Event Notification Report for May 04, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/03/2025 - 05/04/2025
Agreement State
Event Number: 57696
Rep Org: PA Bureau of Radiation Protection
Licensee: Allegheny Health Network
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-1659
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Eric Simpson
Licensee: Allegheny Health Network
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-1659
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Eric Simpson
Notification Date: 05/07/2025
Notification Time: 15:08 [ET]
Event Date: 05/05/2025
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2025
Notification Time: 15:08 [ET]
Event Date: 05/05/2025
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 6/18/2025
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL EXTREMITY OVEREXPOSURE
The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:
"On May 6, 2025, and May 7, 2025, the licensee informed the Department of a possible high ring badge exposure of a nuclear medicine technologist. It is reportable per 10 CFR 20.2202(b)(1)(iii).
"On May 6, 2025, the licensee was notified by Mirion (their dosimetry provider) of a high ring badge exposure to a nuclear medicine technologist in the first quarter (Q1) of 2025. The exposure reading was 57,448 millirem, exceeding the allowable annual limit. The technologist also received a higher-than-normal dose to their whole-body badge of 405 millirem. The nuclear medicine technologist was notified about the exposure. The licensee interviewed the technologist to determine what may have caused the high reading on the ring badge. It was determined that the most likely source of the high reading was American College of Radiology phantom accreditation testing. The technologist performed the test twice in Q1 2025. The test involved injecting 15-25 mCi of Tc-99m into a water-filled phantom. The technologist does not recall injecting or handling the phantom without gloves on but thinks they must have handled the phantom without gloves and touched a small amount of contamination on the outside of the phantom. They also recall carrying the phantom from the hot lab to the camera and back, holding it to their body. This is believed to be the source of the higher-than-normal whole-body badge.
"The licensee believes that the nuclear medicine technologist may have handled the phantom without gloves on and picked up a small amount of contamination on their ring as a result.
"The Department will perform a reactive inspection. More information will be provided as received."
* * * RETRACTION ON 06/17/2025 AT 1403 EDT FROM JOHN CHIPPO TO TENISHA MEADOWS * * *
The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:
"Upon receiving the licensee's report and after being inspected for this event, the Department believes there is not a regulatory event to report. The corrective actions include the nuclear medicine technologist will always wear gloves when handling the phantom, injecting the Tc-99m into the phantom, and doing phantom testing. Also, the technologist will transport the phantom on a cart in the future. Information regarding this event will be shared with all technologists during annual training. Emphasis will be placed on always wearing gloves when handling phantoms and diligent hand or area monitoring upon completion of work. They will also stress the high concentrations of some radiopharmaceutical and quality control doses and how much Tc-99m can be present in a drop. They will also review the doses that can result from the presence of these amounts on the skin if not removed promptly."
Pennsylvania Event Report ID: PA250007
Notified R1DO (Warnek) and NMSS Events Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL EXTREMITY OVEREXPOSURE
The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:
"On May 6, 2025, and May 7, 2025, the licensee informed the Department of a possible high ring badge exposure of a nuclear medicine technologist. It is reportable per 10 CFR 20.2202(b)(1)(iii).
"On May 6, 2025, the licensee was notified by Mirion (their dosimetry provider) of a high ring badge exposure to a nuclear medicine technologist in the first quarter (Q1) of 2025. The exposure reading was 57,448 millirem, exceeding the allowable annual limit. The technologist also received a higher-than-normal dose to their whole-body badge of 405 millirem. The nuclear medicine technologist was notified about the exposure. The licensee interviewed the technologist to determine what may have caused the high reading on the ring badge. It was determined that the most likely source of the high reading was American College of Radiology phantom accreditation testing. The technologist performed the test twice in Q1 2025. The test involved injecting 15-25 mCi of Tc-99m into a water-filled phantom. The technologist does not recall injecting or handling the phantom without gloves on but thinks they must have handled the phantom without gloves and touched a small amount of contamination on the outside of the phantom. They also recall carrying the phantom from the hot lab to the camera and back, holding it to their body. This is believed to be the source of the higher-than-normal whole-body badge.
"The licensee believes that the nuclear medicine technologist may have handled the phantom without gloves on and picked up a small amount of contamination on their ring as a result.
"The Department will perform a reactive inspection. More information will be provided as received."
* * * RETRACTION ON 06/17/2025 AT 1403 EDT FROM JOHN CHIPPO TO TENISHA MEADOWS * * *
The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:
"Upon receiving the licensee's report and after being inspected for this event, the Department believes there is not a regulatory event to report. The corrective actions include the nuclear medicine technologist will always wear gloves when handling the phantom, injecting the Tc-99m into the phantom, and doing phantom testing. Also, the technologist will transport the phantom on a cart in the future. Information regarding this event will be shared with all technologists during annual training. Emphasis will be placed on always wearing gloves when handling phantoms and diligent hand or area monitoring upon completion of work. They will also stress the high concentrations of some radiopharmaceutical and quality control doses and how much Tc-99m can be present in a drop. They will also review the doses that can result from the presence of these amounts on the skin if not removed promptly."
Pennsylvania Event Report ID: PA250007
Notified R1DO (Warnek) and NMSS Events Notification via email.
Power Reactor
Event Number: 57689
Facility: Callaway
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Zach Milligan
HQ OPS Officer: Ian Howard
Region: 4 State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Zach Milligan
HQ OPS Officer: Ian Howard
Notification Date: 05/04/2025
Notification Time: 21:30 [ET]
Event Date: 05/04/2025
Event Time: 12:30 [CDT]
Last Update Date: 05/04/2025
Notification Time: 21:30 [ET]
Event Date: 05/04/2025
Event Time: 12:30 [CDT]
Last Update Date: 05/04/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Agrawal, Ami (R4DO)
Agrawal, Ami (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
BOTH TRAINS OF EMERGENCY CORE COOLING SYSTEM INOPERABLE
The following information was provided by the licensee via phone and email:
"On May 4, 2025, with the plant in mode 4 during restart from a refueling outage, operators were flushing the chemical volume and control system [CVCS] `B' train mixed bed demineralizers, with makeup [water] from the refueling water storage tank (RWST). During the evolution at 1230 CDT, it was discovered that the borated water level in the RWST had been inadvertently lowered to less than the technical specification (TS) limit of 394,000 gallons. Under TS 3.5.4, `Refueling Water Storage Tank (RWST),' surveillance requirement (SR) 3.5.4.2 requires verifying that the RWST borated water volume is [greater than or equal to] 394,000 gallons (93.7 percent level). The minimum level (volume) reached in the tank during the flushing operation was 93 percent.
"Upon discovery of the lowered level in the RWST, the flushing activity was terminated, and water level in the RWST was restored to above the TS limit by 1427.
"The RWST supplies borated water to the CVCS during abnormal operating conditions, and to the emergency core cooling system (ECCS) and the containment spray system during accident conditions. The RWST supplies both trains of the ECCS and the containment spray system through a common suction supply header during the injection phase of a loss of coolant accident recovery. During mode 4, in accordance with TS 3.5.3, `ECCS - Shutdown,' only one ECCS train is required to be operable.
"With the RWST declared inoperable, the one required ECCS train in mode 4 was not supported. Therefore, the identified condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident."
The NRC Resident Inspector was notified.
The following information was provided by the licensee via phone and email:
"On May 4, 2025, with the plant in mode 4 during restart from a refueling outage, operators were flushing the chemical volume and control system [CVCS] `B' train mixed bed demineralizers, with makeup [water] from the refueling water storage tank (RWST). During the evolution at 1230 CDT, it was discovered that the borated water level in the RWST had been inadvertently lowered to less than the technical specification (TS) limit of 394,000 gallons. Under TS 3.5.4, `Refueling Water Storage Tank (RWST),' surveillance requirement (SR) 3.5.4.2 requires verifying that the RWST borated water volume is [greater than or equal to] 394,000 gallons (93.7 percent level). The minimum level (volume) reached in the tank during the flushing operation was 93 percent.
"Upon discovery of the lowered level in the RWST, the flushing activity was terminated, and water level in the RWST was restored to above the TS limit by 1427.
"The RWST supplies borated water to the CVCS during abnormal operating conditions, and to the emergency core cooling system (ECCS) and the containment spray system during accident conditions. The RWST supplies both trains of the ECCS and the containment spray system through a common suction supply header during the injection phase of a loss of coolant accident recovery. During mode 4, in accordance with TS 3.5.3, `ECCS - Shutdown,' only one ECCS train is required to be operable.
"With the RWST declared inoperable, the one required ECCS train in mode 4 was not supported. Therefore, the identified condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident."
The NRC Resident Inspector was notified.