Event Notification Report for November 06, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/03/2023 - 11/06/2023

Agreement State
Event Number: 56819
Rep Org: North Dakota DEQ
Licensee: Innovus Health, LLC
Region: 4
City: Fargo   State: ND
County: Cass
License #: ND 33-02604-01
Agreement: Y
Docket:
NRC Notified By: David Stradinger
HQ OPS Officer: Michael Bloodgood
Notification Date: 10/27/2023
Notification Time: 10:02 [ET]
Event Date: 10/25/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/27/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the North Dakota (ND) Department of Environmental Quality (DEQ) via telephone and email:

"The ND DEQ received a call from Innovis Health, LLC, Fargo, North Dakota, (ND License No. 33-02604-01) at 0945 CDT on October 26, 2023, informing the ND DEQ of a possible medical event (10 CFR 35.3045(a)(1)) which occurred on October 25, 2023. The event involved a patient scheduled to receive a prescribed therapy dose of 120 Gy of yttrium-90 Theraspheres microspheres. During the line check while attempting to administer the microspheres, the licensee experienced some difficulties, stopped the procedure, and noticed a higher-than-normal radiation reading of the delivery system and associated materials. After measuring these materials, it appeared the patient received 41.7 Gy to the target site (liver). Initial imaging of the patient directly following the procedure did not show activity around the target area and surface radiation readings of the patient in this area was 0.06 mR/hr. At this time, the licensee was questioning if any of the dose was administered. The licensee contacted the manufacturer the same day regarding the event.

"The licensee also noted increased radiation activity in other materials used in the procedure. The radiation survey reading of these materials was 140 mR/hr. The license was researching a way to calculate the amount of activity that may have been in these additional materials.

"Further viewing of the images of the upper abdomen of the patient by the Interventional Radiologist (IR) demonstrated a very faint outline of the right lobe of the liver (the intended treatment area). This indicated a very small amount of the dose was delivered. The IR discussed everything with the patient before the patient had left the recovery area. There were no immediate adverse health effects, and the IR would monitor the patient for the next two weeks (about five half-lives)."

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: 56820
Rep Org: Ohio Bureau of Radiation Protection
Licensee: NDC Technologies, Inc
Region: 3
City: Dayton   State: OH
County:
License #: 03214580002
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: John Russell
Notification Date: 10/27/2023
Notification Time: 13:31 [ET]
Event Date: 10/26/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/27/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Feliz-Adorno, Nestor (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL)
Event Text
AGREEMENT STATE - LOST CATEGORY 4 SOURCE

The following information was provided by the Ohio Department of Health (ODH) via email:

"ODH received a notification last night [on 26 October, 2023], that NDC Technologies, Inc. (NDC) discovered a 25 mCi Americium-241 (Am-241) source was missing from their inventory. NDC is located in Dayton.

"The licensee has conducted three inventories of all sources, reviewed all shipping logs, and have searched (both visually and with a survey meter) areas, floors, and drawers where devices are built and stored.

"The source may have mistakenly been put into a trashcan or sent, still mounted in the sodium iodine crystal, for disposal. The last disposal was on July 12, 2023, and the licensee has contacted the disposal company and will speak with them further today.

"ODH will be sending an inspector to further investigate."

NMED report number: OH230010

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
Event Number: 56823
Rep Org: Wisconsin Radiation Protection
Licensee: Payne and Dolan Inc.
Region: 3
City: Waukesha   State: WI
County:
License #: 133-1220-01
Agreement: Y
Docket:
NRC Notified By: Charles Adams III
HQ OPS Officer: John Russell
Notification Date: 10/30/2023
Notification Time: 21:10 [ET]
Event Date: 10/30/2023
Event Time: 14:35 [CDT]
Last Update Date: 10/31/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dickson, Billy (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL)
Event Text
AGREEMENT STATE - STOLEN SOURCE

The following information was provided by the Wisconsin Department of Health Services (the Department) via email and telephone:

"On October 30, 2023, at 1830 CDT, the Department received a notification from the licensee that a CPN MC1DRP gauge containing up to 10 mCi of Cesium-137 and 50 mCi of Americium-241 had been out of their control since 1435 CDT when the vehicle containing the gauge was stolen. Local law enforcement has been notified. The Department will monitor and update."

Event Report Number: WI230019

* * * UPDATE FROM MEGAN SHOBER TO DAN LIVERMORE BY EMAIL ON 10/31/2023 * * *

"The missing gauge was recovered around 0800 [CDT] on October 31, 2023 and is now in the custody of the licensee. The gauge had no visual damage. The Department will follow up with the licensee."

Notified R3DO (Dickson), ILTAB and NMSS Events notification by email.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Power Reactor
Event Number: 56829
Facility: Point Beach
Region: 3     State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Mary Sipiorski
HQ OPS Officer: Thomas Herrity
Notification Date: 11/02/2023
Notification Time: 16:41 [ET]
Event Date: 11/02/2023
Event Time: 07:15 [CDT]
Last Update Date: 11/02/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Ruiz, Robert (R3DO)
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 38 Power Operation 38 Power Operation
2 N Y 100 Power Operation 100 Power Operation
Event Text
FALSE NEGATIVE AND POSITIVE ON BLIND PERFORMANCE SAMPLE

The following information was provided by the licensee via email:

"On November 2, 2023, at 0715 CDT, it was discovered that the results of a blind performance specimen provided to a Health & Human Services (HHS)-certified testing facility were not as expected. The blind specimen results indicated a false negative for MDA/MDMA and a false positive for amphetamines.

"Investigation is ongoing to determine if the results are accurate.

"This report is being made in accordance with 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3).

"The NRC Resident Inspector has been notified by the licensee."


Power Reactor
Event Number: 56830
Facility: Oconee
Region: 2     State: SC
Unit: [1] [2] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: Luis Oliva
HQ OPS Officer: Kerby Scales
Notification Date: 11/03/2023
Notification Time: 15:27 [ET]
Event Date: 11/03/2023
Event Time: 15:30 [EDT]
Last Update Date: 11/03/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Miller, Mark (R2DO)
Grant, Jeffery (IR)
Felts, Russell (NRR EO)
Gasperson, Dave (R2 PAO)
Burnell, Scott (HQ PAO)
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 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation
Event Text
OFFSITE NOTIFICATION - PRESS RELEASE

The following information was provided by the licensee via email:

"A press conference is being held by the Oconee County Sheriff's office today at 1530 EDT in which Duke Energy will be present and may participate regarding the facts pertaining to an event that occurred outside the Oconee Nuclear Power Plant.

"The NRC Resident Inspector was notified.

"This is a four-hour report per 10 CFR 50.72(b)(2)(xi) for any event or situation for which a news release is planned or notification to other government agencies has been or will be made which is related to heightened public or government concern.

"The event is not significant with respect to the health and safety of the public."


Power Reactor
Event Number: 56832
Facility: Comanche Peak
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Damon Schroeder
HQ OPS Officer: Adam Koziol
Notification Date: 11/04/2023
Notification Time: 01:11 [ET]
Event Date: 11/03/2023
Event Time: 22:31 [CDT]
Last Update Date: 11/04/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Roldan-Otero, Lizette (R4DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation
Event Text
CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA

The following information was provided by the licensee via email:

"On 11/03/2023 at 2231 CDT, a security officer found 2 bottles of vanilla extract in the protected area. One bottle was a 1.5 ounce size with a trace amount of vanilla in the bottle, the other bottle was a 4.5 ounce size with approximately 1 ounce of vanilla. Alcohol was identified as an ingredient on the label. It was determined the vanilla extract is 35 percent alcohol by volume (ABV), above the 0.5 percent ABV considered low alcohol content. Security personnel took custody of the bottles of vanilla extract."

The NRC Resident Inspector has been notified.


Power Reactor
Event Number: 56834
Facility: Waterford
Region: 4     State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: Kevin Hale
HQ OPS Officer: Donald Norwood
Notification Date: 11/05/2023
Notification Time: 17:52 [ET]
Event Date: 11/05/2023
Event Time: 10:33 [CST]
Last Update Date: 11/05/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Roldan-Otero, Lizette (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Defueled 0 Defueled
Event Text
DEGRADED CONDITION - TWO STEAM GENERATOR TUBE FAILURES IDENTIFIED

The following information was provided by the licensee via email:

"At 1033 CST on November 5, 2023, while in a refueling outage, it was determined that Waterford Steam Electric Station, Unit 3, did not meet the performance criteria for steam generator structural integrity in accordance with Technical Specification 6.5.9.b.1, Steam Generator Program, due to two tube failures in the number 1 steam generator. The condition was identified during performance of in-situ pressure testing.

"The affected tubes will be plugged.

"The plant is currently stable with all fuel in the spent fuel pool. Decay heat is being removed by normal spent fuel cooling system operation.

"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A) as a degraded condition.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."