Event Notification Report for December 18, 2023

EN Revision Imported Date: 12/18/2023

EN Revision 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


* * * UPDATE ON 12/15/23 AT 1234 EST FROM KAAMILYA NAJEEULLAH TO THOMAS HERRITY * * *

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

The official written report from Wellstar Kennestone Hospital, Georgia License GA 328-1, was received from the Radiation Safety Officer (RSO), on December 15, 2023. The report includes details of the misadministration - human error, and the corrective actions the licensee has instituted to prevent recurrence. The patient was underdosed by 2 percent. The prescribing physician was notified and choose not inform the patient of this incident. No adverse effects to the patient are anticipated.

Notified R1DO(Gray) and NMSS Events Notification via email.

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 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

AGREEMENT STATE REPORT - LIQUID RADIOACTIVE CONTAMINATION

The following information was provided by Utah Department of Environmental Quality, Division of Waste Management [the Division] and Radiation Control, via email:

"On December 8, 2023 at 1550 MST, the RSO [radiation safety officer] for IHC Health Services, Inc. DBA Utah Valley Hospital called the Division to report an incident. This was a preliminary report made by the licensee's RSO who was not on-site at the time. The licensee was exchanging a Bracco Cardiogen Generator at their facility, but when they went to make the exchange, the licensee found approximately one half inch of liquid in the well. The licensee has notified the manufacturer of the incident and is working with them to mitigate the situation.

"This is the second generator of this type that has been found leaking at the licensee's facility. The licensee's RSO does not have all of the necessary information at this time and will contact the Division with the additional information as soon as possible. An update to this report will be provided when the information is received."

Utah Event Report ID No.: UT23-0009

AGREEMENT STATE REPORT - STUCK SOURCE

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

"On December 6, 2023, the radiography crew experienced an issue with retracting the source assembly into the shielded position and notified their radiation safety officer (RSO). The RSO removed an excessive bend in the guide tube. During disassembly it was determined that the guide tube was not connected to the exposure device. This resulted in creating a small gap that caused binding when retracting the source assembly. The radiographer's pocket dosimetry read 18 millirem and the assistant's read 11 millirem at 1057 [EST] and later at 1120 read 21 millirem for the radiographer and the assistant's read 11 millirem. At the shop, the guide tube was inspected, cleaned, and then challenged to verify its function. The radiation safety department identified that the radiographic operations did not notify the State of performing radiography in Cummings, Georgia. Corrective actions have been taken."

Manufacturer: Source Production
Model: Spec-150
Serial Number and Source Serial Number: 1880, EK1501

Georgia Incident Number: 74

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."

REACTOR COOLANT SYSTEM LEAK

"At 2045 EST on December 15, 2023, it was determined that the reactor coolant system barrier had a through wall flaw with leakage. The leakage is minor in nature and unquantifiable. The leakage is coming from the welded connection of a vent valve for safety injection tank 2A2 outlet valve rendering both trains of high-pressure safety injection inoperable. The unit is being cooled down to cold shutdown to comply with technical specifications.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A) and 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The unit was heating up after a maintenance outage. The leak was discovered during mode 3 walkdown.

EN Revision Imported Date: 12/18/2023

EN Revision Text: AUTOMATIC SCRAM DUE TO TURBINE TRIP
The following information was provided by the licensee via email:

"On December 16, 2023, at 0350 CST, Grand Gulf Nuclear Station was operating in mode 1 at 81 percent power when an automatic scram occurred due to a turbine trip signal. Before the scram the unit was performing a rod sequence exchange, and no critical work was underway. The cause of the turbine trip signal is not known at this time and is being investigated. All control rods fully inserted, there were no complications, and all plant systems responded as designed. Reactor water level is being maintained by main feedwater and condensate. Reactor pressure is being maintained with main turbine bypass valves. No radiological releases have occurred due to this event.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A), as any event or condition that results in actuation of the reactor protection system when the reactor is critical and specified system actuation due to expected reactor water level 3 isolation signals on a reactor scram. 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:
Group 2 and Group 3 isolations occurred on the Level 3 isolation signal.