Event Notification Report for July 10, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/09/2024 - 07/10/2024
Agreement State
Event Number: 57222
Rep Org: NJ Dept of Environmental Protection
Licensee: Kennedy Memorial Hospital
Region: 1
City: Cherry Hill State: NJ
County:
License #: 454403
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Robert A. Thompson
Licensee: Kennedy Memorial Hospital
Region: 1
City: Cherry Hill State: NJ
County:
License #: 454403
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Robert A. Thompson
Notification Date: 07/10/2024
Notification Time: 16:32 [ET]
Event Date: 07/10/2024
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2024
Notification Time: 16:32 [ET]
Event Date: 07/10/2024
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - Y-90 UNDERDOSE
The following is a summary of information provided by the New Jersey Department of Environmental Protection (NJDEP) via email:
Kennedy Memorial Hospital University Medical Center (the licensee) was scheduled to administer a Nordion TheraSphere therapy (116 mCi of Y-90) to a patient. The target organ was the right hepatic lobe of the liver. There was a tubing failure in the delivery system and the administration was suspended. It is estimated that only 2.62 mCi (17 percent) of the prescribed dosage was administered.
The patient and referring physician were notified. The patient has been re-scheduled for treatment.
No release of licensed material or contamination was reported.
The licensee will follow-up with a full written report. The licensee is sending the equipment that failed to the manufacturer for detailed analysis.
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.
The following is a summary of information provided by the New Jersey Department of Environmental Protection (NJDEP) via email:
Kennedy Memorial Hospital University Medical Center (the licensee) was scheduled to administer a Nordion TheraSphere therapy (116 mCi of Y-90) to a patient. The target organ was the right hepatic lobe of the liver. There was a tubing failure in the delivery system and the administration was suspended. It is estimated that only 2.62 mCi (17 percent) of the prescribed dosage was administered.
The patient and referring physician were notified. The patient has been re-scheduled for treatment.
No release of licensed material or contamination was reported.
The licensee will follow-up with a full written report. The licensee is sending the equipment that failed to the manufacturer for detailed analysis.
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: 57223
Rep Org: Arizona Dept of Health Services
Licensee: ACS Engineering Group
Region: 4
City: Mesa State: AZ
County: Maricopa
License #: 07- 422
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Natalie Starfish
Licensee: ACS Engineering Group
Region: 4
City: Mesa State: AZ
County: Maricopa
License #: 07- 422
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Natalie Starfish
Notification Date: 07/11/2024
Notification Time: 00:24 [ET]
Event Date: 07/10/2024
Event Time: 00:00 [MST]
Last Update Date: 07/11/2024
Notification Time: 00:24 [ET]
Event Date: 07/10/2024
Event Time: 00:00 [MST]
Last Update Date: 07/11/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico) (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico) (EMAIL)
AGREEMENT STATE - LOST TROXLER GAUGE
The following is a summary of the information provided by the Arizona Department of Health Services (the Department) via email:
On July 10, 2024, a truck carrying a portable gauge was involved in a car accident. The driver was transported to the hospital. The location and the extent of damage to the gauge and truck are currently unknown. The portable gauge is a Troxler 3440, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be.
The Department has requested additional information and continues to investigate the event.
Arizona Incident: 24-008
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
The following is a summary of the information provided by the Arizona Department of Health Services (the Department) via email:
On July 10, 2024, a truck carrying a portable gauge was involved in a car accident. The driver was transported to the hospital. The location and the extent of damage to the gauge and truck are currently unknown. The portable gauge is a Troxler 3440, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be.
The Department has requested additional information and continues to investigate the event.
Arizona Incident: 24-008
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: 57221
Facility: Peach Bottom
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Gino Lombardo
HQ OPS Officer: Eric Simpson
Region: 1 State: PA
Unit: [2] [] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: Gino Lombardo
HQ OPS Officer: Eric Simpson
Notification Date: 07/10/2024
Notification Time: 11:15 [ET]
Event Date: 07/10/2024
Event Time: 07:28 [EDT]
Last Update Date: 07/11/2024
Notification Time: 11:15 [ET]
Event Date: 07/10/2024
Event Time: 07:28 [EDT]
Last Update Date: 07/11/2024
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Henrion, Mark (R1DO)
Henrion, Mark (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 24 | Power Operation | 0 | Hot Shutdown |
EN Revision Imported Date: 7/11/2024
EN Revision Text: AUTOMATIC REACTOR SCRAM DUE TO MANUAL TURBINE TRIP
The following information was provided by the licensee via phone and email:
"At 0728 EDT on July 10, 2024, with Unit 2 in Mode 1 at 24 percent power, the reactor automatically scrammed due to a manual turbine trip. The [reactor] scram was not complex with all systems responding normally. Reactor vessel level reached the low-level set-point following the scram, resulting in valid Group 2 and Group 3 containment isolation signals. Due to the reactor protection system actuation while critical, this event is being reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group 2 and Group 3 isolations.
"Operations responded using emergency operating procedures and stabilized the plant in Mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 3 was not affected.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
EN Revision Text: AUTOMATIC REACTOR SCRAM DUE TO MANUAL TURBINE TRIP
The following information was provided by the licensee via phone and email:
"At 0728 EDT on July 10, 2024, with Unit 2 in Mode 1 at 24 percent power, the reactor automatically scrammed due to a manual turbine trip. The [reactor] scram was not complex with all systems responding normally. Reactor vessel level reached the low-level set-point following the scram, resulting in valid Group 2 and Group 3 containment isolation signals. Due to the reactor protection system actuation while critical, this event is being reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group 2 and Group 3 isolations.
"Operations responded using emergency operating procedures and stabilized the plant in Mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 3 was not affected.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 57302
Facility: Hope Creek
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Brian Padworny
HQ OPS Officer: Nestor Makris
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Brian Padworny
HQ OPS Officer: Nestor Makris
Notification Date: 09/04/2024
Notification Time: 14:31 [ET]
Event Date: 07/10/2024
Event Time: 09:02 [EDT]
Last Update Date: 09/04/2024
Notification Time: 14:31 [ET]
Event Date: 07/10/2024
Event Time: 09:02 [EDT]
Last Update Date: 09/04/2024
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Ferdas, Marc (R1DO)
Ferdas, Marc (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID RESIDUAL HEAT REMOVAL ACTIVATION
The following information was provided by the licensee via phone and email:
"A 10 CFR 50.73(a)(1) invalid specified system actuation reported under 10 CFR 50.73(a)(2)(iv)(a) invalid actuation of residual heat removal (RHR).
"This 60-day telephone notification is being made per 10 CFR 50.73 (a)(2)(iv)(a) under the provision of 10 CFR 50.73 (a)(1) as an invalid actuation of the RHR. On July 10, 2024, while at 100 percent power, a partial train actuation of RHR was initiated by an invalid actuation signal while performing RHR valve logic testing.
"The cause for the RHR system logic actuation was due to improper configuration of an emergency core cooling system (ECCS) logic tester. The RHR system started and functioned as designed for the actuation signals it received from the ECCS logic tester.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC resident inspector was notified."
The following information was provided by the licensee via phone and email:
"A 10 CFR 50.73(a)(1) invalid specified system actuation reported under 10 CFR 50.73(a)(2)(iv)(a) invalid actuation of residual heat removal (RHR).
"This 60-day telephone notification is being made per 10 CFR 50.73 (a)(2)(iv)(a) under the provision of 10 CFR 50.73 (a)(1) as an invalid actuation of the RHR. On July 10, 2024, while at 100 percent power, a partial train actuation of RHR was initiated by an invalid actuation signal while performing RHR valve logic testing.
"The cause for the RHR system logic actuation was due to improper configuration of an emergency core cooling system (ECCS) logic tester. The RHR system started and functioned as designed for the actuation signals it received from the ECCS logic tester.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC resident inspector was notified."