Event Notification Report for August 20, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/19/2024 - 08/20/2024
Agreement State
Event Number: 57275
Rep Org: Kentucky Dept of Radiation Control
Licensee: Leonard Lawson Cancer Center
Region: 1
City: Pikeville State: KY
County:
License #: 202-375-27
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Josue Ramirez
Licensee: Leonard Lawson Cancer Center
Region: 1
City: Pikeville State: KY
County:
License #: 202-375-27
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Josue Ramirez
Notification Date: 08/20/2024
Notification Time: 17:55 [ET]
Event Date: 08/20/2024
Event Time: 13:30 [CDT]
Last Update Date: 08/20/2024
Notification Time: 17:55 [ET]
Event Date: 08/20/2024
Event Time: 13:30 [CDT]
Last Update Date: 08/20/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center [of the following:]
"The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.
"The authorized user physician and the patient have been notified of the medical events.
"The first dose was administered on July 9, 2024, with a prescribed dose of 91.2 micro Ci and an administered dose of 72.46 micro Ci with a difference of 20.5 percent.
[The second dose is being tracked under a different NRC Event number. See EN 57276]
"The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:
"Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).
"The concentration provided in the formula is different than the concentration for each dose. The concentration for the first dose was 19.17 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.
"Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).
"The problem is the document does not instruct one to use an actual concentration for the patient specific dose.
"The two reasons for the medical events are:
"1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.
"2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.
"The incident remains under evaluation and investigation for corrective actions."
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 information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center [of the following:]
"The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.
"The authorized user physician and the patient have been notified of the medical events.
"The first dose was administered on July 9, 2024, with a prescribed dose of 91.2 micro Ci and an administered dose of 72.46 micro Ci with a difference of 20.5 percent.
[The second dose is being tracked under a different NRC Event number. See EN 57276]
"The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:
"Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).
"The concentration provided in the formula is different than the concentration for each dose. The concentration for the first dose was 19.17 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.
"Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).
"The problem is the document does not instruct one to use an actual concentration for the patient specific dose.
"The two reasons for the medical events are:
"1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.
"2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.
"The incident remains under evaluation and investigation for corrective actions."
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: 57276
Rep Org: Kentucky Dept of Radiation Control
Licensee: Leonard Lawson Cancer Center
Region: 1
City: Pikeville State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Josue Ramirez
Licensee: Leonard Lawson Cancer Center
Region: 1
City: Pikeville State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Josue Ramirez
Notification Date: 08/20/2024
Notification Time: 17:55 [ET]
Event Date: 08/20/2024
Event Time: 13:30 [CDT]
Last Update Date: 08/20/2024
Notification Time: 17:55 [ET]
Event Date: 08/20/2024
Event Time: 13:30 [CDT]
Last Update Date: 08/20/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center [of the following:]
"The date of discovery is August 20, 2024 at 13:30 EDT.
"There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.
"The authorized user physician and the patient have been notified of the medical events.
[The first dose is being tracked under a different NRC Event number. See EN 57275]
"The second dose was administered on August 7, 2024, with a prescribed dose of 89.2 micro Ci and an administered dose of 45.53 micro Ci with a difference of 53.9 percent.
"The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:
"Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).
"The concentration provided in the formula is different than the concentration for each dose. The concentration for the second dose was 18.12 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.
"Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).
"The problem is the document does not instruct one to use an actual concentration for the patient specific dose.
"The two reasons for the medical events are:
"1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.
"2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.
"The incident remains under evaluation and investigation for corrective actions."
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 information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center [of the following:]
"The date of discovery is August 20, 2024 at 13:30 EDT.
"There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed.
"The authorized user physician and the patient have been notified of the medical events.
[The first dose is being tracked under a different NRC Event number. See EN 57275]
"The second dose was administered on August 7, 2024, with a prescribed dose of 89.2 micro Ci and an administered dose of 45.53 micro Ci with a difference of 53.9 percent.
"The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation:
"Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml).
"The concentration provided in the formula is different than the concentration for each dose. The concentration for the second dose was 18.12 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula.
"Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml).
"The problem is the document does not instruct one to use an actual concentration for the patient specific dose.
"The two reasons for the medical events are:
"1) The medical physicist did not follow the written directive procedure. He added the volume calculation step.
"2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose.
"The incident remains under evaluation and investigation for corrective actions."
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.
Power Reactor
Event Number: 57278
Facility: Summer
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: Jason Pawlak
HQ OPS Officer: Jordan Wingate
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: Jason Pawlak
HQ OPS Officer: Jordan Wingate
Notification Date: 08/20/2024
Notification Time: 23:32 [ET]
Event Date: 08/20/2024
Event Time: 20:01 [EDT]
Last Update Date: 08/21/2024
Notification Time: 23:32 [ET]
Event Date: 08/20/2024
Event Time: 20:01 [EDT]
Last Update Date: 08/21/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation 50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation 50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
Person (Organization):
Masters, Anthony (R2DO)
Masters, Anthony (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTROL ROOM VENTILATION INOPERABLE
The following information was provided by the licensee via email and phone:
"At 2001 EDT on 8/20/2024, it was discovered that both trains of the control room ventilation system were simultaneously inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour notification per 10 CFR 50.72(b)(3)(v).
"There is no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified.
"One train of control room ventilation was restored to operable status at 2107 EDT on 8/20/2024."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
While performing canister maintenance on train B, it was discovered that the dampener for train A failed to close. Train B was restored at the conclusion of maintenance.
* * * UPDATE ON 08/21/24 AT 1648 EDT FROM LAUREN ANDERSON TO JOSUE RAMIREZ * * *
The following information was provided by the licensee via email and phone:
"This event is also reportable per 10 CFR 50.72(b)(3)(xiii), loss of emergency assessment capability, as the technical support center facility is located inside the control room envelope."
Notified R2DO (Masters)
The following information was provided by the licensee via email and phone:
"At 2001 EDT on 8/20/2024, it was discovered that both trains of the control room ventilation system were simultaneously inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour notification per 10 CFR 50.72(b)(3)(v).
"There is no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified.
"One train of control room ventilation was restored to operable status at 2107 EDT on 8/20/2024."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
While performing canister maintenance on train B, it was discovered that the dampener for train A failed to close. Train B was restored at the conclusion of maintenance.
* * * UPDATE ON 08/21/24 AT 1648 EDT FROM LAUREN ANDERSON TO JOSUE RAMIREZ * * *
The following information was provided by the licensee via email and phone:
"This event is also reportable per 10 CFR 50.72(b)(3)(xiii), loss of emergency assessment capability, as the technical support center facility is located inside the control room envelope."
Notified R2DO (Masters)
Power Reactor
Event Number: 57279
Facility: South Texas
Region: 4 State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Chris Van Fleet
HQ OPS Officer: Jordan Wingate
Region: 4 State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Chris Van Fleet
HQ OPS Officer: Jordan Wingate
Notification Date: 08/21/2024
Notification Time: 01:34 [ET]
Event Date: 08/20/2024
Event Time: 20:10 [CDT]
Last Update Date: 08/21/2024
Notification Time: 01:34 [ET]
Event Date: 08/20/2024
Event Time: 20:10 [CDT]
Last Update Date: 08/21/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Vossmar, Patricia (R4DO)
Vossmar, Patricia (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTROL ROOM FILTRATION SYSTEMS INOPERABLE
The following information was provided by the licensee via fax or email:
"At 2010 CDT on 08/20/2024, with Unit 2 in Mode 1 at 100% power, Train B Essential Chiller was unable to maintain the Chilled Water Outlet Temperature in the required band. Train B Essential Chilled Water and the associated cooled components were declared inoperable. Train B Control Room Makeup and Cleanup Filtration System was declared inoperable due to the unavailability of cooling. Train C Control Room Makeup and Cleanup Filtration System was previously inoperable for planned maintenance for reasons other than loss of cooling. This resulted in the inoperability of two of the three 50-percent capacity safety trains required for accident mitigation.
"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"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:
Train C has been placed back in service and is awaiting testing to verify its ability to perform its safety function. Testing is expected to be completed by 1500 CDT on 08/21/2024. Plant is on a 72 hr S/D clock until restoration is verified.
The following information was provided by the licensee via fax or email:
"At 2010 CDT on 08/20/2024, with Unit 2 in Mode 1 at 100% power, Train B Essential Chiller was unable to maintain the Chilled Water Outlet Temperature in the required band. Train B Essential Chilled Water and the associated cooled components were declared inoperable. Train B Control Room Makeup and Cleanup Filtration System was declared inoperable due to the unavailability of cooling. Train C Control Room Makeup and Cleanup Filtration System was previously inoperable for planned maintenance for reasons other than loss of cooling. This resulted in the inoperability of two of the three 50-percent capacity safety trains required for accident mitigation.
"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"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:
Train C has been placed back in service and is awaiting testing to verify its ability to perform its safety function. Testing is expected to be completed by 1500 CDT on 08/21/2024. Plant is on a 72 hr S/D clock until restoration is verified.
Hospital
Event Number: 57280
Rep Org: VA Boston Healthcare System
Licensee: VA Boston Healthcare System
Region: 3
City: Boston State: MA
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Clinton Abell
HQ OPS Officer: Jordan Wingate
Licensee: VA Boston Healthcare System
Region: 3
City: Boston State: MA
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Clinton Abell
HQ OPS Officer: Jordan Wingate
Notification Date: 08/21/2024
Notification Time: 11:01 [ET]
Event Date: 08/20/2024
Event Time: 13:00 [EDT]
Last Update Date: 08/21/2024
Notification Time: 11:01 [ET]
Event Date: 08/20/2024
Event Time: 13:00 [EDT]
Last Update Date: 08/21/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL UNDERDOSE
The following information was provided by the Department of Veterans Affairs (VA) via email:
"VA Boston Healthcare System, Boston, Massachusetts, which holds Veterans Health Administration (VHA) Permit Number 20-00671-02 under the VA Master Materials License, reported discovery of a medical event to the National Health Physics Program (NHPP) at approximately 1410 CDT, August 20, 2024. A therapeutic administration of Y-90 microspheres (TheraSphere) to the right lobe of a patient's liver was conducted at approximately 1300 EDT on August 20, 2024. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity. The prescribed activity was 42.9 mCi; the administered activity was estimated at 27 mCi. A causal analysis of the medical event is being performed by the medical center.
"The patient and the referring physician have been notified. Short term harm to the patient is not expected. NHPP plans to perform a reactive inspection to assess causes and regulatory compliance. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified the NRC Region III Project Manager, Bryan Parker."
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 information was provided by the Department of Veterans Affairs (VA) via email:
"VA Boston Healthcare System, Boston, Massachusetts, which holds Veterans Health Administration (VHA) Permit Number 20-00671-02 under the VA Master Materials License, reported discovery of a medical event to the National Health Physics Program (NHPP) at approximately 1410 CDT, August 20, 2024. A therapeutic administration of Y-90 microspheres (TheraSphere) to the right lobe of a patient's liver was conducted at approximately 1300 EDT on August 20, 2024. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity. The prescribed activity was 42.9 mCi; the administered activity was estimated at 27 mCi. A causal analysis of the medical event is being performed by the medical center.
"The patient and the referring physician have been notified. Short term harm to the patient is not expected. NHPP plans to perform a reactive inspection to assess causes and regulatory compliance. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified the NRC Region III Project Manager, Bryan Parker."
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: 57281
Rep Org: Utah Division of Radiation Control
Licensee: IGES INGENIEROS DBA Geostrata
Region: 4
City: Magna State: UT
County:
License #: UT 1800434
Agreement: Y
Docket:
NRC Notified By: Tim Butler
HQ OPS Officer: Josue Ramirez
Licensee: IGES INGENIEROS DBA Geostrata
Region: 4
City: Magna State: UT
County:
License #: UT 1800434
Agreement: Y
Docket:
NRC Notified By: Tim Butler
HQ OPS Officer: Josue Ramirez
Notification Date: 08/21/2024
Notification Time: 11:48 [ET]
Event Date: 08/20/2024
Event Time: 14:30 [MDT]
Last Update Date: 08/21/2024
Notification Time: 11:48 [ET]
Event Date: 08/20/2024
Event Time: 14:30 [MDT]
Last Update Date: 08/21/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following summary was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC) via phone and email:
The licensee (IGES INGENIEROS, L.L.C. DBA GEOSTRATA) contacted the DWMRC to report that a portable gauge, Troxler 3430 model, with a 8 mCi Cs-137 and a 40 mCi Am-241/Be source, fall off the back of a truck. Once the licensee noticed the gauge was missing, they returned to the scene and found the damaged gauge. Although the gauge was in pieces, the sources were intact and there was no apparent leakage identified. Swipe tests were taken and the results are pending.
Utah event report ID number: UT 240006
The following summary was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC) via phone and email:
The licensee (IGES INGENIEROS, L.L.C. DBA GEOSTRATA) contacted the DWMRC to report that a portable gauge, Troxler 3430 model, with a 8 mCi Cs-137 and a 40 mCi Am-241/Be source, fall off the back of a truck. Once the licensee noticed the gauge was missing, they returned to the scene and found the damaged gauge. Although the gauge was in pieces, the sources were intact and there was no apparent leakage identified. Swipe tests were taken and the results are pending.
Utah event report ID number: UT 240006
Agreement State
Event Number: 57318
Rep Org: Tennessee Div of Rad Health
Licensee: ARTAZN, LLC
Region: 1
City: Greenville State: TN
County:
License #: R-30012
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Ernest West
Licensee: ARTAZN, LLC
Region: 1
City: Greenville State: TN
County:
License #: R-30012
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Ernest West
Notification Date: 09/11/2024
Notification Time: 17:41 [ET]
Event Date: 08/20/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/11/2024
Notification Time: 17:41 [ET]
Event Date: 08/20/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/11/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Elkhiamy, Sarah (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Elkhiamy, Sarah (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - STUCK OPEN SHUTTER
The following information was provided by the Tennessee Division of Radiological Health via email:
"On August 20, 2024, during a routine calibration of a Global Gauge SS3A, employees at Artazn, LLC were unable to get stable readings. A Global Gauge technician arrived on August 22, 2024, and discovered that the shutter on the gauge was partially stuck open even though operator panel was showing everything as normal. The maximum exposure to workers was calculated to be 3.7 mrem. The available device information is as follows:
"Manufacturer: Global Gauge
"Model: SS3A
"Serial Number: 8376LV
"Isotope: Am-241, 1000 millicuries
"Corrective actions or reports will be updated with a report within 30 days."
Tennessee Event Report ID Number: TN-24-068
The following information was provided by the Tennessee Division of Radiological Health via email:
"On August 20, 2024, during a routine calibration of a Global Gauge SS3A, employees at Artazn, LLC were unable to get stable readings. A Global Gauge technician arrived on August 22, 2024, and discovered that the shutter on the gauge was partially stuck open even though operator panel was showing everything as normal. The maximum exposure to workers was calculated to be 3.7 mrem. The available device information is as follows:
"Manufacturer: Global Gauge
"Model: SS3A
"Serial Number: 8376LV
"Isotope: Am-241, 1000 millicuries
"Corrective actions or reports will be updated with a report within 30 days."
Tennessee Event Report ID Number: TN-24-068
Part 21
Event Number: 57402
Rep Org: Catawba
Licensee: Duke Energy Nuclear Llc
Region: 2
City: York State: SC
County: York
License #:
Agreement: Y
Docket: 05000413
NRC Notified By: Ari Tuckman
HQ OPS Officer: Natalie Starfish
Licensee: Duke Energy Nuclear Llc
Region: 2
City: York State: SC
County: York
License #:
Agreement: Y
Docket: 05000413
NRC Notified By: Ari Tuckman
HQ OPS Officer: Natalie Starfish
Notification Date: 10/28/2024
Notification Time: 13:55 [ET]
Event Date: 08/20/2024
Event Time: 00:00 [EDT]
Last Update Date: 03/13/2025
Notification Time: 13:55 [ET]
Event Date: 08/20/2024
Event Time: 00:00 [EDT]
Last Update Date: 03/13/2025
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Suber, Gregory (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Suber, Gregory (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 3/14/2025
EN Revision Text: PART 21 INTERIM REPORT - POTENTIAL DEFECT WITH CIRCUIT BOARD
The following is a summary of information provided by the licensee via email:
The licensee received two alarms due to direct current (DC) output voltage fluctuating between 127.4 to 131.3 volts. After troubleshooting, the DC output voltage fluctuations were caused by the battery charger printed circuit board. The part has been sent to the vendor, AMETEK, for evaluation. Catawba is the only plant known to have this issue at this time.
The evaluation is expected to be completed on January 31, 2025.
Catawba condition report number: 02526388
AMETEK Part Number: 80-921-4031-90
AMETEK failure analysis number: 24-006
* * * UPDATE ON 01/31/25 AT 1548 EST FROM ETHAN SALSBURY TO KAREN COTTON * * *
AMETEK is continuing its evaluation of the circuit boards. The original evaluation completion date was January 31, 2025. AMETEK is extending the evaluation completion date to February 28, 2025. Remaining steps include completing the cause analysis, identifying all affected equipment, finalizing any corrective action measures, and determining actions required.
Notified R2DO (Suggs), Part 21 Group (email)
* * * UPDATE ON 02/28/25 AT 1509 EST FROM ETHAN SALSBURY TO ERNEST WEST * * *
The following is a synopsis of the information provided from AMETEK:
AMETEK has submitted their final report for the evaluation of the circuit boards in question. AMETEK identified two failed capacitors on a charger control printed circuit board with part number: 80-9214031-90. The two failed capacitors are C35 (part number: 03-010003-00) and C36 (part number: 03-011006-00). These capacitors have been identified to fail prematurely prior to the 10-year replacement schedule in a few identified cases. AMETEK will be conducting further design evaluations on printed circuit board (PCB) 80-9214031-90 and considering design and/or component changes that will further enhance the reliability of the charger control board.
AMETEK reviewed the last 10 years of jobs and identified the following potentially affected U.S. nuclear power plants:
Farley
Braidwood
Byron
Dresden
Fitzpatrick
Ginna
Nine Mile Point
Quad Cities
Millstone
North Anna
Surry
Catawba
Robinson
Harris
McGuire
Oconee
Beaver Valley
Davis Besse 3
Columbia Generating Station
Arkansas Nuclear One
Grand Gulf
River Bend
Waterford
Hatch
Vogtle Unit 1 and Unit 2
DC Cook
Seabrook
Turkey Point
Point Beach
Diablo Canyon
Sequoyah
Watts Bar
Comanche Peak
Prairie Island
Palisades (ISFSI)
Three Mile Island (ISFSI)
Notified R1DO (Defrancisco), R2DO (Penmetsa), R3DO (Feliz-Adorno), R4DO (Roldan-Otero), Part 21 Group (email)
* * * UPDATE ON 03/13/25 AT 1301 EDT FROM ETHAN SALSBURY TO KERBY SCALES * * *
AMETEK provided an update to their final report to include additional variations of the charger control board. There is no change to the affected users, findings, or resolution.
Notified R1DO (Schussler), R2DO (Pearson), R3DO (Edwards), R4DO (Warnick), Part 21 Group (email)
EN Revision Text: PART 21 INTERIM REPORT - POTENTIAL DEFECT WITH CIRCUIT BOARD
The following is a summary of information provided by the licensee via email:
The licensee received two alarms due to direct current (DC) output voltage fluctuating between 127.4 to 131.3 volts. After troubleshooting, the DC output voltage fluctuations were caused by the battery charger printed circuit board. The part has been sent to the vendor, AMETEK, for evaluation. Catawba is the only plant known to have this issue at this time.
The evaluation is expected to be completed on January 31, 2025.
Catawba condition report number: 02526388
AMETEK Part Number: 80-921-4031-90
AMETEK failure analysis number: 24-006
* * * UPDATE ON 01/31/25 AT 1548 EST FROM ETHAN SALSBURY TO KAREN COTTON * * *
AMETEK is continuing its evaluation of the circuit boards. The original evaluation completion date was January 31, 2025. AMETEK is extending the evaluation completion date to February 28, 2025. Remaining steps include completing the cause analysis, identifying all affected equipment, finalizing any corrective action measures, and determining actions required.
Notified R2DO (Suggs), Part 21 Group (email)
* * * UPDATE ON 02/28/25 AT 1509 EST FROM ETHAN SALSBURY TO ERNEST WEST * * *
The following is a synopsis of the information provided from AMETEK:
AMETEK has submitted their final report for the evaluation of the circuit boards in question. AMETEK identified two failed capacitors on a charger control printed circuit board with part number: 80-9214031-90. The two failed capacitors are C35 (part number: 03-010003-00) and C36 (part number: 03-011006-00). These capacitors have been identified to fail prematurely prior to the 10-year replacement schedule in a few identified cases. AMETEK will be conducting further design evaluations on printed circuit board (PCB) 80-9214031-90 and considering design and/or component changes that will further enhance the reliability of the charger control board.
AMETEK reviewed the last 10 years of jobs and identified the following potentially affected U.S. nuclear power plants:
Farley
Braidwood
Byron
Dresden
Fitzpatrick
Ginna
Nine Mile Point
Quad Cities
Millstone
North Anna
Surry
Catawba
Robinson
Harris
McGuire
Oconee
Beaver Valley
Davis Besse 3
Columbia Generating Station
Arkansas Nuclear One
Grand Gulf
River Bend
Waterford
Hatch
Vogtle Unit 1 and Unit 2
DC Cook
Seabrook
Turkey Point
Point Beach
Diablo Canyon
Sequoyah
Watts Bar
Comanche Peak
Prairie Island
Palisades (ISFSI)
Three Mile Island (ISFSI)
Notified R1DO (Defrancisco), R2DO (Penmetsa), R3DO (Feliz-Adorno), R4DO (Roldan-Otero), Part 21 Group (email)
* * * UPDATE ON 03/13/25 AT 1301 EDT FROM ETHAN SALSBURY TO KERBY SCALES * * *
AMETEK provided an update to their final report to include additional variations of the charger control board. There is no change to the affected users, findings, or resolution.
Notified R1DO (Schussler), R2DO (Pearson), R3DO (Edwards), R4DO (Warnick), Part 21 Group (email)