Event Notification Report for September 17, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/16/2024 - 09/17/2024
EVENT NUMBERS
571855723457260572665729157312573225732457325569695724357268572935731557316573175731857326
571855723457260572665729157312573225732457325569695724357268572935731557316573175731857326
Agreement State
Event Number: 57185
Rep Org: New York State Dept. of Health
Licensee: NRD, LLC
Region: 1
City: Grand Island State: NY
County:
License #: C1391
Agreement: Y
Docket:
NRC Notified By: Nathaniel Kishbaugh
HQ OPS Officer: Robert A. Thompson
Licensee: NRD, LLC
Region: 1
City: Grand Island State: NY
County:
License #: C1391
Agreement: Y
Docket:
NRC Notified By: Nathaniel Kishbaugh
HQ OPS Officer: Robert A. Thompson
Notification Date: 06/20/2024
Notification Time: 15:22 [ET]
Event Date: 06/10/2024
Event Time: 16:30 [EDT]
Last Update Date: 09/16/2024
Notification Time: 15:22 [ET]
Event Date: 06/10/2024
Event Time: 16:30 [EDT]
Last Update Date: 09/16/2024
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)
EN Revision Imported Date: 9/17/2024
EN Revision Text: AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION
The following is a summary of information provided by the New York State Department of Health (NYSDOH) via email:
"NYSDOH received an email from the radiation safety officer of NRD on 6/11/2024 to indicate that a non-routine bioassay was started for an employee due to hand contamination. The employee's hand was decontaminated with soap and water and a whole-body frisk and nasal swabs were conducted. The whole-body count and nasal swabs were less than background.
"[After NYSDOH inquiry, the licensee subsequently reported that] the incident occurred on 6/10/2024 at 1630 EDT and was identified when the employee was leaving the facility. As a standard procedure implemented by license condition, the employee was frisking hands and feet for potential removable contamination. It was discovered upon frisking that the employee had 758 disintegrations per minute of suspected Am-241 on the palm of their left hand when leaving the facility. This amount of alpha skin contamination is 63 times the incident levels established on the license.
"[The employee] was transferring contaminated personal protective equipment (PPE) bags into a B25 [shielded waste] container. [The employee is believed to have] incorrectly doffed gloves. No other individuals had contamination present. A survey was performed of the area showing no contamination in excess of background levels on the surfaces, including the external surface of the B25 container.
"NRD is still performing an investigation, reporting their findings, and providing NYSDOH with bioassay data for this employee.
"It is unclear if this event truly meets the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH wishes to voluntarily report this event in the event [it is reportable,] regardless of applicability. NYSDOH will provide updates as appropriate regarding this incident."
NYSDOH Incident Number 1489
* * * UPDATE ON 9/16/2024 AT 1624 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"Following the original notification, the worker in question's bioassay result indicated that no Am-241 or Po-210 in excess of this individual's baseline concentrations were present (all 'undetected'). Additionally, this worker's dosimeter did not record any dose received (dose received was below detection limits). This event did not meet the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH voluntarily reported this event regardless of applicability.
"As a corrective action, this worker was retrained by the licensee in proper use of PPE, including procedures to properly don and doff PPE. As this was the second event within the past month involving a hand contamination, the licensee also provided additional educational signage for reminding staff on proper PPE usage, training videos and hands-on demonstrations during annual refresher training. Furthermore, additional contamination equipment was purchased to improve monitoring capabilities of staff involved with handling radionuclides.
"NYSDOH has accepted these corrective actions and will evaluate the implementation of these actions on the next inspection. NYSDOH has closed this event."
Notified R1DO (Werkheiser), NMSS (email).
EN Revision Text: AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION
The following is a summary of information provided by the New York State Department of Health (NYSDOH) via email:
"NYSDOH received an email from the radiation safety officer of NRD on 6/11/2024 to indicate that a non-routine bioassay was started for an employee due to hand contamination. The employee's hand was decontaminated with soap and water and a whole-body frisk and nasal swabs were conducted. The whole-body count and nasal swabs were less than background.
"[After NYSDOH inquiry, the licensee subsequently reported that] the incident occurred on 6/10/2024 at 1630 EDT and was identified when the employee was leaving the facility. As a standard procedure implemented by license condition, the employee was frisking hands and feet for potential removable contamination. It was discovered upon frisking that the employee had 758 disintegrations per minute of suspected Am-241 on the palm of their left hand when leaving the facility. This amount of alpha skin contamination is 63 times the incident levels established on the license.
"[The employee] was transferring contaminated personal protective equipment (PPE) bags into a B25 [shielded waste] container. [The employee is believed to have] incorrectly doffed gloves. No other individuals had contamination present. A survey was performed of the area showing no contamination in excess of background levels on the surfaces, including the external surface of the B25 container.
"NRD is still performing an investigation, reporting their findings, and providing NYSDOH with bioassay data for this employee.
"It is unclear if this event truly meets the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH wishes to voluntarily report this event in the event [it is reportable,] regardless of applicability. NYSDOH will provide updates as appropriate regarding this incident."
NYSDOH Incident Number 1489
* * * UPDATE ON 9/16/2024 AT 1624 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"Following the original notification, the worker in question's bioassay result indicated that no Am-241 or Po-210 in excess of this individual's baseline concentrations were present (all 'undetected'). Additionally, this worker's dosimeter did not record any dose received (dose received was below detection limits). This event did not meet the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH voluntarily reported this event regardless of applicability.
"As a corrective action, this worker was retrained by the licensee in proper use of PPE, including procedures to properly don and doff PPE. As this was the second event within the past month involving a hand contamination, the licensee also provided additional educational signage for reminding staff on proper PPE usage, training videos and hands-on demonstrations during annual refresher training. Furthermore, additional contamination equipment was purchased to improve monitoring capabilities of staff involved with handling radionuclides.
"NYSDOH has accepted these corrective actions and will evaluate the implementation of these actions on the next inspection. NYSDOH has closed this event."
Notified R1DO (Werkheiser), NMSS (email).
Agreement State
Event Number: 57234
Rep Org: New York State Dept. of Health
Licensee: State University of New York (SUNY) at Stony Brook
Region: 1
City: Stony Brook State: NY
County:
License #: 0455
Agreement: Y
Docket:
NRC Notified By: Nathaniel A. Kishbaugh
HQ OPS Officer: Josue Ramirez
Licensee: State University of New York (SUNY) at Stony Brook
Region: 1
City: Stony Brook State: NY
County:
License #: 0455
Agreement: Y
Docket:
NRC Notified By: Nathaniel A. Kishbaugh
HQ OPS Officer: Josue Ramirez
Notification Date: 07/22/2024
Notification Time: 13:02 [ET]
Event Date: 07/18/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2024
Notification Time: 13:02 [ET]
Event Date: 07/18/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada) (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada) (EMAIL)
EN Revision Imported Date: 9/17/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"The NYSDOH received an email from the radiation safety officer (RSO) on July 22, 2024, to report a lost Fe-55 source. The make and model of the missing source was not disclosed; however, NYSDOH is requesting additional information and will provide this information once available. The source serial no. is 55-1.1-8 and was last assayed 10/1/2015. At the time of manufacture and distribution, this source was 10 mCi.
"The source in question was last seen during routine inventory on January 5, 2023. Following this inventory, this source was not accounted for on March 23, 2023. It was believed that this source may have been utilized by an authorized user between January 5, 2023, and March 23, 2023. However, after many discussions between the authorized user and Stony Brook University's radiation safety office, it was confirmed that the source in question was officially lost on 7/18/2024. Decay calculations suggest that the missing Fe-55 source is approximately 1.07 mCi to date. As this source was last inventoried on January 5, 2023, it is estimated that the Fe-55 source was approximately 1.58 mCi at the time it was last confirmed as present in the storage area. This activity is approximately 15.8 times the quantity for Fe-55 requiring labeling as stated in Appendix C to 10 CFR 20. The loss of this source meets the reportability criteria in 10 CFR 20.2201(a)(1)(ii).
"It is not believed that this source may cause any incidental doses which may exceed the limits in Subparts C or D of 10 CFR 20. Furthermore, the loss of this source would not be expected to have any negative implications on public health. NYSDOH is monitoring this incident and has assigned incident number 1493 to track this event. Additional information will be provided to NMED once available."
Event Report ID No. NY-24-06
NYSDOH Incident Number: 1493
* * * UPDATE ON 9/16/2024 AT 1155 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"On July 31, 2024, NYSDOH performed a full inspection and performed an on-site evaluation of this event. The above information provided indicated that the authorized user in question had their permits administratively terminated and their membership on the university's Radiation Safety Committee revoked because of this event and other compliance issues with the university's Radiation Safety Office.
"To date, the Fe-55 source in question is still missing. The radiation safety office (RSO) for the licensee is maintaining vigilance when performing audits and permit reviews for other permit holders to see if this Fe-55 source may be located. Additionally, the RSO has implemented a new inventory management system at their facility to further improve accountability of similar sources to prevent recurrence. NYSDOH was monitoring this incident and assigned incident number 1493 to track this event. At this time, NYSDOH has closed incident number 1493 given the corrective actions from this event but will reopen this incident in the event additional information is obtained or the source is located. The licensee is aware of the reporting requirement in the event additional information on this source is discovered following closeout."
Notified R1DO (Werkheiser), NMSS (email), ILTAB (email), CNSC (Canada) (email).
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
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"The NYSDOH received an email from the radiation safety officer (RSO) on July 22, 2024, to report a lost Fe-55 source. The make and model of the missing source was not disclosed; however, NYSDOH is requesting additional information and will provide this information once available. The source serial no. is 55-1.1-8 and was last assayed 10/1/2015. At the time of manufacture and distribution, this source was 10 mCi.
"The source in question was last seen during routine inventory on January 5, 2023. Following this inventory, this source was not accounted for on March 23, 2023. It was believed that this source may have been utilized by an authorized user between January 5, 2023, and March 23, 2023. However, after many discussions between the authorized user and Stony Brook University's radiation safety office, it was confirmed that the source in question was officially lost on 7/18/2024. Decay calculations suggest that the missing Fe-55 source is approximately 1.07 mCi to date. As this source was last inventoried on January 5, 2023, it is estimated that the Fe-55 source was approximately 1.58 mCi at the time it was last confirmed as present in the storage area. This activity is approximately 15.8 times the quantity for Fe-55 requiring labeling as stated in Appendix C to 10 CFR 20. The loss of this source meets the reportability criteria in 10 CFR 20.2201(a)(1)(ii).
"It is not believed that this source may cause any incidental doses which may exceed the limits in Subparts C or D of 10 CFR 20. Furthermore, the loss of this source would not be expected to have any negative implications on public health. NYSDOH is monitoring this incident and has assigned incident number 1493 to track this event. Additional information will be provided to NMED once available."
Event Report ID No. NY-24-06
NYSDOH Incident Number: 1493
* * * UPDATE ON 9/16/2024 AT 1155 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"On July 31, 2024, NYSDOH performed a full inspection and performed an on-site evaluation of this event. The above information provided indicated that the authorized user in question had their permits administratively terminated and their membership on the university's Radiation Safety Committee revoked because of this event and other compliance issues with the university's Radiation Safety Office.
"To date, the Fe-55 source in question is still missing. The radiation safety office (RSO) for the licensee is maintaining vigilance when performing audits and permit reviews for other permit holders to see if this Fe-55 source may be located. Additionally, the RSO has implemented a new inventory management system at their facility to further improve accountability of similar sources to prevent recurrence. NYSDOH was monitoring this incident and assigned incident number 1493 to track this event. At this time, NYSDOH has closed incident number 1493 given the corrective actions from this event but will reopen this incident in the event additional information is obtained or the source is located. The licensee is aware of the reporting requirement in the event additional information on this source is discovered following closeout."
Notified R1DO (Werkheiser), NMSS (email), ILTAB (email), CNSC (Canada) (email).
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
Agreement State
Event Number: 57260
Rep Org: NC Dept of Health and Human Serv
Licensee: Volkert
Region: 1
City: Charlotte State: NC
County:
License #: 065-1551-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Robert A. Thompson
Licensee: Volkert
Region: 1
City: Charlotte State: NC
County:
License #: 065-1551-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Robert A. Thompson
Notification Date: 08/02/2024
Notification Time: 13:17 [ET]
Event Date: 08/01/2024
Event Time: 08:00 [EDT]
Last Update Date: 09/16/2024
Notification Time: 13:17 [ET]
Event Date: 08/01/2024
Event Time: 08:00 [EDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 9/17/2024
EN Revision Text: AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE
The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:
"The licensee reported that around 0800 EDT on August 1, 2024, it was discovered that a break-in had occurred at a construction site. Their portable nuclear gauge (PNG) containing 8 mCi Cs-137 and 40 mCi of Am-241/Be was stolen. The construction site is a locked and secured fenced area with the licensee's Conex box inside that secured area. The PNG was located inside the Conex box, locked inside its own secured steel storage box, secured via chains and locks to the inside of the Conex box. The steel box containing the PNG was also locked with chains and locks.
"The fenced area was broken into and the doors to the Conex box were forced open with a large sheepsfoot roller, allowing the thieves' access to the steel box containing the PNG.
"RMB's investigation is ongoing. A follow-up report will be made to close and complete the record."
NC event number: NC240004
NMED Number 240271
* * * UPDATE ON 9/16/2024 AT 0951 EDT FROM TRAVIS CARTOSKI to SAMUEL COLVARD * * *
The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:
"RMB have completed the investigation and consider the case closed given the following information."
"No additional party was involved. Corrective action is not needed as the licensee was not found in violation and adhered to all security requirements as required by the rule. Device info: Portable nuclear gauge, Troxler model 3440, serial number 14357."
Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email).
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.pdfThe following information was provided by the licensee via fax or email:
EN Revision Text: AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE
The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:
"The licensee reported that around 0800 EDT on August 1, 2024, it was discovered that a break-in had occurred at a construction site. Their portable nuclear gauge (PNG) containing 8 mCi Cs-137 and 40 mCi of Am-241/Be was stolen. The construction site is a locked and secured fenced area with the licensee's Conex box inside that secured area. The PNG was located inside the Conex box, locked inside its own secured steel storage box, secured via chains and locks to the inside of the Conex box. The steel box containing the PNG was also locked with chains and locks.
"The fenced area was broken into and the doors to the Conex box were forced open with a large sheepsfoot roller, allowing the thieves' access to the steel box containing the PNG.
"RMB's investigation is ongoing. A follow-up report will be made to close and complete the record."
NC event number: NC240004
NMED Number 240271
* * * UPDATE ON 9/16/2024 AT 0951 EDT FROM TRAVIS CARTOSKI to SAMUEL COLVARD * * *
The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:
"RMB have completed the investigation and consider the case closed given the following information."
"No additional party was involved. Corrective action is not needed as the licensee was not found in violation and adhered to all security requirements as required by the rule. Device info: Portable nuclear gauge, Troxler model 3440, serial number 14357."
Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email).
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.pdfThe following information was provided by the licensee via fax or email:
Agreement State
Event Number: 57266
Rep Org: New York State Dept. of Health
Licensee: Kleinfelder, Inc.
Region: 1
City: Syracuse State: NY
County:
License #: MD-05-248-01
Agreement: Y
Docket:
NRC Notified By: Nate Kishbaugh
HQ OPS Officer: Robert A. Thompson
Licensee: Kleinfelder, Inc.
Region: 1
City: Syracuse State: NY
County:
License #: MD-05-248-01
Agreement: Y
Docket:
NRC Notified By: Nate Kishbaugh
HQ OPS Officer: Robert A. Thompson
Notification Date: 08/08/2024
Notification Time: 13:29 [ET]
Event Date: 08/07/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2024
Notification Time: 13:29 [ET]
Event Date: 08/07/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 9/17/2024
EN Revision Text: AGREEMENT STATE - DAMAGED MOISTURE DENSITY GAUGE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"NYSDOH received a phone call from the radiation safety officer (RSO) on August 7, 2024, to report a damaged moisture density gauge. The gauge was struck by a passing skid steer.
"Device Make: Instrotek
"Device Model: 3500
"Isotopes: Am-241/Be (44mCi), Cs-137 (11mCi)
"The area was cordoned off. The gauge base plate appeared damaged. The source rod was not exposed. Measurements taken with a survey meter were 0.2 mR/hr at 3ft, which appears consistent with the radiation dose profile for this instrument per the sealed source and device registry.
"The RSO reports that the device was removed from the site at the request of the client and transported to the Kleinfelder Scranton, PA, location for leak testing. A leak test was performed and sent out for analysis, however, at this time is not believed that the source would be leaking. It is not believed that this event led to any degradation of the source, source housing, or shielding. NYSDOH is monitoring this incident and has assigned incident number 1496 to track this event.
"As this company was performing work under reciprocity, the State of Maryland and the Commonwealth of Pennsylvania have also been notified of this event for their awareness. Additional information will be provided to NMED once available."
New York event report ID: NY-24-07
* * * UPDATE ON 8/09/2024 AT 1643 EDT FROM ATNATIWOS MESHESHA TO JOSUE RAMIREZ * * *
This event was also reported by the State of Maryland under EN 57267.
Notified R1DO (Bickett), NMSS Events Notifications (Email).
* * * UPDATE ON 9/16/2024 AT 1643 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"Following the original notification of this event, it was confirmed via leak testing of both the Cs-137 source and Am-241/Be source that neither source was breached, damaged, or leaking from this event. Furthermore, an additional radiation protection survey indicated that there were no breaches to the shielding or integrity of this device and no essential safety functions were damaged. The extent of damage to the baseplate was cosmetic.
"As a corrective action, the licensee retrained the responsible authorized user of the device, including manufacturer's operation training, licensee specific policies and procedure, and a demonstration of proper use of the device with the radiation safety officer (RSO). On August 8, 2024, all authorized users were retrained in constant surveillance and immediate control of the gauges when not secured in permanent storage. Additionally, the licensee placed highly visible stickers affixed to their gauges to remind authorized users to maintain constant surveillance and immediate control over gauges.
"NYSDOH has accepted the findings from this investigation and have accepted the licensee's proposed corrective actions. As a result, NYSDOH has closed this incident."
Notified R1DO (Werkheiser), NMSS Events Notifications (Email).
EN Revision Text: AGREEMENT STATE - DAMAGED MOISTURE DENSITY GAUGE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"NYSDOH received a phone call from the radiation safety officer (RSO) on August 7, 2024, to report a damaged moisture density gauge. The gauge was struck by a passing skid steer.
"Device Make: Instrotek
"Device Model: 3500
"Isotopes: Am-241/Be (44mCi), Cs-137 (11mCi)
"The area was cordoned off. The gauge base plate appeared damaged. The source rod was not exposed. Measurements taken with a survey meter were 0.2 mR/hr at 3ft, which appears consistent with the radiation dose profile for this instrument per the sealed source and device registry.
"The RSO reports that the device was removed from the site at the request of the client and transported to the Kleinfelder Scranton, PA, location for leak testing. A leak test was performed and sent out for analysis, however, at this time is not believed that the source would be leaking. It is not believed that this event led to any degradation of the source, source housing, or shielding. NYSDOH is monitoring this incident and has assigned incident number 1496 to track this event.
"As this company was performing work under reciprocity, the State of Maryland and the Commonwealth of Pennsylvania have also been notified of this event for their awareness. Additional information will be provided to NMED once available."
New York event report ID: NY-24-07
* * * UPDATE ON 8/09/2024 AT 1643 EDT FROM ATNATIWOS MESHESHA TO JOSUE RAMIREZ * * *
This event was also reported by the State of Maryland under EN 57267.
Notified R1DO (Bickett), NMSS Events Notifications (Email).
* * * UPDATE ON 9/16/2024 AT 1643 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"Following the original notification of this event, it was confirmed via leak testing of both the Cs-137 source and Am-241/Be source that neither source was breached, damaged, or leaking from this event. Furthermore, an additional radiation protection survey indicated that there were no breaches to the shielding or integrity of this device and no essential safety functions were damaged. The extent of damage to the baseplate was cosmetic.
"As a corrective action, the licensee retrained the responsible authorized user of the device, including manufacturer's operation training, licensee specific policies and procedure, and a demonstration of proper use of the device with the radiation safety officer (RSO). On August 8, 2024, all authorized users were retrained in constant surveillance and immediate control of the gauges when not secured in permanent storage. Additionally, the licensee placed highly visible stickers affixed to their gauges to remind authorized users to maintain constant surveillance and immediate control over gauges.
"NYSDOH has accepted the findings from this investigation and have accepted the licensee's proposed corrective actions. As a result, NYSDOH has closed this incident."
Notified R1DO (Werkheiser), NMSS Events Notifications (Email).
Power Reactor
Event Number: 57291
Facility: Farley
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: David Hershman
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: David Hershman
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/26/2024
Notification Time: 16:54 [ET]
Event Date: 08/26/2024
Event Time: 12:00 [CDT]
Last Update Date: 09/16/2024
Notification Time: 16:54 [ET]
Event Date: 08/26/2024
Event Time: 12:00 [CDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Masters, Anthony (R2DO)
FFD Group, (EMAIL)
Masters, Anthony (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 9/17/2024
EN Revision Text: FALSE NEGATIVE INDICATED ON A FITNESS FOR DUTY BLIND QUALITY ASSURANCE TEST
The following information was provided by the licensee via email:
"On 8/26/2024 at 1200 CDT, Farley Nuclear Plant Medical Services identified a false negative quality assurance test. [The contracted laboratory] was provided an adulterated sample of hydrocodone and hydromorphone that was part of a blind performance test. The results from the [contracted laboratory] returned a false negative. This false negative test result will be investigated, and the results reported as required.
"This event is being reported in accordance with 10 CFR 26.719(c)(3).
"The NRC resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officer Report Guidance:
The contracted laboratory was a U.S. Department of Health and Human Service (HHS) certified laboratory.
* * * RETRACTION ON 09/16/24 AT 1014 EDT FROM RONNIE SUBER TO KERBY SCALES * * *
The following update was provided by the licensee via email:
"Following further review of the event, it has been determined that this issue is not reportable under 10CFR26.719(c)(3) as the unsatisfactory test was not for a validity screening test. This event is reportable for testing errors in accordance with 10CFR26.719(c)(1) and a 30 day report will be submitted."
Notified R2DO (Suber) and FFD Group (email).
EN Revision Text: FALSE NEGATIVE INDICATED ON A FITNESS FOR DUTY BLIND QUALITY ASSURANCE TEST
The following information was provided by the licensee via email:
"On 8/26/2024 at 1200 CDT, Farley Nuclear Plant Medical Services identified a false negative quality assurance test. [The contracted laboratory] was provided an adulterated sample of hydrocodone and hydromorphone that was part of a blind performance test. The results from the [contracted laboratory] returned a false negative. This false negative test result will be investigated, and the results reported as required.
"This event is being reported in accordance with 10 CFR 26.719(c)(3).
"The NRC resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officer Report Guidance:
The contracted laboratory was a U.S. Department of Health and Human Service (HHS) certified laboratory.
* * * RETRACTION ON 09/16/24 AT 1014 EDT FROM RONNIE SUBER TO KERBY SCALES * * *
The following update was provided by the licensee via email:
"Following further review of the event, it has been determined that this issue is not reportable under 10CFR26.719(c)(3) as the unsatisfactory test was not for a validity screening test. This event is reportable for testing errors in accordance with 10CFR26.719(c)(1) and a 30 day report will be submitted."
Notified R2DO (Suber) and FFD Group (email).
Agreement State
Event Number: 57312
Rep Org: Kentucky Dept of Radiation Control
Licensee: Coal mining facility
Region: 1
City: Helton State: KY
County:
License #: TBD
Agreement: Y
Docket:
NRC Notified By: Matthew McKinley
HQ OPS Officer: Josue Ramirez
Licensee: Coal mining facility
Region: 1
City: Helton State: KY
County:
License #: TBD
Agreement: Y
Docket:
NRC Notified By: Matthew McKinley
HQ OPS Officer: Josue Ramirez
Notification Date: 09/06/2024
Notification Time: 18:49 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2024
Notification Time: 18:49 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ferdas, Marc (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Ferdas, Marc (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
EN Revision Imported Date: 9/17/2024
EN Revision Text: AGREEMENT STATE REPORT - MISSING GAUGES
The following is a summary of information provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via phone:
In the conduct of their regulatory duties, RHB established a program to collect and store nuclear gauges from closed or abandoned mining sites. This initiative is aimed at preventing improper disposal of nuclear gauges during reclamation operations.
On September 6, 2024, RHB inspected one such coal mining facility located in Helton, KY, in an attempt to recover six fixed Cs-137 level gauges with an aggregate activity of approximately 700 mCi. The storage facility for the gauges was found open and the gauges were missing. The last recorded inventory of the gauges occurred in 2021. Local law enforcement and state emergency operations were notified. It is believed that the gauges were improperly discarded either by the previous owner or by the reclamation company.
RHB will continue to investigate this event and provide updates in accordance with SA-300. No risk to the public is anticipated from this event.
* * * UPDATE ON 9/16/2024 AT 0959 EDT FROM RUSSELL HESTAND TO SAMUEL COLVARD * * *
The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email:
"RHB is in the process of repossessing nuclear gauges from abandoned coal mines. In the process of assessing the number and state of each gauge, it was discovered that the building at the [Big Laurel #1 prep plant] was demolished. The storage cabinet located in that building was missing. On September 6, 2024, an onsite investigation of the facility was performed. The storage cabinet was located on the property. The storage cabinet was damaged and the contents of the cabinet (6 gauges with 700 mCi of Cs-137) were missing.
"The last known pictures and inventory from a routine inspection on June 23, 2021, showed the gauges stored in the locked metal cabinet at the warehouse where Big Laurel #1 prep plant, operated by Bledsoe Coal, then Revelation Energy and later under reclamation by Black Mountain Resources, are now gone.
"On September 10, 2024, at 1153 EDT, RHB was notified of a smelter in West Virginia that had their portal monitors alarmed. The load was returned to its origin site located in Hazard, Kentucky. RHB representatives were dispatched to the facility. Upon arrival at the scrapyard facility, two gauges were present. The gauges were compared to the last known inventory at Big Laurel. Both gauges were positively identified as property of said plant. Both gauges were surveyed for removable contamination. All levels for removable contamination were at or below background. The two gauges were then packaged and secured for transport to RHB in Frankfort, Kentucky. RHB has possession of the two gauges.
"On September 13, 2024, RHB was notified that that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel will be dispatched on September 17, 2024, to secure the additional gauge. The gauge will be stored at RHB in a secure location."
Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email)
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
EN Revision Text: AGREEMENT STATE REPORT - MISSING GAUGES
The following is a summary of information provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via phone:
In the conduct of their regulatory duties, RHB established a program to collect and store nuclear gauges from closed or abandoned mining sites. This initiative is aimed at preventing improper disposal of nuclear gauges during reclamation operations.
On September 6, 2024, RHB inspected one such coal mining facility located in Helton, KY, in an attempt to recover six fixed Cs-137 level gauges with an aggregate activity of approximately 700 mCi. The storage facility for the gauges was found open and the gauges were missing. The last recorded inventory of the gauges occurred in 2021. Local law enforcement and state emergency operations were notified. It is believed that the gauges were improperly discarded either by the previous owner or by the reclamation company.
RHB will continue to investigate this event and provide updates in accordance with SA-300. No risk to the public is anticipated from this event.
* * * UPDATE ON 9/16/2024 AT 0959 EDT FROM RUSSELL HESTAND TO SAMUEL COLVARD * * *
The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email:
"RHB is in the process of repossessing nuclear gauges from abandoned coal mines. In the process of assessing the number and state of each gauge, it was discovered that the building at the [Big Laurel #1 prep plant] was demolished. The storage cabinet located in that building was missing. On September 6, 2024, an onsite investigation of the facility was performed. The storage cabinet was located on the property. The storage cabinet was damaged and the contents of the cabinet (6 gauges with 700 mCi of Cs-137) were missing.
"The last known pictures and inventory from a routine inspection on June 23, 2021, showed the gauges stored in the locked metal cabinet at the warehouse where Big Laurel #1 prep plant, operated by Bledsoe Coal, then Revelation Energy and later under reclamation by Black Mountain Resources, are now gone.
"On September 10, 2024, at 1153 EDT, RHB was notified of a smelter in West Virginia that had their portal monitors alarmed. The load was returned to its origin site located in Hazard, Kentucky. RHB representatives were dispatched to the facility. Upon arrival at the scrapyard facility, two gauges were present. The gauges were compared to the last known inventory at Big Laurel. Both gauges were positively identified as property of said plant. Both gauges were surveyed for removable contamination. All levels for removable contamination were at or below background. The two gauges were then packaged and secured for transport to RHB in Frankfort, Kentucky. RHB has possession of the two gauges.
"On September 13, 2024, RHB was notified that that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel will be dispatched on September 17, 2024, to secure the additional gauge. The gauge will be stored at RHB in a secure location."
Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email)
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: 57322
Facility: Brunswick
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Joseph Atkinson
HQ OPS Officer: Robert A. Thompson
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Joseph Atkinson
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/16/2024
Notification Time: 13:02 [ET]
Event Date: 09/16/2024
Event Time: 12:40 [EDT]
Last Update Date: 09/17/2024
Notification Time: 13:02 [ET]
Event Date: 09/16/2024
Event Time: 12:40 [EDT]
Last Update Date: 09/17/2024
Emergency Class: Unusual Event
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
Person (Organization):
Suber, Gregory (R2DO)
Laura Dudes (RA)
Andrea Veil (NRR)
Craig Erlanger (NSIR)
Crouch, Howard (IR)
Suber, Gregory (R2DO)
Laura Dudes (RA)
Andrea Veil (NRR)
Craig Erlanger (NSIR)
Crouch, Howard (IR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 9/18/2024
EN Revision Text: NOTIFICATION OF UNUSUAL EVENT DUE TO SITE ACCESS IMPEDED
The following information was provided by the licensee via fax and phone:
"On September 16, 2024, at 1240 EDT, with Unit 1 in mode 1 at 100 percent power and Unit 2 in mode 1 at 100 percent power, an Unusual Event was declared due to roads in the area leading to the plant being flooded and having the potential to prohibit plant staff from accessing the site via personal vehicles (Emergency Action Level HU3.4). Current onsite plant staff is sufficient for plant operation.
"This event is being reported in accordance with 10 CFR 50.72(a)(1)(i) due to the declaration of an emergency classification as specified in the approved Emergency Plan.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The NRC decided to remain in the Normal mode of operation at 1320 EDT.
Notified DHS SWO, FEMA Ops Center, CISA Central Watch Officer, FEMA NWC (email), DHS Nuclear SSA (email), CWMD Watch Desk (email).
* * * UPDATE ON 9/17/2024 AT 1411 EDT FROM DAVID MACDONALD TO ROBERT THOMPSON * * *
The following information was provided by the licensee via phone and email:
"At approximately 1400 EDT on September 17, 2024, the Unusual Event at Brunswick was terminated due to the flood waters receding and roads to the plant becoming passable.
"The NRC resident inspector has been notified."
Notified R2DO (Suber), NRR EO (Felts), IR MOC (Crouch), DHS SWO, FEMA Ops Center, CISA Central Watch Officer, FEMA NWC (email), DHS Nuclear SSA (email), CWMD Watch Desk (email).
EN Revision Text: NOTIFICATION OF UNUSUAL EVENT DUE TO SITE ACCESS IMPEDED
The following information was provided by the licensee via fax and phone:
"On September 16, 2024, at 1240 EDT, with Unit 1 in mode 1 at 100 percent power and Unit 2 in mode 1 at 100 percent power, an Unusual Event was declared due to roads in the area leading to the plant being flooded and having the potential to prohibit plant staff from accessing the site via personal vehicles (Emergency Action Level HU3.4). Current onsite plant staff is sufficient for plant operation.
"This event is being reported in accordance with 10 CFR 50.72(a)(1)(i) due to the declaration of an emergency classification as specified in the approved Emergency Plan.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The NRC decided to remain in the Normal mode of operation at 1320 EDT.
Notified DHS SWO, FEMA Ops Center, CISA Central Watch Officer, FEMA NWC (email), DHS Nuclear SSA (email), CWMD Watch Desk (email).
* * * UPDATE ON 9/17/2024 AT 1411 EDT FROM DAVID MACDONALD TO ROBERT THOMPSON * * *
The following information was provided by the licensee via phone and email:
"At approximately 1400 EDT on September 17, 2024, the Unusual Event at Brunswick was terminated due to the flood waters receding and roads to the plant becoming passable.
"The NRC resident inspector has been notified."
Notified R2DO (Suber), NRR EO (Felts), IR MOC (Crouch), DHS SWO, FEMA Ops Center, CISA Central Watch Officer, FEMA NWC (email), DHS Nuclear SSA (email), CWMD Watch Desk (email).
Power Reactor
Event Number: 57324
Facility: Watts Bar
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Chris Mitschelen
HQ OPS Officer: Robert A. Thompson
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Chris Mitschelen
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/16/2024
Notification Time: 16:30 [ET]
Event Date: 07/22/2024
Event Time: 12:48 [EDT]
Last Update Date: 09/16/2024
Notification Time: 16:30 [ET]
Event Date: 07/22/2024
Event Time: 12:48 [EDT]
Last Update Date: 09/16/2024
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):
Suber, Gregory (R2DO)
Suber, Gregory (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 |
EN Revision Imported Date: 9/17/2024
EN Revision Text: 60-DAY NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"At 1248 EDT on July 22, 2024, with Unit 1 in mode 1 at 100% power, a complete actuation of the 'A' train containment ventilation isolation (CVI) occurred. The 'A' train CVI resulted from the failure of a radiation monitor providing input to the isolation circuitry. This radiation monitor was subsequently repaired and a restoration from the CVI was made. The CVI removes containment purge from operation should it be in service and secures other radiation monitors which measure reactor coolant system leakage.
"This report is being made under 10 CFR 50.73(a)(2)(iv)(A) as an event that resulted in an invalid actuation of the 'A' train CVI.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector was notified of the event."
EN Revision Text: 60-DAY NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"At 1248 EDT on July 22, 2024, with Unit 1 in mode 1 at 100% power, a complete actuation of the 'A' train containment ventilation isolation (CVI) occurred. The 'A' train CVI resulted from the failure of a radiation monitor providing input to the isolation circuitry. This radiation monitor was subsequently repaired and a restoration from the CVI was made. The CVI removes containment purge from operation should it be in service and secures other radiation monitors which measure reactor coolant system leakage.
"This report is being made under 10 CFR 50.73(a)(2)(iv)(A) as an event that resulted in an invalid actuation of the 'A' train CVI.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector was notified of the event."
Power Reactor
Event Number: 57325
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Richard Beck
HQ OPS Officer: Robert A. Thompson
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Richard Beck
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/16/2024
Notification Time: 20:24 [ET]
Event Date: 09/16/2024
Event Time: 13:29 [EDT]
Last Update Date: 09/16/2024
Notification Time: 20:24 [ET]
Event Date: 09/16/2024
Event Time: 13:29 [EDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
Person (Organization):
Ziolkowski, Michael (R3DO)
Ziolkowski, Michael (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
ACTIVE SEISMIC MONITORING SYSTEM INOPERABLE
The following information was provided by the licensee via phone and email:
"On September 16, 2024, at 1329 EDT, the Fermi 2 active seismic monitoring system provided indication of a potential seismic activity event. Plant abnormal procedures were entered and compensatory measures were met and remain in place. Neither the United States Geological Survey (USGS), nor the next closest nuclear power plant could confirm or validate the readings obtained at Fermi. The seismic monitoring system was declared inoperable to validate the calibration of the system. Fermi 2 has two active seismic monitors. One on the reactor pressure vessel pedestal and one in the high pressure core injection (HPCI) room. Only the HPCI room seismic monitor was declared inoperable. The HPCI room accelerometer is the sole 'trigger' for the seismic recording system (which outputs peak accelerations experienced during a seismic event) and the associated control room alarm. This is used in assessment of the magnitude of an earthquake for emergency action level HU 2.1.
"The loss of the active seismic monitoring system is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).
"No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area.
"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 licensee confirmed alternative means of recognizing a seismic event for emergency plan entry are available.
The following information was provided by the licensee via phone and email:
"On September 16, 2024, at 1329 EDT, the Fermi 2 active seismic monitoring system provided indication of a potential seismic activity event. Plant abnormal procedures were entered and compensatory measures were met and remain in place. Neither the United States Geological Survey (USGS), nor the next closest nuclear power plant could confirm or validate the readings obtained at Fermi. The seismic monitoring system was declared inoperable to validate the calibration of the system. Fermi 2 has two active seismic monitors. One on the reactor pressure vessel pedestal and one in the high pressure core injection (HPCI) room. Only the HPCI room seismic monitor was declared inoperable. The HPCI room accelerometer is the sole 'trigger' for the seismic recording system (which outputs peak accelerations experienced during a seismic event) and the associated control room alarm. This is used in assessment of the magnitude of an earthquake for emergency action level HU 2.1.
"The loss of the active seismic monitoring system is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).
"No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area.
"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 licensee confirmed alternative means of recognizing a seismic event for emergency plan entry are available.
Agreement State
Event Number: 56969
Rep Org: New York State Dept. of Health
Licensee: Cardinal Health
Region: 1
City: Plainview State: NY
County:
License #: C3046
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Bill Gott
Licensee: Cardinal Health
Region: 1
City: Plainview State: NY
County:
License #: C3046
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Bill Gott
Notification Date: 02/15/2024
Notification Time: 09:49 [ET]
Event Date: 02/05/2024
Event Time: 09:00 [EST]
Last Update Date: 09/17/2024
Notification Time: 09:49 [ET]
Event Date: 02/05/2024
Event Time: 09:00 [EST]
Last Update Date: 09/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Carey (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSC (Canada) (EMAIL)
Bickett, Carey (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSC (Canada) (EMAIL)
EN Revision Imported Date: 9/18/2024
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the New York State Department of Health (the Department) via fax:
"The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at [the Plainview facility], RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause.
"Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements."
New York State Event Report Number: NY-24-01
* * * UPDATE ON 9/17/2024 AT 1517 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"Cardinal Health (the licensee) provided a description of the event, actions taken to attempt to recover the vial, and preventative measures to prevent recurrence. The licensee interviewed staff, performed recovery surveys, and provided an investigation to attempt to locate this source. It is believed that this In-111 vial was placed on a cart with return waste in a similar delivery case, and it was inadvertently mistaken as returned customer waste. The vial was likely placed into decay-in-storage. To date, the vial in question has not been recovered and has decayed to background levels. To prevent recurrence, delivery personnel are required to immediately sign all acknowledgements of receipt prior to transferring the package and leaving the facility.
"NYSDOH has accepted these corrective actions and will evaluate them on the next inspection. This event was closed by NYSDOH."
Notified R1DO (Werkheiser), NMSS Events Notification (email), ILTAB (email), Canadian Nuclear Safety Commission (email).
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
EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the New York State Department of Health (the Department) via fax:
"The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at [the Plainview facility], RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause.
"Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements."
New York State Event Report Number: NY-24-01
* * * UPDATE ON 9/17/2024 AT 1517 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"Cardinal Health (the licensee) provided a description of the event, actions taken to attempt to recover the vial, and preventative measures to prevent recurrence. The licensee interviewed staff, performed recovery surveys, and provided an investigation to attempt to locate this source. It is believed that this In-111 vial was placed on a cart with return waste in a similar delivery case, and it was inadvertently mistaken as returned customer waste. The vial was likely placed into decay-in-storage. To date, the vial in question has not been recovered and has decayed to background levels. To prevent recurrence, delivery personnel are required to immediately sign all acknowledgements of receipt prior to transferring the package and leaving the facility.
"NYSDOH has accepted these corrective actions and will evaluate them on the next inspection. This event was closed by NYSDOH."
Notified R1DO (Werkheiser), NMSS Events Notification (email), ILTAB (email), Canadian Nuclear Safety Commission (email).
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
Part 21
Event Number: 57243
Rep Org: RSSC dba Marmon
Licensee:
Region: 1
City: East Granby State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: Phillip Sargenski
HQ OPS Officer: Adam Koziol
Licensee:
Region: 1
City: East Granby State: CT
County:
License #:
Agreement: N
Docket:
NRC Notified By: Phillip Sargenski
HQ OPS Officer: Adam Koziol
Notification Date: 07/25/2024
Notification Time: 11:05 [ET]
Event Date: 07/23/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Notification Time: 11:05 [ET]
Event Date: 07/23/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Lilliendahl, Jon (R1DO)
Feliz-Adorno, Nestor (R3DO)
Azua, Ray (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
Lilliendahl, Jon (R1DO)
Feliz-Adorno, Nestor (R3DO)
Azua, Ray (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 9/18/2024
EN Revision Text: PART 21 REPORT - NON-COMPLAINT INSULATED CONDUCTOR
The following is a synopsis of information received via fax:
A reel of insulated conductor was found non-compliant due to failure of insulation tensile and elongation at break test following air oven aging. Wire from the non-compliant reel was delivered to nine plants.
Affected plants: Wolf Creek, Dresden, LaSalle, Limerick, Peach Bottom, Arkansas Nuclear One, Waterford, Susquehanna, and Davis Besse.
Reporting company point of contact:
RSSC Wire and Cable LLC
dba Marmon Industrial Energy and Infrastructure
20 Bradley Park Road
East Granby, CT 06026
Phillip Sargenski - Quality Assurance Manager
Phone: 860-653-8376
Fax: 860-653-8301
Phillip.sargenski@marmoniei.com
* * * UPDATE ON 08/23/24 AT 1315 EDT FROM PHILLIP SARGENSKI TO JOSUE RAMIREZ * * *
The vendor provided the final report for this event listing corrective actions and the estimated completion dates.
Notified R1DO (Lilliendahl), R3DO (Skokowski), R4DO (Vossmar), and Part 21 group (Email).
* * * UPDATE ON 09/04/24 AT 1044 EDT FROM PHILLIP SARGENSKI TO NESTOR MAKRIS * * *
The vendor notified the NRC that they plan to send additional finding data regarding this notification via fax and/or email within the next day or two.
Notified R1DO (Ferdas), R3DO (Hills), R4DO (Drake), and Part 21 group (Email).
* * * UPDATE ON 09/06/24 AT 1327 EDT FROM PHILLIP SARGENSKI TO ADAM KOZIOL * * *
The vendor identified an additional non-compliant shipment of insulated conductor.
Affected plant: Calvert Cliffs
Notified R1DO (Ferdas), R3DO (Hills), R4DO (Drake), and Part 21 group (Email).
* * * UPDATE ON 9/17/24 AT 1641 EDT FROM PHILLIP SARGENSKI TO ROBERT THOMPSON * * *
The vendor identified an additional non-compliant shipment of insulated conductor.
Affected customer: Curtiss-Wright Nuclear Division.
Notified R1DO (Werkheiser), R3DO (Ziolkowski), R4DO (Azua), and Part 21 group (Email).
EN Revision Text: PART 21 REPORT - NON-COMPLAINT INSULATED CONDUCTOR
The following is a synopsis of information received via fax:
A reel of insulated conductor was found non-compliant due to failure of insulation tensile and elongation at break test following air oven aging. Wire from the non-compliant reel was delivered to nine plants.
Affected plants: Wolf Creek, Dresden, LaSalle, Limerick, Peach Bottom, Arkansas Nuclear One, Waterford, Susquehanna, and Davis Besse.
Reporting company point of contact:
RSSC Wire and Cable LLC
dba Marmon Industrial Energy and Infrastructure
20 Bradley Park Road
East Granby, CT 06026
Phillip Sargenski - Quality Assurance Manager
Phone: 860-653-8376
Fax: 860-653-8301
Phillip.sargenski@marmoniei.com
* * * UPDATE ON 08/23/24 AT 1315 EDT FROM PHILLIP SARGENSKI TO JOSUE RAMIREZ * * *
The vendor provided the final report for this event listing corrective actions and the estimated completion dates.
Notified R1DO (Lilliendahl), R3DO (Skokowski), R4DO (Vossmar), and Part 21 group (Email).
* * * UPDATE ON 09/04/24 AT 1044 EDT FROM PHILLIP SARGENSKI TO NESTOR MAKRIS * * *
The vendor notified the NRC that they plan to send additional finding data regarding this notification via fax and/or email within the next day or two.
Notified R1DO (Ferdas), R3DO (Hills), R4DO (Drake), and Part 21 group (Email).
* * * UPDATE ON 09/06/24 AT 1327 EDT FROM PHILLIP SARGENSKI TO ADAM KOZIOL * * *
The vendor identified an additional non-compliant shipment of insulated conductor.
Affected plant: Calvert Cliffs
Notified R1DO (Ferdas), R3DO (Hills), R4DO (Drake), and Part 21 group (Email).
* * * UPDATE ON 9/17/24 AT 1641 EDT FROM PHILLIP SARGENSKI TO ROBERT THOMPSON * * *
The vendor identified an additional non-compliant shipment of insulated conductor.
Affected customer: Curtiss-Wright Nuclear Division.
Notified R1DO (Werkheiser), R3DO (Ziolkowski), R4DO (Azua), and Part 21 group (Email).
Agreement State
Event Number: 57268
Rep Org: New York State Dept. of Health
Licensee: NY Dept. of Health Wadsworth Center
Region: 1
City: Albany State: NY
County:
License #: 0448
Agreement: Y
Docket:
NRC Notified By: Nathaniel Kishbaugh
HQ OPS Officer: Josue Ramirez
Licensee: NY Dept. of Health Wadsworth Center
Region: 1
City: Albany State: NY
County:
License #: 0448
Agreement: Y
Docket:
NRC Notified By: Nathaniel Kishbaugh
HQ OPS Officer: Josue Ramirez
Notification Date: 08/12/2024
Notification Time: 16:38 [ET]
Event Date: 08/06/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Notification Time: 16:38 [ET]
Event Date: 08/06/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 9/18/2024
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"NYSDOH Bureau of Environmental Radiation Protection (BERP) received an email from the radiation safety officer (RSO) of NYSDOH Wadsworth Laboratories on August 12, 2024, to report a leaking Ni-63 electron capture device (ECD) contained within a decommissioned gas chromatograph. This sample was collected on August 6, 2024, and was analyzed (and quality control tested) following collection.
"Device Make: Agilent Technologies, Inc.
"Device Model: 19233
"Device Serial Number: L2075
"Isotopes: Ni-63 (18 mCi at time of manufacture)
"NYSDOH Wadsworth Laboratory staff were conducting a leak test and wipe of a decommissioned gas chromatography unit that had not been used for over 20 years. The ECD housing within the unit did have removable contamination detected at 30,000 disintegrations per minute (approximately 0.015 micro Ci) when analyzed using a liquid scintillation counter. The gas chromatograph was isolated, and an enhanced survey showed that the gas chromatograph chamber (which sits below the ECD housing) had removable contamination consistent with the ECD housing. Other areas of the gas chromatograph were surveyed and showed levels indistinguishable from background. Furthermore, checks of areas around the gas chromatograph were surveyed as well as personnel and personal protective equipment and no levels exceeding background were discovered. The extent of contamination appears to be isolated to the open port of the ECD, which has been sealed.
"The entire gas chromatograph is isolated pending disposal. NYSDOH Wadsworth staff contacted the RSO for Agilent [Technologies] and confirmed that the device may be sent to them for disposal."
"The cause of this leaking source is unknown as the device had been removed from service for several decades. Routine surveys have indicated that the extent of contamination was localized to areas of the chromatograph that would not be touched or in contact with any laboratory equipment or personnel.
"NYSDOH BERP is actively monitoring this event under Incident No. 1497. Additional information will be provided to the Nuclear Material Events Database (NMED) once available."
Event Report ID No. NY-24-08
NYSDOH Incident Number: 1497
* * * UPDATE ON 9/17/2024 AT 1355 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"The leaking source and affected device in question were returned to the vendor in Wilmington, DE. On September 3, 2024, NYSDOH received an acknowledgement of receipt of the device. The exact cause of the leaking source is unknown, however, NYSDOH will focus on this aspect during the next routine inspection to inquire if any contributing or primary causes for this leaking source maybe attributed to the use, maintenance, or storage of these types of devices. Any additional follow-up will occur under the scope of the inspection; therefore, NYSDOH has closed out this incident."
Notified R1DO (Werkheiser), NMSS Events Notification (email).
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"NYSDOH Bureau of Environmental Radiation Protection (BERP) received an email from the radiation safety officer (RSO) of NYSDOH Wadsworth Laboratories on August 12, 2024, to report a leaking Ni-63 electron capture device (ECD) contained within a decommissioned gas chromatograph. This sample was collected on August 6, 2024, and was analyzed (and quality control tested) following collection.
"Device Make: Agilent Technologies, Inc.
"Device Model: 19233
"Device Serial Number: L2075
"Isotopes: Ni-63 (18 mCi at time of manufacture)
"NYSDOH Wadsworth Laboratory staff were conducting a leak test and wipe of a decommissioned gas chromatography unit that had not been used for over 20 years. The ECD housing within the unit did have removable contamination detected at 30,000 disintegrations per minute (approximately 0.015 micro Ci) when analyzed using a liquid scintillation counter. The gas chromatograph was isolated, and an enhanced survey showed that the gas chromatograph chamber (which sits below the ECD housing) had removable contamination consistent with the ECD housing. Other areas of the gas chromatograph were surveyed and showed levels indistinguishable from background. Furthermore, checks of areas around the gas chromatograph were surveyed as well as personnel and personal protective equipment and no levels exceeding background were discovered. The extent of contamination appears to be isolated to the open port of the ECD, which has been sealed.
"The entire gas chromatograph is isolated pending disposal. NYSDOH Wadsworth staff contacted the RSO for Agilent [Technologies] and confirmed that the device may be sent to them for disposal."
"The cause of this leaking source is unknown as the device had been removed from service for several decades. Routine surveys have indicated that the extent of contamination was localized to areas of the chromatograph that would not be touched or in contact with any laboratory equipment or personnel.
"NYSDOH BERP is actively monitoring this event under Incident No. 1497. Additional information will be provided to the Nuclear Material Events Database (NMED) once available."
Event Report ID No. NY-24-08
NYSDOH Incident Number: 1497
* * * UPDATE ON 9/17/2024 AT 1355 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *
The following information was provided by the New York State Department of Health (NYSDOH) via email:
"The leaking source and affected device in question were returned to the vendor in Wilmington, DE. On September 3, 2024, NYSDOH received an acknowledgement of receipt of the device. The exact cause of the leaking source is unknown, however, NYSDOH will focus on this aspect during the next routine inspection to inquire if any contributing or primary causes for this leaking source maybe attributed to the use, maintenance, or storage of these types of devices. Any additional follow-up will occur under the scope of the inspection; therefore, NYSDOH has closed out this incident."
Notified R1DO (Werkheiser), NMSS Events Notification (email).
Agreement State
Event Number: 57293
Rep Org: Georgia Radioactive Material Pgm
Licensee: PIEDMONT ATHENS REGIONAL MED CENTER
Region: 1
City: Athens State: GA
County:
License #: GA 4-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Robert A. Thompson
Licensee: PIEDMONT ATHENS REGIONAL MED CENTER
Region: 1
City: Athens State: GA
County:
License #: GA 4-1
Agreement: Y
Docket:
NRC Notified By: Kaamilya Najeeullah
HQ OPS Officer: Robert A. Thompson
Notification Date: 08/27/2024
Notification Time: 15:12 [ET]
Event Date: 08/26/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Notification Time: 15:12 [ET]
Event Date: 08/26/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 9/18/2024
EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE
The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email:
The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose.
The RSO will send an official written report to the Program within 15 days.
Georgia Incident Number: 86
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 9/17/2024 AT 1131 EDT FROM KAAMILYA NAJEEULLAH TO ROBERT THOMPSON * * *
The following information was provided by the Georgia Radioactive Materials Program (the Program) via email:
"The Program received the official written report from the licensee radiation safety officer (RSO) on September 12, 2024. The RSO stated that one dosage was successfully delivered. The second dosage was not fully delivered due to a kink in the catheter.
"Prescribed dosage: 15.68 mCi and 16.76 mCi Y-90 microspheres
"Administered dosage: 5.39 mCi and 16.87 mCi Y-90 microspheres"
Notified R1DO (Werkheiser), NMSS Events Notification (email).
EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE
The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email:
The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose.
The RSO will send an official written report to the Program within 15 days.
Georgia Incident Number: 86
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 9/17/2024 AT 1131 EDT FROM KAAMILYA NAJEEULLAH TO ROBERT THOMPSON * * *
The following information was provided by the Georgia Radioactive Materials Program (the Program) via email:
"The Program received the official written report from the licensee radiation safety officer (RSO) on September 12, 2024. The RSO stated that one dosage was successfully delivered. The second dosage was not fully delivered due to a kink in the catheter.
"Prescribed dosage: 15.68 mCi and 16.76 mCi Y-90 microspheres
"Administered dosage: 5.39 mCi and 16.87 mCi Y-90 microspheres"
Notified R1DO (Werkheiser), NMSS Events Notification (email).
Agreement State
Event Number: 57315
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Cooper Health System at Camden
Region: 1
City: Camden City State: NJ
County:
License #: 438814
Agreement: Y
Docket:
NRC Notified By: Claire Drozd
HQ OPS Officer: Ernest West
Licensee: Cooper Health System at Camden
Region: 1
City: Camden City State: NJ
County:
License #: 438814
Agreement: Y
Docket:
NRC Notified By: Claire Drozd
HQ OPS Officer: Ernest West
Notification Date: 09/11/2024
Notification Time: 14:09 [ET]
Event Date: 09/09/2024
Event Time: 12:07 [EDT]
Last Update Date: 09/11/2024
Notification Time: 14:09 [ET]
Event Date: 09/09/2024
Event Time: 12:07 [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)
ILTAB, (EMAIL) (EMAIL)
Elkhiamy, Sarah (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST EXIT SIGN
The following information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email:
"On September 9, 2024, during a routine inspection of the licensee, information for the exit sign was provided to the radiation safety officer (RSO). The inspectors asked for the sign's location and for the facility contact listed to be updated if necessary. After the inspection, follow up emails and searches of the facility led to the determination that the sign could not be located. The sign's manufacturer was contacted to confirm whether or not the sign might have been returned. SRB Technologies (the manufacturer) confirmed that the sign was not assigned a return number, and that paperwork for its return was not submitted. After additional follow up with the RSO, and final search of the facility, it was determined that the sign has been lost."
New Jersey Event Report ID number: To be determined.
Additional information: The lost exit sign contained approximately 9210 millicuries of tritium (H-3).
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 information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email:
"On September 9, 2024, during a routine inspection of the licensee, information for the exit sign was provided to the radiation safety officer (RSO). The inspectors asked for the sign's location and for the facility contact listed to be updated if necessary. After the inspection, follow up emails and searches of the facility led to the determination that the sign could not be located. The sign's manufacturer was contacted to confirm whether or not the sign might have been returned. SRB Technologies (the manufacturer) confirmed that the sign was not assigned a return number, and that paperwork for its return was not submitted. After additional follow up with the RSO, and final search of the facility, it was determined that the sign has been lost."
New Jersey Event Report ID number: To be determined.
Additional information: The lost exit sign contained approximately 9210 millicuries of tritium (H-3).
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
Agreement State
Event Number: 57316
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Exxon Mobil Oil Corp
Region: 3
City: Channahon State: IL
County:
License #: IL-01742-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Licensee: Exxon Mobil Oil Corp
Region: 3
City: Channahon State: IL
County:
License #: IL-01742-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Notification Date: 09/11/2024
Notification Time: 14:31 [ET]
Event Date: 09/10/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/11/2024
Notification Time: 14:31 [ET]
Event Date: 09/10/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/11/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ziolkowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ziolkowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - STUCK OPEN GAUGE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On September 11, 2024, the Agency was contacted by a representative for the Exxon Mobile refinery in Channahon to advise of a fixed gauge containing 20 mCi of Cs-137 [sealed source] had a reportable equipment failure. Specifically, on September 10, 2024, during routine shutter checks, the handle that operates the shutter broke off, leaving the gauge in the open position. The gauge is mounted to a production vessel which is full of commodity. There were no exposures, and due to the vessel being in use, personnel exposure is not a concern. The manufacturer has been contacted for repairs. The licensee met the notification requirements. This report will be updated with the source serial number and verification of repair and replacement upon receipt."
Illinois Event Item Number: IL240021
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On September 11, 2024, the Agency was contacted by a representative for the Exxon Mobile refinery in Channahon to advise of a fixed gauge containing 20 mCi of Cs-137 [sealed source] had a reportable equipment failure. Specifically, on September 10, 2024, during routine shutter checks, the handle that operates the shutter broke off, leaving the gauge in the open position. The gauge is mounted to a production vessel which is full of commodity. There were no exposures, and due to the vessel being in use, personnel exposure is not a concern. The manufacturer has been contacted for repairs. The licensee met the notification requirements. This report will be updated with the source serial number and verification of repair and replacement upon receipt."
Illinois Event Item Number: IL240021
Agreement State
Event Number: 57317
Rep Org: Texas Dept of State Health Services
Licensee: EQUISTAR CHEMICALS LP
Region: 4
City: Bay City State: TX
County:
License #: L03938
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ernest West
Licensee: EQUISTAR CHEMICALS LP
Region: 4
City: Bay City State: TX
County:
License #: L03938
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ernest West
Notification Date: 09/11/2024
Notification Time: 16:52 [ET]
Event Date: 09/11/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/11/2024
Notification Time: 16:52 [ET]
Event Date: 09/11/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/11/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - STUCK OPEN SHUTTER
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On September 11, 2024, the Department was notified by the licensee that the shutter on a Ronan model SA-1 gauge containing a 50 millicurie Cs-137 source, was found stuck in the open position during routine testing. Open is the normal position for the gauge. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-10129
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On September 11, 2024, the Department was notified by the licensee that the shutter on a Ronan model SA-1 gauge containing a 50 millicurie Cs-137 source, was found stuck in the open position during routine testing. Open is the normal position for the gauge. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-10129
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
Power Reactor
Event Number: 57326
Facility: Vogtle 3/4
Region: 2 State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Jason Hayes
HQ OPS Officer: Sam Colvard
Region: 2 State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Jason Hayes
HQ OPS Officer: Sam Colvard
Notification Date: 09/17/2024
Notification Time: 04:48 [ET]
Event Date: 09/17/2024
Event Time: 01:27 [EDT]
Last Update Date: 09/17/2024
Notification Time: 04:48 [ET]
Event Date: 09/17/2024
Event Time: 01:27 [EDT]
Last Update Date: 09/17/2024
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
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):
Suber, Gregory (R2DO)
Crouch, Howard (IR)
Russell Felts (NRR EO) (NRR EO)
Suber, Gregory (R2DO)
Crouch, Howard (IR)
Russell Felts (NRR EO) (NRR EO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | A/R | Y | 100 | Power Operation | 0 | Safe Shutdown |
AUTOMATIC REACTOR TRIP AND MANUAL SAFEGUARDS ACTUATION
The following information was provided by the licensee via phone and email:
"At 0127 EDT on 9/17/2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped due to the passive residual heat removal heat exchanger outlet flow control valve failing open. A manual safeguards actuation was initiated due to the lowering pressurizer water level resulting from the reactor coolant system cooldown that was caused by the passive residual heat removal heat exchanger outlet flow control valve failing open. 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 failure of the control valve does not inhibit the residual heat removal system from functioning as it is passive. The reactor coolant system maximum allowable cooldown rate was exceeded (Technical Specification 3.4.3). The limit is 100 degrees F per hour above 350 degrees F. The maximum observed cooldown rate was 226 degrees F per hour. At time 0458 EDT, reactor coolant system temperature is 369.1 degrees F, reactor pressure is 900 psig. Currently, the plant is not cooling down but is making ready to place shutdown cooling online.
The following information was provided by the licensee via phone and email:
"At 0127 EDT on 9/17/2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped due to the passive residual heat removal heat exchanger outlet flow control valve failing open. A manual safeguards actuation was initiated due to the lowering pressurizer water level resulting from the reactor coolant system cooldown that was caused by the passive residual heat removal heat exchanger outlet flow control valve failing open. 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 failure of the control valve does not inhibit the residual heat removal system from functioning as it is passive. The reactor coolant system maximum allowable cooldown rate was exceeded (Technical Specification 3.4.3). The limit is 100 degrees F per hour above 350 degrees F. The maximum observed cooldown rate was 226 degrees F per hour. At time 0458 EDT, reactor coolant system temperature is 369.1 degrees F, reactor pressure is 900 psig. Currently, the plant is not cooling down but is making ready to place shutdown cooling online.