Event Notification Report for October 31, 2024

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Pennsylvania Department Bureau of Radiation Protection (the Department) via email:

"On October 23, 2024, the licensee informed the Department of a medical event involving a treatment with SirSpheres. It is reportable per 10 CFR 35.3045.

"On October 22, 2024, a patient was receiving a SirSphere treatment. During the course of administration of the Y-90 spheres, the microcatheter became blocked, and the procedure was stopped. The remaining dose/waste was assessed, and it was calculated that the patient received approximately 30 mCi out of a prescribed 50 mCi. This represents an approximate 40 percent underdose. The authorized user (AU) was satisfied with that amount, believing it to be therapeutic and does not expect any harmful effects to the patient. Both the patient and AU were notified.

"The Department will perform a reactive inspection. More information will be provided as received."

Event Report ID No: PA240020

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.

LOSS OF ITEM RELIED ON FOR SAFETY

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

"Loss or degradation of items relied on for safety that results in failure to meet the performance requirement of 10 CFR 70.61.

"A temperature interlock, designated as item relied on for safety (IROFS), failed to actuate at setpoint.

"NRC Region II has been notified."

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

The licensee is troubleshooting the cause, and the system was placed in safe shutdown.

AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following information was provided by the Tennessee Division of Radiological Health via email:

"During a scheduled six-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. The open position is the normal operating position. No abnormal levels of radiation were detected. A VEGA field technician has been contacted to service the gauge.

"Corrective actions or reports, as well as additional information, will be updated with a NMED report within 30 days."

Manufacturer: Ohmart/Vega
Source Holder Model: SHF2
Source Holder SN: 99949B
Isotope: Cs-137, 24.4 mCi

Tennessee Event Report ID Number: TN-24-081

FITNESS FOR DUTY

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

A non-licensed contract supervisor violated the station's fitness-for-duty program. The employee's access to the plant has been terminated.

AGREEMENT STATE REPORT - STOLEN DENSITY GAUGE

The following information was provided by the New York State Department of Health (NYSDOH) via phone and email:

"The New York State Department of Health was notified by the New York State Office of Emergency Management at 0230 EDT that Materials Testing Laboratories called to report a stolen Troxler Model 4640 surface thin layer density gauge (serial number 1289) containing 10 mCi of Cs-137.

"The gauge was stolen at 572 11th Ave between 43rd and 44th Streets in Manhattan at 2130 EDT on 10/23/24. NYPD were immediately notified and a report was filed.

"The gauge recently had a tracking device affixed. They are not seeing any 'pings' on the device location probably because it is out of WIFI range and not moving. They are actively monitoring for movement and location information."

NY Event Number: TBD

* * * UPDATE ON 10/25/2024 AT 0137 FROM NATHANIEL KISHBAUGH TO BILL NYTKO * * *

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"At approximately 0230 EDT, on October 24, 2024, New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH BERP) was notified by New York State Office of Emergency Management (NYS OEM) that the radiation safety officer (RSO) of Materials Testing Laboratories reported a stolen Troxler Model 4640 Serial number 1289, surface thin layer density gauge. The RSO reported that [the source activity] was 10 millicurie (mCi) of cesium-137 (Cs-137). According to the United States Nuclear Regulatory Commission Sealed Source and Device registry the source activity is 9 mCi of Cs-137. Based on information provided, it appears that the actual activity of the Cs-137 source was approximately 9 mCi.

[Information stated in original message]

"At 1229 EDT, on October 24, 2024, NYSDOH BERP called the RSO. The RSO said the employee was working on 11th street and the road was blocked off due to repaving. The gauge was on a hand truck to facilitate multiple surveys at various areas along, approximately, a several mile distance. At the time of the suspected theft, the employee was closer to the east side of the road, set up the gauge, walked 100 feet to take a measurement, and when the employee turned around the gauge was gone. The employee searched the area for 20 minutes and then called the RSO. The RSO then instructed the employee to call the police. Since the incident the RSO and staff have been surveying a 30-block area, posting flyers, and [made multiple] attempts to use the tracking device program.

"At 1340 EDT, on October 24, 2024, NYSDOH BERP called RSO for additional clarification and assessment as the original report failed to mention whether the device was stolen with the source in an unshielded or shielded position. Additional discussion indicated that the gauge was about to be in use, but was in the source in locked position. Allegedly, by the RSO, the authorized user of the device, turned to walk 100 feet to mark the next measurement location, and then completed paperwork. Thereby suggesting that the device was in a shielded position when stolen.

"Please note that this is a formal follow up to the email sent by NYSDOH sent at 0350 EDT, on October 24, 2024.

"NYSDOH is closely monitoring this event and has assigned NYSDOH Incident No. 1504 to continue monitoring this event."

Notified R1DO (Dentel), NMSS Events Notification (email), and ILTAB (email)

* * * UPDATE ON 10/29/2024 AT 0917 EDT FROM NATHANIEL KISHBAUGH TO BILL NYTKO * * *

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"On October 25, 2024, NYSDOH received an email from the RSO stating that they has retrieved the stolen density gauge from an individual that found the device. Prior to use, the RSO stated that they will perform a leak test and send the gauge to a licensed repairer/servicer for visual and operational inspection of the device.

"The NYSDOH acknowledged the updated information from the RSO and is still requesting a final report of the incident. This final report will include steps to prevent recurrence."

Notified R1DO (Eve), NMSS Events Notification (email), and 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

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following is a summary of information provided by the Georgia Radioactive Materials Program (the State) via phone and email:

On October 24, 2024, the State was notified of a source holder that was inoperable and stuck open. The source is located in an area where there are no radiation exposure concerns to personnel or the public. No entry will be permitted until after the source can be safely removed and replaced.

Manufacturer: Ohmart
Source holder model: SHF2
Source holder serial number: 66577
Isotope: Cs-137, 250 mCi

Georgia incident number: 88

AUTOMATIC REACTOR TRIP

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

"At 1023 CDT, on 10/29/2024, with Unit 2 in Mode 1 at 100 percent [reactor] power, during the performance of surveillance procedure 2047, CONTROL ROD QUARTERLY EXERCISE, Unit 2 experienced an automatic reactor trip [followed by a] turbine trip. All control rods fully inserted into the core following the reactor trip. The cause of the Unit 2 reactor trip is being investigated.

"Operations responded and stabilized the plant. Auxiliary feedwater actuated as expected. Decay heat is being removed by the steam generators through the main steam dumps to the condenser. The Unit 2 reactor trip was not complex with all systems responding normally post trip.

"Due to the actuation of the reactor protection system (RPS) of Unit 2, this event is being reported as a RPS Actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B).

"Due to the actuation of the auxiliary feedwater system following the Unit 2 reactor trip, this event is being reported as a specified system actuation in accordance with the reporting criteria of 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."

INOPERABILITY OF DIVISION 3 DIESEL GENERATOR SUPPORTING HIGH PRESSURE CORE SPRAY

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

"At 1152 EDT, on 10/29/2024, the division 3 diesel generator was declared inoperable due to variations in steady state voltage during a planned monthly surveillance run. Troubleshooting of the issue is in progress. This condition could prevent the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). All other emergency core cooling systems were operable during this time.

"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:

Limiting condition for operations (LCO) 3.8.1.b was entered as a result of this event.

OFFSITE NOTIFICATION

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

"At 1730 [EDT], on 10/29/2024, Vistra authorized a report to the State of Ohio in accordance with NEI 07-07, 'Industry Groundwater Protection Initiative,' of a liquid spill to the plant's outdoor ground from an outdoor cask holding radioactive waste. This spill contained radionuclides cobalt-60 and manganese-54 with activities greater than the site procedural limits for state reporting. The outdoor cask has been removed from the onsite storage area; remediation and causal investigation activities are being performed. This exceedance did not exceed any NRC regulations or reporting criteria. There was no impact on the health and safety of the public or plant personnel.

"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

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

No EPA limits were exceeded