Event Notification Report for July 10, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/09/2024 - 07/10/2024

EVENT NUMBERS
57110 57205 57208 57213 57214 57215
Hospital
Event Number: 57110
Rep Org: Saint Francis Medical Center
Licensee: Saint Francis Medical Center
Region: 3
City: Cape Girardeau   State: MO
County:
License #: 24-00158-03
Agreement: N
Docket:
NRC Notified By: Jamie Eisenberg
HQ OPS Officer: Adam Koziol
Notification Date: 05/07/2024
Notification Time: 14:56 [ET]
Event Date: 05/06/2024
Event Time: 11:00 [CDT]
Last Update Date: 07/09/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Event Text
EN Revision Imported Date: 7/10/2024

EN Revision Text: MEDICAL EVENT - Y-90 OVERDOSE

The following information was provided by the licensee via telephone:

A patient had a written directive to receive 90 Gy of Y-90 TheraSpheres to the liver. When the order was entered into the system, the wrong activity was entered. The higher activity of 360 Gy Y-90 TheraSpheres was then administered to the patient. The calculated dose to the liver may exceed 50 rem.

The patient and referring physician were informed. No health effect or permanent functional damage is expected.

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.

* * * UPDATE ON 7/9/24 AT 1644 EDT FROM JAMIE EISENBERG TO KAREN COTTON * * *

The following summary was provided by the licensee via telephone:

After further assessment of the event, it was discovered that the patient also received an unintended dose of 360 Gy Y-90 TheraSpheres to the lungs. No health effect or permanent functional damage is expected.

Notified R3DO (Nguyen), NMSS Events Notification (email), NMSS Regional Coordinator (Sun)


Non-Agreement State
Event Number: 57205
Rep Org: Agilent Technologies
Licensee: Agilent Technologies
Region: 1
City: Wilmington   State: DE
County: New Castle
License #: 07-28762-01
Agreement: N
Docket:
NRC Notified By: David Bennett
HQ OPS Officer: Robert A. Thompson
Notification Date: 07/02/2024
Notification Time: 07:45 [ET]
Event Date: 06/05/2024
Event Time: 07:00 [EDT]
Last Update Date: 07/02/2024
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
LOST SOURCE

The following information was provided by Agilent Technologies (the licensee) via phone:

A single electron capture device (ECD) containing 15 mCi of Ni-63 was reported to be lost. The ECD was one of ten in a package being transferred by a customer on June 5, 2024. The licensee believes that the ECD was erroneously discarded by a licensee operator. The licensee attempted to recover the ECD without success.

The licensee's root cause analysis determined the event occurred due to the employee not following the established procedure. In addition, employee training was inadequate due to failure to update the training program. Corrective action to update the training program has been undertaken by the licensee.

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

The licensee believes that the ECD was discarded in the facility's normal waste stream.


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


Non-Agreement State
Event Number: 57208
Rep Org: Midwest Subsurface Testing
Licensee: Midwest Subsurface Testing
Region: 3
City: Osage Beach   State: MO
County:
License #: 24-24619-02
Agreement: N
Docket:
NRC Notified By: Joseph Honich
HQ OPS Officer: Natalie Starfish
Notification Date: 07/03/2024
Notification Time: 13:26 [ET]
Event Date: 07/03/2024
Event Time: 11:46 [CDT]
Last Update Date: 07/03/2024
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Hartman, Tom (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
DAMAGED DENSITY GAUGE

The following information is a summary of the information provided by the licensee via phone:

At 1146 CDT on 7/3/2024, the radiation safety officer at Midwest Subsurface Testing reported a gauge was damaged on a construction site. An InstroTek MC1 Elite moisture density gauge containing 10 millicuries of cesium-137 and 50 millicuries of americium-241/beryllium was backed over by a skid loader. The source was stuck in the shielded position. A radiological survey was conducted, which verified there was no contamination. The damaged gauge was recovered and transported to a vendor facility to conduct a leak test.

This event was reported under 10 CFR 30.50 (b)(2).


Power Reactor
Event Number: 57213
Facility: Harris
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: Trent Plummer
HQ OPS Officer: Ernest West
Notification Date: 07/08/2024
Notification Time: 11:04 [ET]
Event Date: 07/08/2024
Event Time: 07:48 [EDT]
Last Update Date: 07/08/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Suggs, LaDonna (R2DO)
Grant, Jeffery (IR)
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
Event Text
INADVERTENT SIREN ACTIVATION

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

"On July 8, 2024, at 0748 EDT, six emergency response sirens were inadvertently actuated. Four sirens are located in Chatham County and two sirens are in Wake County. The first notification was made to Wake County at 0754. Investigation is ongoing to determine the cause of the actuation. Duke Energy notified the state and all counties within the emergency planning zone (EPZ). A press release was issued by Wake and Chatham Counties.

"This is a four-hour notification, non-emergency for the notification of another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

"There was no impact to the health and safety of the public or plant personnel.

"The NRC resident inspector has been notified."


Power Reactor
Event Number: 57214
Facility: Watts Bar
Region: 2     State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Paul Blakely
HQ OPS Officer: Sam Colvard
Notification Date: 07/08/2024
Notification Time: 18:24 [ET]
Event Date: 07/08/2024
Event Time: 15:21 [EDT]
Last Update Date: 07/08/2024
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
Person (Organization):
Suggs, LaDonna (R2DO)
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 Standby
Event Text
AUTOMATIC REACTOR TRIP

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

"At 1521 EDT on July 8, 2024, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main turbine trip. The [reactor] trip was not complex with all systems responding normally post trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the steam dump system and the auxiliary feedwater (AFW) system. Unit 2 is not affected.

"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). The expected actuation of the AFW system (an engineered safety feature) is being reported as an eight-hour report under 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact on the health and safety of the public or plant personnel. 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 specific cause of the turbine trip is under investigation by the licensee.


Power Reactor
Event Number: 57215
Facility: Vogtle 3/4
Region: 2     State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Tommie Sweat
HQ OPS Officer: Ernest West
Notification Date: 07/09/2024
Notification Time: 01:11 [ET]
Event Date: 07/08/2024
Event Time: 21:25 [EDT]
Last Update Date: 07/09/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(2)(iv)(A) - ECCS Injection
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Suggs, LaDonna (R2DO)
Grant, Jeffery (IR)
Felts, Russell (NRR EO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 100 Power Operation 0 Safe Shutdown
Event Text
MANUAL REACTOR TRIP AND AUTOMATIC SAFEGUARDS ACTUATION

The following information was provided by the licensee via email:

"At 2125 EDT on 07/08/2024, with Unit 3 in Mode 1 at 100 percent power, the reactor was manually tripped due to main feedwater pump `A' miniflow valve failing open, which resulted in lowering steam generator water level. Additionally, an automatic safeguards actuation occurred due to the cooldown of the reactor coolant system. The trip was not complex, with all safety systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by the passive residual heat removal heat exchanger. Units 1, 2, and 4 are not affected.

"Due to the core makeup tank actuation, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). The reactor protection system actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, this event is reportable per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid containment isolation actuation and a valid passive residual heat removal heat exchanger actuation.

"There was no impact on the health and safety of the public or plant personnel. 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 cause of the main feedwater pump 'A' miniflow valve failing open was unknown and under investigation at the time of the notification of this event to the NRC.