Event Notification Report for December 15, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
12/14/2023 - 12/15/2023

EVENT NUMBERS
56880 56881 56883 56887 56888 56889
Agreement State
Event Number: 56880
Rep Org: Texas Dept of State Health Services
Licensee: U of Texas MD Anderson Cancer Ctr
Region: 4
City: Houston   State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 12/07/2023
Notification Time: 14:36 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [CST]
Last Update Date: 12/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE - SOURCE STUCK IN UNSHIELDED POSITION

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On December 7, 2023, the Department was notified by a Texas licensee's radiation safety officer (RSO) that while testing an MDS Nordion, Model Eldorado 8, teletherapy unit, the 1,817 curie cobalt-60 source became stuck in the unshielded position. The RSO stated that the room was isolated and dose rates taken outside the room did not create an exposure risk to any individual. The RSO stated that a service contractor would likely repair the unit on December 9, 2023. Access to the room was posted to prevent inadvertent entry into the room. An update will be provided when the source is returned to the shielded position and then further information will be provided per SA-300."

Texas Incident Number: I-10070

NMED Number: TX230056

* * * UPDATE ON 12/9/23 AT 1137 EST FROM RANDELL REDD TO KAREN COTTON * * *

"On December 9, 2023, the Department was notified that the cobalt-60 source had been returned to the shielded position by the licensed servicing company. The technician who returned the source received around 0.3 millirem. The source activity is likely around 1,000 curies and not 1,817 curies, as originally reported. The Department will wait for the licensee and service company reports for information regarding the cause of the incident and report this to NMED per SA-300."

Notified R4DO (Dixon) and NMSS Events Notification via email.


Agreement State
Event Number: 56881
Rep Org: Georgia Radioactive Material Pgm
Licensee: Wellstar Kennestone Hospital
Region: 2
City: Marietta   State: GA
County:
License #: GA 328-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/08/2023
Notification Time: 16:01 [ET]
Event Date: 12/07/2023
Event Time: 00:00 [EST]
Last Update Date: 12/11/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL MISADMINSTRATION

The following information is a synopsis of information provided by the Georgia Radioactive Materials Program via email:

The State received a call from the licensee's radiation safety officer on December 7, 2023, stating that a patient, who was scheduled for a high-dose rate (HDR) Ir-192 procedure, received the wrong dose. As of December 8, 2023, the state has not received any additional information. The state will provide updated information once it is provided.

Manufacturer: Nucletron Flexitron
Model: 136149A02

Georgia Incident Number: 73

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: 56883
Rep Org: Texas Dept of State Health Services
Licensee: Rone Engineering Services LTD
Region: 4
City: Dallas   State: TX
County:
License #: L02356
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/08/2023
Notification Time: 21:35 [ET]
Event Date: 12/08/2023
Event Time: 00:00 [CST]
Last Update Date: 12/08/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STAE REPORT - DAMAGED TROXLER GAUGE

The following information was provided by the Texas Department of State Health Services via email:

"On December 8, 2023, the licensee's radiation safety officer (RSO) reported a Troxler 3430 plus gauge was damaged at a job site. The gauge contains a 40 millicurie AmBe (americium-beryllium) source and an 8 millicurie cesium-137 source. The RSO stated that a technician was using the gauge in a trench to test soil compaction. The technician had completed a reading and was reporting the reading to another contractor outside the trench when the soil compacter was moved and struck the gauge. The soil compacter was moved back, and the technician went to the gauge. The only damage appeared to be to the plastic part of the case. The cesium source was in the fully shielded position. The RSO stated that the operating rod appeared to be operating properly. Dose rates at 3 feet from the gauge were 0.1 millirem per hour. The RSO stated that the gauge will be taken to their storage location and marked 'DO NOT USE.' The RSO stated that the gauge will be delivered to a service company on December 11, 2023, for inspection. No individual received an exposure that would exceed any limit. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10072

Texas NMED Number: TX230057


Power Reactor
Event Number: 56887
Facility: River Bend
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Chris Dwyer
HQ OPS Officer: Ernest West
Notification Date: 12/13/2023
Notification Time: 05:50 [ET]
Event Date: 12/13/2023
Event Time: 01:02 [CST]
Last Update Date: 12/13/2023
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):
Agrawal, Ami (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown
Event Text
AUTOMATIC REACTOR SCRAM

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

"At 0102 CST, while operating at 100 percent [reactor] power, River Bend Station experienced an automatic reactor scram caused by a turbine trip signal. The cause of the turbine trip signal is not known at this time and is being investigated. At 0108, reactor core isolation cooling (RCIC) was initiated due to a loss of reactor feed pumps following feedwater heater string isolation. At 0114, reactor water level control was transferred back to feedwater and RCIC was secured. Reactor water level is being maintained by feedwater pumps and reactor pressure is being maintained by turbine bypass valves. The scram was uncomplicated and all other plant systems responded as designed.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical and 10 CFR 50.72(b)(3)(iv)(A) specified system actuation as result of expected post scram [reactor water] level 3 isolations and manual initiation of RCIC.

"No radiological releases have occurred due to this event from the unit.

"The NRC Senior Resident Inspector has been notified of this event."

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

The cause of the turbine trip, while still under investigation, was likely due to an electrical transient involving the main generator. Walkdowns in the switchyard post-scram identified damage to one of the output breaker disconnects.


Part 21
Event Number: 56888
Rep Org: Sequoyah Nuclear Plant
Licensee: Sequoyah Nuclear Plant
Region: 2
City: Soddy-Daisy   State: TN
County: Hamilton
License #:
Agreement: Y
Docket:
NRC Notified By: Jeff Sowa
HQ OPS Officer: Ernest West
Notification Date: 12/13/2023
Notification Time: 09:45 [ET]
Event Date: 12/11/2023
Event Time: 13:32 [EST]
Last Update Date: 12/13/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 - CIRCUIT BREAKER DEFECTS

The following information is a synopsis of information provided by the licensee via phone and email:

On December 11, 2023, Tennessee Valley Authority Sequoyah Nuclear Plant completed an internal 10 CFR Part 21 evaluation concerning Siemens 6.9kV, 1200A vacuum circuit breakers, Model No. 7-HKR-50-1200-130. Three separate breakers were found with issues including loose wires terminated incorrectly and the mechanism-operated control switch clevis pin missing a cotter key. Additionally, the mastic insulating pads were found defective on all three lower primaries by way of separation. The affected breakers were never installed in a safety related application.

The NRC Resident Inspector will be notified.

A written notification will be provided within 30 days.

The manufacturer, Siemens, was notified of the defects.

The only plant known to be affected at the time of the report is the Sequoyah Nuclear Plant.


Power Reactor
Event Number: 56889
Facility: Hope Creek
Region: 1     State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Jordan Halstead
HQ OPS Officer: Adam Koziol
Notification Date: 12/14/2023
Notification Time: 21:05 [ET]
Event Date: 12/14/2023
Event Time: 19:39 [EST]
Last Update Date: 12/14/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Gray, Mel (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 88 Power Operation 0 Hot Shutdown
Event Text
AUTOMATIC REACTOR SCRAM

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

"On December 14, 2023, at 1939 EST, Hope Creek reactor scrammed following closure of turbine control valve number 4.

"All control rods fully inserted into the core. All safety systems responded as designed and expected. There was no radiological release. The unit is stable in mode 3 with decay heat being removed via the turbine bypass valves rejecting steam to the main condenser. Normal feedwater level control is providing makeup to the reactor vessel.

"No personnel injuries resulted from the event.

"The outage control center has been staffed to determine the cause of the reactor scram.

"The Hope Creek NRC Resident Inspector has been notified."