Skip to main content

Event Notification Report for October 06, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/05/2023 - 10/06/2023

Part 21
Event Number: 56683
Rep Org: Curtiss Wright Flow Control Co.
Licensee: Curtiss Wright Flow Control Co.
Region: 3
City: Cincinnati   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tim Franchuk
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/17/2023
Notification Time: 13:17 [ET]
Event Date: 06/22/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2023

EN Revision Text: PART 21 INTERIM REPORT - FAILURE OF CURTISS WRIGHT SUPPLIED SAFETY RELATED RELAY

The following is a summary of the Part 21 report provided by Curtiss Wright:

On June 20, 2023, Duke Energy sent a letter to Curtiss Wright (CW) to formally notify them that a Tyco (Agastat) relay had failed. Duke Energy had identified certain contacts that were found sticking in the open position.

The relay was returned to CW for evaluation; however, CW could not duplicate the failure. As the relay is questionable for reliable service, CW is having the relay returned to Tyco for their evaluation. Once the evaluation is complete, the current report will be updated. CW anticipates an update to the notification with final results by October 15th.

Affected plant: Catawba

* * * UPDATE ON OCTOBER 5, 2023 AT 1146 EDT FROM JENNIFER HARRISON TO KAREN COTTON * * *

The following information was provided by Curtiss Wright via email:

"The relay was subsequently returned to TYCO for their evaluation. TYCO tested the relay with and without the LL auxiliary switch option and could not duplicate the failure. In all tested conditions, the relay performed within manufacturer specifications, and with no contact binding.

"As the noted failure could not be reproduced by Curtiss-Wright or TYCO, there is no evidence of part malfunction and thus no further evaluation or notification applies."

Notified RDO2 (Miller) and Part 21/50.55 Reactors


Part 21
Event Number: 56720
Rep Org: Paragon Energy Solutions, LLC
Licensee: Paragon Energy Solutions, LLC
Region: 1
City: York   State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Richard Knott
HQ OPS Officer: Ernest West
Notification Date: 09/06/2023
Notification Time: 17:50 [ET]
Event Date: 09/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Young, Matt (R1DO)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2023

EN Revision Text: PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS

The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.

On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.

Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077

Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna


* * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *

The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows:

Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence.

Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory.

Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation.

To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check.

These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities.

Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors


Non-Agreement State
Event Number: 56763
Rep Org: Marathon Pipe Line LLC
Licensee: Marathon Pipe Line LLC
Region: 3
City: Indianapolis   State: IN
County:
License #: GL-714799-28
Agreement: N
Docket:
NRC Notified By: Matthew Grimes
HQ OPS Officer: Sam Colvard
Notification Date: 09/28/2023
Notification Time: 13:35 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/28/2023
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
NON-AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was provided by the licensee via phone:

On September 27, 2023, at 1500 EDT, Marathon Pipe Line, LLC evaluated that a fixed density gauge device shutter (Ohmart/VEGA, SR-2, SN 3767GG, Cs-137 250 mCi) was stuck in the open position. The device is located in a locked location with controlled access. There was no personnel exposure. The vendor has been contacted for repairs.


Agreement State
Event Number: 56765
Rep Org: Kentucky Dept of Radiation Control
Licensee: University of Kentucky
Region: 1
City: Lexington   State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/29/2023
Notification Time: 10:55 [ET]
Event Date: 09/28/2023
Event Time: 09:30 [CDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - POSSIBLE MISADMINISTRATION

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 9/29/2023, by a representative from the University of Kentucky that two patients were scheduled for treatment with Lu-177, one with commercially available Lu-177 dotatate (Lutathera) and one under a research protocol also using Lu-177 dotatate but distributed under an investigational new drug label. Both vials contained the same drug and differed only in their label for distribution / intended use. The nuclear medicine technologist prepared and administered Lu-177 dotatate from the vial labeled for research to the standard of care patient instead of the correct (commercial) vial. The patient received the correct amount of drug (prescribed activity), the correct chemical form (identical Lu-177 dotatate) by the correct route of administration as intended for their treatment. However, since the drug was dispensed from the vial distributed under the investigational new drug application intended for the research study patient, KY RHB considers this to meet the reporting requirements in Part 35 for a medical event.

"The physician was informed, the patient was informed, and no harm is anticipated as a result of this incident. Additional notifications have also been made as required considering the involvement of investigational drug product and the Institutional Review Board.

"The incident remains under evaluation and investigation for corrective actions."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.


Agreement State
Event Number: 56766
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush University Medical Center
Region: 3
City: Chicago   State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Thomas Herrity
Notification Date: 09/29/2023
Notification Time: 14:55 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/29/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported.

"The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available."

Illinois Item Number: IL230027

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
Event Number: 56767
Rep Org: Virginia Rad Materials Program
Licensee: ECS Mid-Atlantic, LLC
Region: 1
City: Salem   State: VA
County:
License #: 770-314-5
Agreement: Y
Docket:
NRC Notified By: Sheila Nelson
HQ OPS Officer: Sam Colvard
Notification Date: 09/29/2023
Notification Time: 18:43 [ET]
Event Date: 09/29/2023
Event Time: 09:30 [EDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report summary was received by email from Virginia Radioactive Materials Program (VRMP):

"On September 29, 2023, at approximately 0930 EDT, a Troxler moisture density gauge (model number: 3430, serial number: 32732, 8 mCi Cs-137, 40 mCi Am-241:Be) was struck by a bulldozer while the rod was extended out into the soil for measurements. The area was secured. The gauge was left in place so that the source would remain shielded by the soil and the radiation safety officer (RSO) was notified. The impact cracked the plastic housing and significantly bent the source rod handle above the gauge. The RSO verified that the source rod below the gauge was still intact. They were unable to get the source to retract. With the source inserted back into the soil, survey readings were obtained by the licensee as follows: 1 mR/hr on top of the gauge on contact; @ 5 ft away to the side 0.1 mR/hr.

"According to the RSO, no public exposure occurred. The licensee has fitted a lead pig [lead shielded container] around the source for transport to a licensed nuclear gauge service company."

Virginia Event Report ID Number: VA230002


Power Reactor
Event Number: 56779
Facility: Vogtle 3/4
Region: 2     State: GA
Unit: [4] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: William Garrett
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/05/2023
Notification Time: 12:29 [ET]
Event Date: 08/07/2023
Event Time: 14:39 [EDT]
Last Update Date: 10/06/2023
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
4 N N 0 Defueled 0 Cold Shutdown
Event Text
EN Revision Imported Date: 10/6/2023

EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION

The following information was provided by the licensee via phone and email:

"At 1439 EDT on August 7, 2023, a spurious level spike on the unit 4 reactor coolant system (RCS) level instrument (4-RCS-LT160A, 'Hot Leg 1 Level') caused actuation of containment isolation, reactor trip, automatic depressurization system (ADS) stage 4, and in containment refueling water storage tank (IRWST) isolation signals. The spurious level changes caused an invalid signal based on the incidental response of the 4-RCS-LT160A instrumentation due to water spray that was being used for reactor vessel cleaning (being performed prior to initial fuel loading). The level fluctuations resulted in engineered safety features actuation signals (containment isolation, ADS stage 4, and IRWST isolation signals) and a reactor trip signal, with the reactor trip signal already present. Three containment isolation valves closed due to the containment isolation signal that was generated. These valves were: 4-CAS-V014, 'instrument air supply containment isolation, air-operated valve,' 4-SFS-V034, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve,' and 4-SFS-V035, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve.' The other automatic containment isolation valves were either already closed at the time of the event or properly removed from service. All affected equipment functioned properly. The other actuation signals that were observed during this event (ADS stage 4, IRWST isolation, and reactor trip) did not result in any equipment changing position or automatically operating (i.e., the actuation signals occurred while the systems were properly removed from service).

"Units 1, 2, and 3 were not affected. This event did not result in any adverse impact to the health and safety of the public."

The NRC Resident Inspector was notified.


Agreement State
Event Number: 56768
Rep Org: Louisiana DEQ
Licensee: Acuren Inspection, Inc.
Region: 4
City: St. Martin   State: LA
County:
License #: LA-7072-L02, Amendment Number 130
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 09/30/2023
Notification Time: 15:18 [ET]
Event Date: 09/30/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/30/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK UNSHIELDED AND RECOVERED

The following was received from the Louisiana Department of Environmental Quality (the Department) via email:

"On September 30, 2023, Acuren Inspection, Inc. notified the Department that an industrial radiography camera failed to retract the source after an exposure. The industrial radiography camera was a Century 330 QSA Cobalt camera. The serial number of the camera is P30078. The radiation source is a Cobalt-60 with an activity strength of 52.2 curie. The source serial number is 59740G. The source was cranked back out the end of the source guide tube with a collimator.

"The facility where this event occurred is in St. Martin, Louisiana. Only the two man radiography crew was present at the site during the event, which occurred between 0300 [CDT] and 0350. A source retrieval was performed, resulting with the source in a shielded condition in the radiography camera. The individual performing the source retrieval received only 1 millirem."

Louisiana Event Report ID No.: LA20230010


Agreement State
Event Number: 56770
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pittsburgh
Region: 1
City: Pittsburgh   State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Ernest West
Notification Date: 10/02/2023
Notification Time: 10:19 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE - I-125 SEED INADVERTENTLY TRANSECTED

The following information was provided by the Pennsylvania Bureau of Radiation Protection via email:

"On September 28, 2023, staff from Magee Pathology department called the [University of Pittsburgh] radiation safety office to report that they had accidentally transected an I-125 seed used for radioactive seed localization (RSL) in breast tissue during the pathology processing in the laboratory. The seed was a Best Medical International Model 2301 containing 169 microcuries of I-125. Two staff members were involved, and they were told to sequester in the room until personnel from radiation safety could respond. Shortly after, radiation safety personnel performed surveys to determine the extent of the contamination. No personnel contamination was observed. All contamination was discovered in waste material and on the tissue samples. The transected seed was contained. The radiation safety office took possession of the damaged seed and all radioactive waste. At the time of reporting, it is estimated that approximately 50 percent of the activity was lost to open contamination, which is greater than 1 annual limit on intake (ALI) of I-125, and therefore reached the criteria for [10 CFR] 22.2202 reportability. Workers had bioassays performed for thyroid exposure and all returned negative."

PA event report ID: PA230028


Agreement State
Event Number: 56771
Rep Org: Louisiana DEQ
Licensee: Syngenta Crop Protection, LLC
Region: 4
City: St. Gabriel   State: LA
County:
License #: LA-2219-L01, Amendment Number 60
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Thomas Herrity
Notification Date: 10/02/2023
Notification Time: 16:43 [ET]
Event Date: 10/02/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received from the Louisiana Department of Environmental Quality (the Department) via email:

"On October 2, 2023, Syngenta Crop Protection, LLC notified the Department that a nuclear level gauge shutter was broken. The shutter is stuck open at approximately 40 percent. The gauge manufacturer is Texas Nuclear, Model: 5182, serial number 149. The source is Cs-137 with 50 mCi activity, serial number: J34.

"BBP Sales has been contacted to come out to the facility to perform repairs on the nuclear gauge."

Louisiana Event Report ID No.: LA20230012


Agreement State
Event Number: 56772
Rep Org: Louisiana DEQ
Licensee: Union Carbide Corp
Region: 4
City: Taft   State: LA
County:
License #: LA-2163-L01, Amendment Number 55
Agreement: Y
Docket:
NRC Notified By: Russell Clark
HQ OPS Officer: Thomas Herrity
Notification Date: 10/02/2023
Notification Time: 17:09 [ET]
Event Date: 08/30/2023
Event Time: 09:00 [CDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received from the Louisiana Department of Environmental Quality (LDEQ) via email:

"On August 30, 2023, at approximately 0900 [CDT], an Ohmart Model SH-F1-0 level/density gauge experienced a shutter malfunction during a routine semiannual shutter test. The gauge was installed on the Reactor 3, West Production vessel within the Poly Process Unit. The gauge possesses a nominal 500 millicurie sealed source of Cs-137. The above gauge was undergoing a routine semiannual shutter test when the malfunction was observed. The gauge sealed source serial number is: 1560CO. The device serial number has not been provided by the licensee. The gauge containing source number 1560CO, is mounted on the Reactor 3, West Production Chamber vessel in the polyethylene unit. On the above date, the Radiation Safety Officer (RSO) for Union Carbide Corporation contacted BBP Sales (BBP), radioactive material license LA-10799-L01. BBP arrived on site on that day to repair the stuck shutter. After several unsuccessful attempts to break the shutter free, the licensee and the BBP service engineer decided the best course of action would be to order a rotor replacement kit and the BBP service engineer should return on site to replace it. BBP is currently awaiting delivery of the new rotor kit.

"On October 2, 2023, at 0824, Union Carbide RSO notified the LDEQ concerning this equipment malfunction. According to RSO, the gauge rotor bracket broke due to corrosion, which prevented the gauge shutter from closing fully. The gauge is under the licensee's control. There were no exposures to members of the public approaching regulatory limits. Currently, the shutter on the gauge remains in the open position as the gauge source is needed to operate process control equipment. The gauge cannot be locked out in its current state. No entry to the vessel will be conducted until the gauge is repaired by BBP. The licensee will continue to monitor the gauge until repaired. The licensee stated they will keep the LDEQ updated on the progress of repairs."

Louisiana Event Report ID No.: LA230011


Agreement State
Event Number: 56773
Rep Org: New Mexico Rad Control Program
Licensee: Acuren Inspection, Inc.
Region: 4
City: Loving   State: NM
County:
License #: IR-573-02
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Eric Simpson
Notification Date: 10/03/2023
Notification Time: 11:01 [ET]
Event Date: 10/02/2023
Event Time: 14:30 [MDT]
Last Update Date: 10/03/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DISCONNECTED RADIOGRAPHY SOURCE

The following information was provided by the New Mexico Radiation Control Bureau via phone:

On October 2, 2023, at 1430 MDT, a radiography camera source became disconnected from its cable while still inside the guide tube during operations at a fabrication facility in Loving, NM. The device was described as a QSA D880 Model A424-9 camera with a 79.7 Ci iridium-192 source, serial number: 76167M. The licensee reconnected the source and secured the source inside the device in the shielded position by 2100 MDT. There were no public or occupational overexposure related to the source being disconnected from its control cable.


Agreement State
Event Number: 56775
Rep Org: OR Dept of Health Rad Protection
Licensee: Oregon Health & Sciences University
Region: 4
City: Portland   State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Michelle Martin
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/03/2023
Notification Time: 16:42 [ET]
Event Date: 09/21/2023
Event Time: 10:00 [PDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Oregon Department of Health Radiation Protection via email:

"At 1000 PDT on September 21, 2023, during an administration of a split-dose of Y-90 [yttrium] SirSpheres to the liver, the first dose was not completely delivered to the patient. The second dose, same lobe but a different site, was delivered completely. (First prescribed dose: 7.2mCi; First delivered dose: 5.614 mCi)

"The physician does not believe additional treatment will be needed but the case will be discussed by the licensee in a follow-up conference. The senior radiologist believes there was a `clump of spheres' remaining at the hub of the syringe for the first dose, resulting in under-dosing the patient by more than 20 percent.

"Corrective action is still to be determined."

Oregon Event Report Number: 23-0051

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: 56781
Facility: Diablo Canyon
Region: 4     State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: James Morris
HQ OPS Officer: Kerby Scales
Notification Date: 10/06/2023
Notification Time: 18:12 [ET]
Event Date: 08/08/2023
Event Time: 11:07 [PDT]
Last Update Date: 10/06/2023
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Kellar, Ray (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Refueling
Event Text
60 DAY NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION

The following information was provided by the licensee via phone and email:

"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A)."

"On August 8, 2023, at 1107 hours pacific daylight time (PDT) with Unit 1 in Mode 1 at 100 percent power, an invalid actuation occurred when Unit 1 4-kV vital bus 'G' was automatically transferred from auxiliary power to startup power due to an invalid bus under voltage signal, which occurred during planned maintenance activities.

"As a result of the actuation signal, auxiliary salt water and containment fan cooling units transferred automatically and started as designed. Plant systems responded as expected. This event was entered into the Diablo Canyon Power Plant corrective action program for resolution.

"There was no plant or public safety impact.

"The NRC Senior Resident Inspector has been notified."


Power Reactor
Event Number: 56784
Facility: Farley
Region: 2     State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Richard Langford
HQ OPS Officer: Adam Koziol
Notification Date: 10/09/2023
Notification Time: 21:52 [ET]
Event Date: 10/09/2023
Event Time: 19:10 [CDT]
Last Update Date: 10/09/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N N 0 Cold Shutdown 0 Cold Shutdown
Event Text
FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

A non-licensed employee supervisor failed a test specified by the fitness for duty testing program. The individual's authorization for site access has been terminated.

The NRC Resident Inspector has been notified.