's thyroid.     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.|
Power Reactor|55046|LaSalle|Exelon Nuclear Co.|3|Marseilles|IL|La Salle||Y|||2||[1] GE-5,[2] GE-5|Matt Tutich|Andrew Waugh|12/23/2020|12:28:00|12/23/2020|6:53:00|CST|12/23/2020 12:00:00 AM|Non Emergency|50.72(b)(3)(v)(D)|Accident Mitigation|||||||JAMNES CAMERON|R3DO|||||||||||||||||||N|N|0||0||N|Y|100|Power Operation|100|Power Operation|N|N|0||0||HIGH PRESSURE CORE SPRAY INOPERABLE    "At 0653 CST on 12/23/20, it was discovered the single train of high pressure core spray was 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, non-emergency notification per 10 CFR 50.72(b)(3)(v). 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 high pressure core spray is inoperable because the water lake pump tripped. This inoperability puts the licensee in a 14-day limiting condition for operability.|
Agreement State|55047|CALIFORNIA RADIATION CONTROL PRGM|ABI Engineering, Inc.|4|Santa Ana|CA||7945-30|Y||||||L. Robert Greger|Andrew Waugh|12/23/2020|20:46:00|12/23/2020|0:00:00|PST|12/23/2020 12:00:00 AM|Non Emergency| |Agreement State|||||||JEREMY GROOM|R4DO|NMSS_EVENTS_NOTIFICATION|EMAIL|||||||||||||||||N|N|0||0||N|N|0||0||N|N|0||0||AGREEMENT STATE REPORT -  LOST THEN FOUND MOISTURE / DENSITY GAUGE    The following information was received via email:    "On December 23, 2020, the Radiation Safety Officer (RSO) for ABI Engineering, Inc. contacted the California Department of Public Health - Radiologic Health Branch to report a moisture density gauge that was lost while transporting the gauge from the worksite in Orange, CA to the office. The gauge was locked in the transport case and placed in the vehicle, a pickup truck with a camper shell. During the short trip back to the office, the driver of another vehicle alerted the licensee's operator that the rear door of the camper shell was open. The licensee's operator then discovered that the gauge was missing, with one end of the chain used to secure the transport case loose. The licensee's operator backtracked to the jobsite in an attempt to find the gauge but did not locate it. The driver then notified the RSO and went to file a police report. Approximately 20-30 minutes after the RSO reported the incident to the Radiologic Health Branch, the RSO received a call from an individual who found the gauge. The gauge will be returned to the licensee. The gauge is a CPN International MC-3 (10 mCi Cs-137, 50 mCi Am-241:Be), S/N M39048766. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."    California 5010 Number: 122320    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|55049|Callaway|Ameren Ue|4|Fulton|MO|Callaway||N|05000483|1|||[1] W-4-LP|John Lauf|Andrew Waugh|12/24/2020|16:14:00|12/24/2020|12:35:00|CST|12/24/2020 12:00:00 AM|Non Emergency|50.72(b)(2)(iv)(B)|RPS Actuation - Critical|50.72(b)(3)(iv)(A)|Valid Specif Sys Actuation|||||JEREMY GROOM|R4DO|||||||||||||||||||A/R|Y|90|Power Operation|0|Hot Standby|N|N|0||0||N|N|0||0||AUTOMATIC TURBINE AND REACTOR TRIP    "At 1235 CST on December 24, 2020, Callaway Plant was in Mode 1 at approximately 90 percent power when a turbine trip/reactor trip, from a vital main generator trip signal, occurred. All safety systems responded as expected with exception of an indication issue with the 'B' Feedwater Isolation Valve, which was confirmed closed, and one intermediate range nuclear instrumentation channel which failed off-scale low following the trip. A valid Feedwater Isolation Signal and Auxiliary Feedwater Actuation Signal were also received as a result of the plant trip. The plant is being maintained stable in Mode 3.     "All control rods fully inserted from the reactor trip signal, and decay heat is being removed via the Auxiliary Feedwater and Steam Dump Systems.    "The NRC Senior Resident Inspector was notified."|
Power Reactor|55053|South Texas|Stp Nuclear Operating Company|4|Wadsworth|TX|Matagorda||Y|05000498|1|2||[1] W-4-LP,[2] W-4-LP|David Wurtz|Howie Crouch|12/30/2020|20:30:00|12/30/2020|15:50:00|CST|12/30/2020 12:00:00 AM|Non Emergency|50.72(b)(2)(xi)|Offsite Notification|||||||WERNER, GREG|R4|||||||||||||||||||N|Y|100|Power Operation|100|Power Operation|N|Y|100|Power Operation|100|Power Operation|N|N|0||0||OFFSITE NOTIFICATION DUE TO INADVERTENT EMERGENCY SIREN ACTIVATION    "On December 30, 2020 at 1550 CST, South Texas Project (STP) received a report that two Emergency Notification System sirens inadvertently actuated. The sirens were heard by residents in the area who contacted the Matagorda County Sheriff's office, which notified the Emergency Response Division at STP of the siren actuation at 1557 CST.     "Both sirens were initially restored, however siren #24 subsequently actuated again at 1735 CST. Siren #24 has been disconnected. Siren #27 remains available. Thirty-one  of  thirty-two sirens are available.    "This notification is being made under 10CFR50.72(b)(2)(xi) as an event where other government agencies were notified. The sirens are no longer alarming. A social media release is planned.    "The NRC Resident Inspector has been notified of the event."    The licensee believes the sirens actuated due to significant rain in the area but will be investigating the cause of the inadvertent actuation.|