Event Notification Report for January 29, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/28/2025 - 01/29/2025
Agreement State
Event Number: 57501
Rep Org: Colorado Dept of Health
Licensee: Casa Bonita
Region: 4
City: Lakewood State: CO
County:
License #: GL002469
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Kerby Scales
Notification Date: 01/21/2025
Notification Time: 14:50 [ET]
Event Date: 01/21/2025
Event Time: 00:00 [MST]
Last Update Date: 01/21/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following is a summary of information received from the Colorado Department of Public Health and Environment via email:
Three exit signs, each containing 10 curies of tritium (30 curies total), were determined to be lost by the licensee.
Manufacturer: Isolite Corporation
Model Number: SLX60
Colorado Event Number: CO25001
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: 57502
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Metro Cardiovacular Consultants
Region: 3
City: Oak Lawn State: IL
County:
License #: IL-02117-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Natalie Starfish
Notification Date: 01/21/2025
Notification Time: 14:44 [ET]
Event Date: 10/01/2023
Event Time: 00:00 [CST]
Last Update Date: 01/21/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
AGREEMENT STATE - LOST/MISSING SOURCE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"On December 13, 2024, the Agency was advised of a licensee that returned an Agency invoice and informed fiscal that they were a closed location. A review of the license and most recent inspection report (April 2021) showed that the licensee was in possession of (1) Cs-137 sealed source. Agency staff conducted a reactive inspection which continued through January 16, 2025, and after extensive investigation, including radiation surveys conducted at the site and interviews of personnel involved, the source could not be traced or located. Therefore, the Cs-137 sealed source (N.A. Scientific, MED 3550 sealed source, serial number 20074, 220.9 microcuries on 6/1/2002) is being reported as a lost source.
"Current activity is calculated as approximately 131 microcuries. Investigation findings indicate the most likely scenario to be that the Cs-137 sealed source was accidentally thrown out as regular trash at some point during the shutdown of nuclear medicine operations at the site. It is believed the source was disposed of around October 2023. Given the time since disposal, it is unlikely any further investigation or corrective action is possible. After initiating appropriate enforcement action, licensing staff will facilitate proper termination of the license.
"Pending no further developments, this matter is considered closed."
Illinois item number: IL250002
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
Non-Agreement State
Event Number: 57503
Rep Org: Goshen General Hospital
Licensee: Goshen General Hospital
Region: 3
City: Goshen State: IN
County:
License #: 13-18845-01
Agreement: N
Docket:
NRC Notified By: Samantha Korda
HQ OPS Officer: Josue Ramirez
Notification Date: 01/22/2025
Notification Time: 14:03 [ET]
Event Date: 01/10/2025
Event Time: 00:00 [EST]
Last Update Date: 01/22/2025
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
DAMAGED I-125 SEED
The following is a summary of information provided by the licensee via phone and email:
On January 10, 2025, two seeds were removed from a patient and placed in a safe in pathology. On January 14, 2025, a nuclear medicine technologist, retrieved the seeds from the safe for check-in with nuclear medicine. When checking in the used seeds the technologist noticed one of the seeds was shorter in length than the other. A seed evaluation was performed and comparisons revealed that seeds were different in size and that the shorter seed appeared to be hollow.
The pathology assistant ceased working and pulled excisions from the patient. Access to the workspace area was restricted. After surveying all tissue samples, only one tissue sample was determined to be radioactive. The radioactive tissue was then immediately placed in a locked box in pathology. The cutting workspace area was surveyed and determined not to be contaminated.
A medical health physicist consultant from Ohio Medical Physics Consulting (OMPC) was contacted for further direction.
A radiation safety officer (RSO) was called but was not in the office at the time. Therefore, a medical physicist took the call. The entire work area and the personnel in pathology were re-surveyed. After the second set of surveys was completed, all surfaces, floors, and previous instruments used in cutting the samples were all determined to be background. All trash and biohazard material in the pathology lab was surveyed. All surveyed material read background. The compactor and biohazard storage room were surveyed and resulted in background readings. Surgery and the cold room, where the samples were stored prior to coming to pathology, were also surveyed. The room and storage area measured background.
A radiologist was consulted regarding the imaging that was taken at the time of surgery. He stated specimen radiograph demonstrates the coil clip and the I-125 seed as well as the circular clip. The I-125 seed associated with the axillary clip was not imaged.
The imaging director and RSO were then notified of the events.
The RSO then requested to have the tissue and any items the tissue had come in contact within pathology surveyed. The specimen was determined to be radioactive along with blocks and slides the sample was placed on. A total of 9 blocks and 4 slides were determined to be contaminated. All items were placed in a lockbox. After which another area survey was completed including the pathologist's microscope, tissue processor, embedding center, microtome, and stainer. All equipment measured background. Wipe tests were also completed and measured background.
The seed and the contaminated blocks and slides will be stored in the nuclear medicine hot lab until it is deemed safe to dispose of properly.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The I-125 seed contained an estimated activity of 269 microcuries.
Agreement State
Event Number: 57504
Rep Org: Georgia Radioactive Material Pgm
Licensee: Northside Heart
Region: 1
City: Lawrenceville State: GA
County:
License #: GA 1337-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Kerby Scales
Notification Date: 01/22/2025
Notification Time: 14:18 [ET]
Event Date: 11/21/2024
Event Time: 00:00 [EST]
Last Update Date: 01/22/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST RADIOACTIVE MATERIAL
The following is summary of information received from the Georgia Radioactive Materials Program Environmental Protection Division (EPD) via email:
On January 20, 2025, the licensee reported to EPD that during the closure of their location in Lawrenceville, GA sources were lost in transit back to the manufacturer. Many sealed sources were shipped by this locations staff in multiple shipments to E and Z for disposal. One shipment contained 2 packages under one [contract carrier] tracking number, and one of these packages contained the Co-60 vial. This shipment was cancelled and returned to CVG Physicians Group, LLC by the [contact carrier] due to improper labeling, but only one package was returned.
The licensee radiation safety officer (RSO) discovered the loss months later on November 21, 2024, when reviewing documentation for a radioactive material license amendment request to remove this location as a location of use. The RSO noticed a closeout survey performed by West Physics that reported the sealed sources were transferred to a radioactive materials license which the RSO was not familiar with. Further investigation showed this was not accurate, and most sources were sent back to E and Z. Reviewing the return receipts sent by E and Z, the RSO discovered seven sources could not be accounted for. Of these sources, the Co-60 source was the only missing source with a high enough activity to be a reportable event.
The licensee has searched the location and contacted other locations on the license to make sure that the sources were not transferred to those locations. The sources were not transferred and were no longer on site. The [common carrier] has been contacted and has not been able to locate the lost package. The source was shipped inside a shielded lead pig labeled as radioactive within a box. It is unlikely that any occupational worker or member of the public received any significant exposure. All staff involved in the incident have received training. EPD staff is investigating further and will update as new information becomes available.
Georgia Incident Number: 90
Isotope: Co-60
Activity: 53 microcuries (12/1/2018)
Manufacturer: E and Z
Serial Number: 2029-29-3
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: 57505
Rep Org: Colorado Dept of Health
Licensee: Community Hospital
Region: 4
City: Grand Junction State: CO
County:
License #: CO 0043-01
Agreement: Y
Docket:
NRC Notified By: James Jarvis
HQ OPS Officer: Kerby Scales
Notification Date: 01/22/2025
Notification Time: 15:57 [ET]
Event Date: 01/21/2025
Event Time: 12:12 [MST]
Last Update Date: 01/22/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received from the Colorado Department of Health via email:
"On January 21, 2025, at 1400 MST, an authorized medical physicist for Community Hospital, reported a medical event to the Radiation Program of the Colorado Department of Public Health and Environment resulting from a yttrium-90 (Y-90) SIR-Sphere administration. The licensee reported that 78.8 percent (14.9 mCi) of the prescribed 18.9 mCi Y-90 dose was delivered to the treatment site and the remaining approximately 21.2 percent (4.4 mCi) of the prescribed dose remained in the delivery line post-procedure.
"The licensee reported and confirmed that there was no shunting or other blockage and the patient did not experience any emergent medical conditions during the treatment that would have resulted in the medical event. At the conclusion of the case, the authorized user was delivering the dose as normal and did not encounter increased pressure or stasis. The licensee confirmed through post treatment radiation area surveys that no spills had occurred and that there was no additional significant radioactive material that was not accounted for. The Colorado Radiation program is continuing to investigate this medical event."
Colorado Event Report ID Number: CO250002
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.
Power Reactor
Event Number: 57516
Facility: River Bend
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Darren Farthing
HQ OPS Officer: Tenisha Meadows
Notification Date: 01/27/2025
Notification Time: 14:15 [ET]
Event Date: 01/27/2025
Event Time: 12:05 [CST]
Last Update Date: 01/27/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Gaddy, Vincent (R4DO)
Power Reactor Unit Info
Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
1 |
N |
Y |
100 |
Power Operation |
100 |
Power Operation |
Event Text
OFFSITE NOTIFICATION DUE TO WASTEWATER DISCHARGE
The following information was provided by the licensee via phone and email:
"On January 27, 2025, at 1205 CST, River Bend Station performed a notification to the Louisiana Department of Environmental Quality per the Louisiana Pollutant Discharge Elimination System (LPDES) Permit (# LA0042731) due to a wastewater leak. The wastewater leak originated at a sewage lift pump station and resulted in an unauthorized discharge. This notification is being made as a four-hour, non-emergency report for notification to other government agency in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 57517
Facility: Catawba
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Aaron Michalski
HQ OPS Officer: Brian P. Smith
Notification Date: 01/28/2025
Notification Time: 10:43 [ET]
Event Date: 01/28/2025
Event Time: 08:32 [EST]
Last Update Date: 01/28/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(i) - Plant S/D Reqd By TS
Person (Organization):
Suggs, LaDonna (R2DO)
Power Reactor Unit Info
Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
1 |
N |
Y |
100 |
Power Operation |
67 |
Power Operation |
Event Text
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
The following information was provided by the licensee via phone or email:
"On January 28, 2025 at 0832 EST, a technical specification (TS) required shutdown was initiated at Catawba Unit 1. TS action 3.4.13, condition 'B', was entered on January 28, 2025 at 0430 when operators detected a 1.4 gpm unidentified reactor coolant system leak. TS action 3.4.13, condition 'B' has a 'required action' to reduce leakage to within limits within 4 hours. This 'required action' was not completed within the completion time; therefore, a TS required shutdown was initiated per TS 3.4.13 condition 'C'.
"This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i) for `the initiation of any nuclear plant shutdown required by the plant's technical specifications.'
"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:
Based on elevated temperature readings on the pressurizer cavity in their lower containment, the licensee anticipates that the leak is in that location. The investigation is ongoing and they will ascertain more information when they reach Mode 3 and enter containment.
In addition, all safety systems are operable for Unit 1. Unit 2 was unaffected.