Event Notification Report for October 14, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/13/2024 - 10/14/2024
Non-Power Reactor
Event Number: 57382
Rep Org: Univ Of Missouri-Columbia (MISC)
Licensee: University Of Missouri
Region: 3
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Deborah Farnsworth
HQ OPS Officer: Natalie Starfish
Licensee: University Of Missouri
Region: 3
City: Columbia State: MO
County: Boone
License #: R-103
Agreement: N
Docket: 05000186
NRC Notified By: Deborah Farnsworth
HQ OPS Officer: Natalie Starfish
Notification Date: 10/15/2024
Notification Time: 15:39 [ET]
Event Date: 10/14/2024
Event Time: 14:00 [CDT]
Last Update Date: 10/15/2024
Notification Time: 15:39 [ET]
Event Date: 10/14/2024
Event Time: 14:00 [CDT]
Last Update Date: 10/15/2024
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Jessica Lovett (NRR)
Andrew Waugh (NRR)
Jessica Lovett (NRR)
Andrew Waugh (NRR)
NONCOMPLIANCE WITH TECHNICAL SPECIFICATION
The following information was provided by the licensee via phone and email:
"University of Missouri Research Reactor (MURR), a 10 MW reactor, is reporting an abnormal occurrence as required per Technical Specification (TS) 1.1 b and c. One of two redundant switches on the Fluxtrap irradiations reactivity safety trip device failed reactor pre-startup checks on October 14, 2024. This failure would have prevented the switch from sending a scram input to the reactor protection system. MURR TS 3.2.g.21 requires a 1/N logic of 2, meaning both switches must be operational during operation of the reactor.
"The faulty switch was last confirmed operating properly prior to reactor startup on October 7, 2024. MURR cannot positively state when the switch failed. This condition could have existed during operations at some point between October 7 and October 13, 2024.
"The second switch was verified to be operable. The faulty switch and its associated wiring were replaced, retested satisfactorily, and the reactor was returned to operation the evening of Monday, October 14, 2024 with authorization from the Facility Director.
"MURR will follow up with a written report to the NRC within 14 days as required by TS 6.6.c.
"NRC Project Manager has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
A causal investigation is in progress. Equipment age is the potential cause of the failure.
The following information was provided by the licensee via phone and email:
"University of Missouri Research Reactor (MURR), a 10 MW reactor, is reporting an abnormal occurrence as required per Technical Specification (TS) 1.1 b and c. One of two redundant switches on the Fluxtrap irradiations reactivity safety trip device failed reactor pre-startup checks on October 14, 2024. This failure would have prevented the switch from sending a scram input to the reactor protection system. MURR TS 3.2.g.21 requires a 1/N logic of 2, meaning both switches must be operational during operation of the reactor.
"The faulty switch was last confirmed operating properly prior to reactor startup on October 7, 2024. MURR cannot positively state when the switch failed. This condition could have existed during operations at some point between October 7 and October 13, 2024.
"The second switch was verified to be operable. The faulty switch and its associated wiring were replaced, retested satisfactorily, and the reactor was returned to operation the evening of Monday, October 14, 2024 with authorization from the Facility Director.
"MURR will follow up with a written report to the NRC within 14 days as required by TS 6.6.c.
"NRC Project Manager has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
A causal investigation is in progress. Equipment age is the potential cause of the failure.
Agreement State
Event Number: 57385
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush University Medical Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Karen Cotton-Gross
Licensee: Rush University Medical Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/16/2024
Notification Time: 13:06 [ET]
Event Date: 10/14/2024
Event Time: 00:00 [CDT]
Last Update Date: 10/16/2024
Notification Time: 13:06 [ET]
Event Date: 10/14/2024
Event Time: 00:00 [CDT]
Last Update Date: 10/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Illinois Emergency Management Agency (The Agency) via phone and email:
"The Agency was contacted by the radiation safety officer (RSO) for Rush University Medical Center, on October 15, 2024, to report that a patient prescribed 66.67 mCi (479 Gy) of Y-90 Theraspheres on October 14, 2024, received only 20.14 mCi (144.7 Gy) of the prescribed dose. The patient has been notified and the RSO is still attempting to notify the referring physician who left on vacation immediately after the procedure. There was no reported adverse impact on the patient and the licensee is still discussing possible retreatment. The administering physician reported significant resistance during the administration and filling of the overflow vial. An investigation remains ongoing. The underdose (69.8 percent deviation between the prescribed and administered dose) meets the criteria as a reportable incident under 32 Illinois administrative code 335.1080. Inspectors will perform a reactive inspection on October 17, 2024."
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.
The following information was provided by the Illinois Emergency Management Agency (The Agency) via phone and email:
"The Agency was contacted by the radiation safety officer (RSO) for Rush University Medical Center, on October 15, 2024, to report that a patient prescribed 66.67 mCi (479 Gy) of Y-90 Theraspheres on October 14, 2024, received only 20.14 mCi (144.7 Gy) of the prescribed dose. The patient has been notified and the RSO is still attempting to notify the referring physician who left on vacation immediately after the procedure. There was no reported adverse impact on the patient and the licensee is still discussing possible retreatment. The administering physician reported significant resistance during the administration and filling of the overflow vial. An investigation remains ongoing. The underdose (69.8 percent deviation between the prescribed and administered dose) meets the criteria as a reportable incident under 32 Illinois administrative code 335.1080. Inspectors will perform a reactive inspection on October 17, 2024."
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: 57379
Facility: South Texas
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ronald Rohan
HQ OPS Officer: Tenisha Meadows
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ronald Rohan
HQ OPS Officer: Tenisha Meadows
Notification Date: 10/14/2024
Notification Time: 13:22 [ET]
Event Date: 10/14/2024
Event Time: 09:34 [CDT]
Last Update Date: 10/14/2024
Notification Time: 13:22 [ET]
Event Date: 10/14/2024
Event Time: 09:34 [CDT]
Last Update Date: 10/14/2024
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
FFD Group, (EMAIL)
Taylor, Nick (R4DO)
FFD Group, (EMAIL)
Taylor, Nick (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
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."
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."
Independent Spent Fuel Storage Installation
Event Number: 57380
Rep Org: Oyster Creek
Licensee: Holtec International
Region: 1
City: Forked River State: NJ
County: Ocean
License #: GL
Agreement: Y
Docket: 72-15
NRC Notified By: David Gebhardt
HQ OPS Officer: Sam Colvard
Licensee: Holtec International
Region: 1
City: Forked River State: NJ
County: Ocean
License #: GL
Agreement: Y
Docket: 72-15
NRC Notified By: David Gebhardt
HQ OPS Officer: Sam Colvard
Notification Date: 10/14/2024
Notification Time: 15:11 [ET]
Event Date: 10/14/2024
Event Time: 12:33 [EDT]
Last Update Date: 10/14/2024
Notification Time: 15:11 [ET]
Event Date: 10/14/2024
Event Time: 12:33 [EDT]
Last Update Date: 10/14/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Arner, Frank (R1DO)
Arner, Frank (R1DO)
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.
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
Event Number: 57381
Rep Org: Texas Dept of State Health Services
Licensee: The Dow Chemical Company
Region: 4
City: Lake Jackson State: TX
County:
License #: L 00451
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Tenisha Meadows
Licensee: The Dow Chemical Company
Region: 4
City: Lake Jackson State: TX
County:
License #: L 00451
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Tenisha Meadows
Notification Date: 10/14/2024
Notification Time: 17:33 [ET]
Event Date: 10/14/2024
Event Time: 17:33 [CDT]
Last Update Date: 10/14/2024
Notification Time: 17:33 [ET]
Event Date: 10/14/2024
Event Time: 17:33 [CDT]
Last Update Date: 10/14/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
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
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