Event Notification Report for October 03, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/02/2023 - 10/03/2023

EVENT NUMBERS
56757 56758 56769
Agreement State
Event Number: 56757
Rep Org: Georgia Radioactive Material Pgm
Licensee: International Paper Company
Region: 1
City: Savannah   State: GA
County:
License #: GA 143-1
Agreement: Y
Docket:
NRC Notified By: Anastasia Bennett
HQ OPS Officer: Adam Koziol
Notification Date: 09/25/2023
Notification Time: 09:04 [ET]
Event Date: 08/16/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the Georgia Radioactive Materials Program via email:

"During a routine shutter check, it was discovered that a shutter was not working on an in service source device. This device is an Ohmart/Vega containing sealed source of 400 mCi cesium-137, serial number 65574, Model SHF2-45 K2 Chip Bin. The radiation safety officer (RSO) reported that the shutter had failed in the open position. The source was then barricaded from the area with appropriate signage. On August 21, 2023, a qualified technician from VEGA visited the site and repaired this shutter. The technician removed the old rotor and installed a new rotor on the source holder."

Georgia incident number: 70


Hospital
Event Number: 56758
Rep Org: Stamford Hospital
Licensee: Stamford Hospital
Region: 1
City: Stamford   State: CT
County:
License #: 06-06697-02
Agreement: N
Docket:
NRC Notified By: Peter Mas
HQ OPS Officer: John Russell
Notification Date: 09/26/2023
Notification Time: 15:35 [ET]
Event Date: 09/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/26/2023
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
MEDICAL EVENT - DOSE TO UNINTENDED PART OF ORGAN

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

On September 21, 2023, a female patient received the first of three scheduled doses using a vaginal cylinder containing 5 curies of Iridium 192. The cylinder shifted inadvertently during the administration by about 3.5 centimeters outward causing the dose to the intended site to be different than the intended dose. The patient was informed.

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
Event Number: 56769
Facility: Diablo Canyon
Region: 4     State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Brian Engleton
HQ OPS Officer: Ernest West
Notification Date: 10/01/2023
Notification Time: 03:02 [ET]
Event Date: 09/30/2023
Event Time: 20:14 [PDT]
Last Update Date: 10/01/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Young, Cale (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 11 Power Operation 0 Hot Standby
Event Text
MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 2014 [PDT] on 09/30/2023, with [Diablo Canyon] Unit 1 in Mode 1 at 11 percent reactor power in preparation for a pre-planned manual reactor trip into a scheduled refueling outage, the reactor was manually tripped due to a failed secondary system dump valve. Auxiliary feedwater was manually started in accordance with plant procedures.

"This event is being reported in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"There was no plant or public safety impact.

"The NRC Senior Resident Inspector has been notified."


The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Diablo Canyon Unit 2 was unaffected.