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Event Notification Report for September 24, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
09/23/2024 - 09/24/2024

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
Notification Date: 08/02/2024
Notification Time: 13:17 [ET]
Event Date: 08/01/2024
Event Time: 08:00 [EDT]
Last Update Date: 09/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
EN Revision Imported Date: 9/24/2024

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).

* * * UPDATE ON 9/23/2024 AT 1244 EDT FROM TRAVIS CARTOSKI to IAN HOWARD* * *

The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:

"On 9/23/24, the gauge was found, intact and fully functional."

Notified R1DO (Dimitriadis), 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: 57320
Rep Org: New Mexico Rad Control Program
Licensee: Lovelace Medical Center
Region: 4
City: Albuquerque   State: NM
County:
License #: 210-132
Agreement: Y
Docket:
NRC Notified By: Victor Diaz
HQ OPS Officer: Ernest West
Notification Date: 09/12/2024
Notification Time: 11:28 [ET]
Event Date: 07/18/2024
Event Time: 00:00 [MDT]
Last Update Date: 09/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 9/24/2024

EN Revision Text: AGREEMENT STATE REPORT - Y-90 DOSE MISADMINISTRATION

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

At approximately 1830 MDT on September 10, 2024, the licensee's radiation safety officer discovered that on July 18, 2024, a dose of 0.2 Gbq of yttrium-90 was prescribed for delivery to a patient, but the patient received a reported dose of 0.25 Gbq. The cause for the discrepancy between the prescribed and delivered dose is unknown. The licensee has been instructed to provide a complete written report.

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 09/23/2024 AT 1005 EDT FROM VICTOR DIAZ TO ROBERT THOMPSON * * *

The following information was provided by the New Mexico Radiation Control Program via email:

"On July 18, 2024, two microsphere radioembolization (yttrium-90) administrations were performed on the same patient. For the first dosage, 5.4 mCi was prescribed, 7.6 mCi was drawn, and 90 percent of the drawn dosage was delivered (6.84 mCi). For the second dosage, the prescribed dosage was 5.4 mCi, 7.2 mCi was drawn, and 60 percent of the drawn dosage was delivered (4.32 mCi). The first treatment is reportable because the total dosage delivered differs from the prescribed dosage by more than 20 percent and was not discovered to be due to stasis or an emergent condition. The second dosage is not reportable because the error was due to stasis as certified by the authorized user (AU).

"The misadministration was discovered on September 10, 2024, by the radiation safety officer (RSO) during the quarterly review of records. Upon discovery, a thorough review of the associated records was completed along with an investigation involving the lead certified nuclear medicine technologist (CNMT), the SirTex representative who was assisting with the procedure, the AU, and radiology management. It was determined that this misadministration occurred because the prescribed dosage was so small that the CNMT had a difficult time drawing it up into the syringe. When the CNMT would push one drop out of the syringe, the dosage would be too low. When adding a drop back to the syringe, the dosage would be too high. Since dosages under 10 mCi typically have a 15 percent residual, the CNMT and SirTex representative decided it was acceptable to supply a dosage that was 140 percent of the prescribed dosage, even though the facility policy is that the final activity in the syringe must be within 10 percent of the prescribed dosage. In addition, the AU was not informed that the drawn activity was outside of the allowed 10 percent range. Once it was determined that the first treatment met the definition of a medical event, the event was immediately reported.

"No adverse effects are anticipated. Follow up medical appointments with the patient have not indicated any immediate effects. This patient will continue to be monitored in line with standard of care.

"Due to the minimal risk expected due to this excess dosage, the AU along with the patient's medical oncologist decided notifying the patient would not be advisable. Notifying the patient would cause more stress than benefit."

Notified R4DO (Young), NMSS Events Notification (email).


Agreement State
Event Number: 57323
Rep Org: Louisiana Radiation Protection Div
Licensee: BASF Corporation
Region: 4
City: Geismar   State: LA
County:
License #: LA-2304-L01
Agreement: Y
Docket:
NRC Notified By: Scott Blackwell
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/16/2024
Notification Time: 14:08 [ET]
Event Date: 09/15/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following information was provided by the LA Department of Environmental Quality, (LDEQ) via email:

"The LDEQ was notified on September 16, 2024, of a stuck shutter on a nuclear gauge. While the licensee was trying to isolate the T220B tower for maintenance on September 15, 2024, the shutter handle on an Ohmart Vega SHS1 nuclear gauge with a 50 mCi Cs-137 source broke leaving the shutter in the open position. The licensee's gauge vendor was contacted and on September 16, 2024, the nuclear gauge was removed and put into storage."

Louisiana event report ID: 20240009


Agreement State
Event Number: 57327
Rep Org: SC Dept of Environmental Services
Licensee: Alpek Polyester USA, LLC
Region: 1
City: Gaston   State: SC
County:
License #: 189
Agreement: Y
Docket:
NRC Notified By: Andrew Roxburgh
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/17/2024
Notification Time: 12:03 [ET]
Event Date: 09/16/2024
Event Time: 10:30 [EDT]
Last Update Date: 09/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - SOURCES FAILED TO RETRACT

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:

"On September 16, 2024, at 1415 EDT, the Department was notified by Alpek Polyester (the licensee) that while performing semi-annual shutter checks the licensee discovered that two gauges (model: Berthold LB 300 IRL) had cables that were malfunctioning, and that the sources were unable to be retracted to the shielded and locked position. One gauge contains a 6 mCi (original activity) cobalt-60 source and the other contains a 2.5 mCi (original activity) cobalt-60 source. Currently the cobalt sources are 1.07 mCi and 0.044 mCi, respectively. These sources were placed into service on September 17, 2011. On September 17, 2024, the department on-call duty officer met the licensee's radiation safety officer at 0900 EDT to perform a visual inspection and radiation survey of the gauge. The highest radiation measured was 0.5 microR/hr. The licensee has contacted a licensed vendor to schedule the repair of the drive cables."


Power Reactor
Event Number: 57333
Facility: FitzPatrick
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Ryan Perry
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/23/2024
Notification Time: 11:02 [ET]
Event Date: 09/23/2024
Event Time: 07:20 [EDT]
Last Update Date: 09/23/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Dimitriadis, Anthony (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown
Event Text
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)


Power Reactor
Event Number: 57334
Facility: Nine Mile Point
Region: 1     State: NY
Unit: [2] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Ryan Loomis
HQ OPS Officer: Bill Nytko
Notification Date: 09/23/2024
Notification Time: 11:08 [ET]
Event Date: 09/23/2024
Event Time: 07:20 [EDT]
Last Update Date: 09/23/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS Injection
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Dimitriadis, Anthony (R1DO)
Felts, Russell (NRR EO) (NRR EO)
Grant, Jeffery (IR)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 0 Hot Shutdown
Event Text
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).


Power Reactor
Event Number: 57336
Facility: Watts Bar
Region: 2     State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Robert Smithson
HQ OPS Officer: Jon Lilliendahl
Notification Date: 09/23/2024
Notification Time: 21:46 [ET]
Event Date: 08/01/2024
Event Time: 21:27 [EDT]
Last Update Date: 09/23/2024
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Suber, Gregory (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation
Event Text
60-DAY NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION

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

"At 2127 EDT, on 8/01/2024, with Unit 1 in mode 1 at 98 percent 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. The CVI removes containment purge from operation should it be in service and secures other radiation monitors which measure reactor coolant system leakage. In accordance with the station's procedures and technical specifications, a restoration from the CVI was made. Troubleshooting revealed that replacement of this obsolete radiation monitor was justified; a design change to perform this replacement is in progress.

"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."