Event Notification Report for September 23, 2024

AGREEMENT STATE REPORT - STOLEN SOURCE

The following is a summary of information that was provided by the New Mexico Radiation Control Program via phone and email:

During the weekend, Acme Environmental, Inc. (the licensee) was burglarized. An XRF lead paint analyzer, model Heuresis Pb200i, containing 5 mCi of Co-57 was stolen, along with numerous other items. The licensee notified the police, and the police are actively investigating.

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

AUTOMATIC REACTOR SCRAM DUE TO GENERATOR TRIP

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

"At 0720 EDT on September 23, 2024, James A. FitzPatrick was at 100 percent power when an automatic scram occurred as a result of a main turbine trip due to an automatic trip of the generator output breakers; the cause is still under investigation.

"The scram was not complex. The automatic scram inserted all control rods. A subsequent reactor pressure vessel (RPV) low water level resulted in a group 2 isolation and initiation of high pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) systems. RCIC did inject, but HPCI did not inject, as expected, based on RPV water level recovery with the feedwater system. Reactor pressure is being maintained by main steam line bypass valves. The plant is stable in Mode 3 with the 'A' reactor feed pump maintaining RPV water level.

"The initiation of the reactor protection system (RPS) due to the automatic scram signal while critical is reportable per 10 CFR 50.72(b)(2)(iv)(B). The general containment Group 2 isolations and HPCI and RCIC system actuations are reportable per 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

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

The group 2 containment isolation affects multiple systems.

* * * UPDATE ON 9/23/2024 AT 1540 EDT FROM RYAN PERRY TO SAMUEL COLVARD * * *

"On 9/23/2024 at 1156 EDT Constellation communications provided a media statement to Oswego area news media contacts summarizing the events that had occurred at Nine Mile Point Unit 2 and FitzPatrick Unit 1. This is a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(xi). The NRC Senior Resident Inspector has been notified."

Notified R1DO (Dimitriadis)

AUTOMATIC REACTOR SCRAM DUE TURBINE TRIP

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

"On 9/23/2024 at 0720 EDT, with Unit 2 in mode 1 at 100 percent power, the reactor automatically scrammed due to turbine stop valve closure on a turbine trip. The scram was not complex. Due to the reactor protection system (RPS) actuation while critical, this event is being reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Following the scram, reactor water level dropped below level 2 (108.8 inches), starting high pressure core spray (HPCS) and reactor core isolation cooling (RCIC); both injected into the reactor. RCIC is being used with turbine bypass valves to remove decay heat. Due to the emergency core cooling systems HPCS and RCIC discharging into the reactor coolant system, this event is being reported a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A), and an eight hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). In addition, with reactor water level below level 2 (108.8 inches), primary containment isolation signals actuated resulting in group 2 recirculation sample system isolation, group 3 traveling in-core probe (TIP) isolation valve isolation, group 6 and 7 reactor water cleanup isolation, group 8 containment isolations, and group 9 containment purge isolations. This event is being reported as an eight hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). Operations responded using procedure N2-EOP-RPV (1-3) and stabilized the plant in mode 3. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector was informed. There was no impact on Unit 1."

* * * UPDATE ON 9/23/2024 AT 1550 EDT FROM RYAN LOOMIS TO IAN HOWARD * * *

"On 9/23/2024 at 1156 EDT Constellation communications provided a media statement to Oswego area news media contacts summarizing the events that had occurred at Nine Mile Point Unit 2 and FitzPatrick Unit 1. This is a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(xi). The NRC Senior Resident Inspector has been notified."

Notified R1DO (Dimitriadis), NRR EO (Felts), and IR MOC (Grant).

EN Revision Imported Date: 8/4/2025

EN Revision Text: AGREEMENT STATE REPORT - THERASPHERE DEVICE FAILURE

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was contacted on October 10, 2024, by Northwestern Memorial Healthcare in Chicago, IL, to advise of a suspected TheraSphere device failure. There was no associated medical event, nor any contamination resulting from the equipment failure.

"Reportedly, on September 23, 2024, during the administration of Y-90 TheraSpheres, the treatment was immediately halted by the authorized user (AU) following infusion of 3 mL of saline through the system due to observation of excessive air bubbles present in the outlet line. Both the [authorized medical physicist] (AMP) and the AU noticed what appeared to be flakes in the bottom of the 'V' vial and possible microspheres in the outlet line. The source vial and attached microcatheter were removed following standard procedures. The licensee followed the standard protocol and determined that the patient received 42.18 Gy of the prescribed 45.48 Gy. No follow up or medical action was required of the patient. No contamination of staff, patient, or the area was identified. Staff were interviewed to determine possible causes of the leak, with no deviations from the protocol noted. No initial defects in the administration kit were noted, however, after concluding their investigation, the licensee made the determination of a reportable equipment failure on October 9, 2024. The investigation remains ongoing, and a report was sent by the licensee to the manufacturer on October 9, 2024. This matter is reportable under 32 Illinois Administrative Code 340.1220(c)(2)."

NMED number: IL240023

* * * UPDATE ON AUGUST 1, 2025 AT 1544 EDT FROM GARY FORSEE TO JON LILLIENDAHL * * *

The following update was provided by the Illinois Emergency Management Agency via email:

"On May 22, 2025, the manufacturer provided their assessment. They suspect the cause of the event was low flow rate (which allows the microspheres to fall from suspension), possibly due to kinks observed in the microcatheter. Absent the availability of additional data, this matter is considered closed."

Notified R3DO (Hills) and NMSS Events Notification (email)