Event Notification Report for October 15, 2024

MEDICAL EVENT - Y-90 UNDERDOSE

The following information was provided by the licensee via phone:

A medical event involving Y-90 TheraSpheres occurred on 10/03/2024 at approximately 1000 EDT. A patient received an underdose of about 67 percent due to leakage at a connection point to the catheter.

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

The leak appears to be caused from a crooked connection. Modifications are being made to the procedure to review the connections from different angles to assure alignment.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

AGREEMENT STATE REPORT - MISSING CATEGORY 2 SOURCE

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via phone and email:

"On 10/4/2024, at 1244 EDT, QSA Global, Inc. (license number 12-8361) was notified that a package containing a 109.1 Ci Ir-192 sealed source in a type B package was missing in transit and notified the Agency at 1315 EDT on the same day. The following information was provided at the time of notification:

"Isotope: Ir-192
Source Serial Number: 97855M
Form: Sealed source
Activity (at time of shipment): 109.1 Ci
Container Model Number: 650L
Container Serial Number: 1063
Transportation Index: 0.6
Shipping Date: 9/13/24
Last Known Location: [Common carrier] hub in Memphis, TN

"The reporting requirement is immediate and is required by 105 Code of Massachusetts Regulations (CMR) 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

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

The last physical scan was on 9/17/24, at 1403 EDT, in Memphis, TN. The recipient reached out to the common carrier on 10/1/24 asking to track the package. The response from the common carrier was that they were experiencing high volume and the package was waiting to be cleared in customs. The recipient followed up again on 10/4/24, at 0928 EDT, asking for an update, and received an update at 1108 EDT stating that they could not locate the package. The Agency has contacted the State of Tennessee regarding this event.

Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email).

* * * UPDATE AT 1308 EDT ON OCTOBER 8, 2024 FROM BOB LOCKE TO BRIAN P. SMITH * * *

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via email:

"At 1108 EDT on October 8, 2024, the missing package was delivered undamaged to the intended recipient. The Agency considers this event closed."

Notified R1DO (Arner), IR (Grant), NMSS (Fisher), ILTAB (Brown), INES (Smith), NMSS Events Notification.

Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email).

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

STUCK-OPEN GAUGE SHUTTER

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

While the licensee was performing semi-annual shutter functional checks, on the initial attempt to close one normally open Vega gauge shutter, resistance was felt. The shutter mechanism was lubricated and a second attempt to close the shutter was made some time later. During this second attempt, two bolts connecting the handle to the shutter sheared off. This disabled the shutter operating mechanism, leaving the shutter stuck open. The licensee verified area radiation levels were unchanged. The licensee has contacted the manufacturer for assistance in repairing the gauge.

The licensee has notified the NRC regional inspector.

NON-AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

The licensee's radiation safety officer reported that during a routine maintenance check at approximately 1300 EDT on 10/07/2024, a gauge shutter would not close. The open position is the normal operating position of the shutter. The source contains 100 mCi of Cs-137.

The gauge is in a normally inaccessible location that has been cordoned off until the manufacturer arrives next week for assessment and repair.

A radiation survey confirmed radiation levels are less than 0.06 mrem/hr. There are no radiation exposure concerns to personnel or the public.

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following report was received via phone and email from the Texas Department of State Health Services (the Department):

"On October 8, 2024, the Department was notified by the licensee that the shutter on a Vega model SH-F2 nuclear gauge containing a 200 millicurie [source] (original activity) was stuck in the open position. Open is the normal operation position of the shutter. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. The licensee reported that the current plan is to dispose of the source. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10133
Texas NMED Number: TX240033

AUTOMATIC REACTOR TRIP DUE TO TURBINE GENERATOR LOSS OF FIELD

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

"At 0557 EDT on 10/10/2024, with Unit 2 in mode 1 at 100 percent power, the reactor automatically tripped due to turbine generator loss of field. The trip was not complex with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Operations responded using EOP-0, post trip immediate actions, and stabilized the plant in mode 3. Decay heat is removed by discharging steam to the main condenser using the turbine bypass valves.

"Unit 1 is not affected.

"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 exciter is suspected to being the cause and is under investigation. All control rods fully inserted.

UNANALYZED CONDITION

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

"On October 10, 2024, at 1045 EDT, it was determined that an additional failure mechanism existed for a previous issue with the emergency diesel generator (EDG) speed switches. As a result, for some initiating events such as a fire or high energy line break potentially causing a ground on the negative buses on both trains of the station direct current (DC) system, both EDG speed switches could have been affected, resulting in a failure of the EDGs to function.

"This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel, as the EDG speed switches were replaced in January 2022 with a different design that is not susceptible to grounds on the station DC system. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."

FITNESS-FOR-DUTY REPORT

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

"On October 14, 2024, a licensed employee violated the station's fitness for duty (FFD) policy. The employee's unescorted access to the site has been terminated. The event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been notified."

OFFSITE NOTIFICATION

The following information was provided by the licensee via phone:

On October 14, 2024, at 1233 EDT, a brush fire started in the Oyster Creek Unit 1 switchyard due to an electrical failure. The station contacted local 911 and fire company for response. At approximately 1247 EDT, the fire company arrived at the switchyard. At approximately 1300 EDT, the fire company began extinguishing efforts. The fire was officially put out at 1449 EDT. There was no radiological or fuel storage impact from this event.

The NRC Resident Inspector and the State of New Jersey have been notified.

AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following report was received from the Texas Department of State Health Services (the Department) via phone and email:

"On October 14, 2024, the Department was notified by the licensee that while preparing to lock shut the Ronan model SA1 nuclear gauge, the shutter would not close. The gauge contains a 10 millicurie cesium-137 source. The licensee reported 'open' is the normal position for the shutter. The licensee reported access to the tank, where the gauge is used to monitor, has been posted no entry. The licensee reported a service contractor has been contacted to assist in getting the gauge repaired. The licensee stated no additional exposure is expected to its employees or members of the general public due to this event. Additional information will be provided in accordance with SA-300."

Texas Incident Number: 10136
NMED Number: TX240036