Event Notification Report for April 04, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/03/2025 - 04/04/2025
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 57646
Rep Org: Texas Dept of State Health Services
Licensee: High Mountain Inspection
Region: 4
City: Odessa State: TX
County:
License #: L-07197
Agreement: Y
Docket:
NRC Notified By: Bruce Hammond
HQ OPS Officer: Robert A. Thompson
Licensee: High Mountain Inspection
Region: 4
City: Odessa State: TX
County:
License #: L-07197
Agreement: Y
Docket:
NRC Notified By: Bruce Hammond
HQ OPS Officer: Robert A. Thompson
Notification Date: 04/04/2025
Notification Time: 17:10 [ET]
Event Date: 04/04/2025
Event Time: 00:00 [CDT]
Last Update Date: 08/07/2025
Notification Time: 17:10 [ET]
Event Date: 04/04/2025
Event Time: 00:00 [CDT]
Last Update Date: 08/07/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 8/8/2025
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On April 4, 2025, the Department was notified by the licensee of a telephonic overexposure report they received from their dosimetry provider. The licensee radiation safety officer stated the report had one of their employees with an exposure of 7.7 rem for the month of February 2025. The licensee had other readings (pocket dosimeters) that did not match this level of exposure. The licensee removed the employee from the work environment until the dose can be confirmed. The employee affected is an assistant, and neither of the other two radiographers had any exposure near this level. The licensee is still investigating.
"More information will be made available according to SA-300 requirements."
Texas incident number: 10189
NMED number: TX250022
* * * RETRACTION ON 08/07/2025 AT 1600 EDT FROM TEXAS DEPARTMENT OF STATE HEALTH SERVICES TO JORDAN WINGATE * * *
The following retraction was provided by the Texas Department of State Health Services (the Department) via email:
"After review by the radiation safety officer (RSO) and corporate RSO it was determined to be an anomaly in the processing of the dosimeter. The person was not near anything capable of that [level of] exposure and no one the person worked with was exposed to anything above expected numbers. The licensee assigned a dose of 285 mR for the period in question and notified the dosimetry provider."
Notified R4DO (Bywater) and NMSS Events Notifications (email).
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On April 4, 2025, the Department was notified by the licensee of a telephonic overexposure report they received from their dosimetry provider. The licensee radiation safety officer stated the report had one of their employees with an exposure of 7.7 rem for the month of February 2025. The licensee had other readings (pocket dosimeters) that did not match this level of exposure. The licensee removed the employee from the work environment until the dose can be confirmed. The employee affected is an assistant, and neither of the other two radiographers had any exposure near this level. The licensee is still investigating.
"More information will be made available according to SA-300 requirements."
Texas incident number: 10189
NMED number: TX250022
* * * RETRACTION ON 08/07/2025 AT 1600 EDT FROM TEXAS DEPARTMENT OF STATE HEALTH SERVICES TO JORDAN WINGATE * * *
The following retraction was provided by the Texas Department of State Health Services (the Department) via email:
"After review by the radiation safety officer (RSO) and corporate RSO it was determined to be an anomaly in the processing of the dosimeter. The person was not near anything capable of that [level of] exposure and no one the person worked with was exposed to anything above expected numbers. The licensee assigned a dose of 285 mR for the period in question and notified the dosimetry provider."
Notified R4DO (Bywater) and NMSS Events Notifications (email).
Agreement State
Event Number: 57649
Rep Org: NC Div of Radiation Protection
Licensee: UNC Hospitals
Region: 1
City: Chapel Hill State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Jon Lilliendahl
Licensee: UNC Hospitals
Region: 1
City: Chapel Hill State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Jon Lilliendahl
Notification Date: 04/07/2025
Notification Time: 11:02 [ET]
Event Date: 04/04/2025
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2025
Notification Time: 11:02 [ET]
Event Date: 04/04/2025
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Schussler, Jason (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schussler, Jason (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the North Carolina Radioactive Materials Branch via email:
On April 4, 2025, Y-90 SIR-spheres therapeutic split dose administration resulted in a patient being underdosed per the written directive. One of three doses administered was 27 percent or less of the prescribed dose. The referring physician and patient were notified on the same day of treatment. The cause of the underdose was a catheter clog or kink. Corrective actions consisted of retraining of personnel.
NC Event Number: 250004
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 is a summary of information provided by the North Carolina Radioactive Materials Branch via email:
On April 4, 2025, Y-90 SIR-spheres therapeutic split dose administration resulted in a patient being underdosed per the written directive. One of three doses administered was 27 percent or less of the prescribed dose. The referring physician and patient were notified on the same day of treatment. The cause of the underdose was a catheter clog or kink. Corrective actions consisted of retraining of personnel.
NC Event Number: 250004
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.
Non-Agreement State
Event Number: 57650
Rep Org: White Forest Resources
Licensee: Clearco Preparation Plant
Region: 1
City: Clearco State: WV
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: Dustin Smith
HQ OPS Officer: Josue Ramirez
Licensee: Clearco Preparation Plant
Region: 1
City: Clearco State: WV
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: Dustin Smith
HQ OPS Officer: Josue Ramirez
Notification Date: 04/04/2025
Notification Time: 18:59 [ET]
Event Date: 04/04/2025
Event Time: 18:00 [EDT]
Last Update Date: 04/09/2025
Notification Time: 18:59 [ET]
Event Date: 04/04/2025
Event Time: 18:00 [EDT]
Last Update Date: 04/09/2025
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Schussler, Jason (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schussler, Jason (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
STUCK OPEN GAUGE SHUTTER
The following is a summary of the information provided by the licensee via phone:
The licensee discovered a stuck-open shutter during routine checks on a gauge with a normally open shutter. The gauge is a Berthold model LB444 with a 500 mCi Cs-137 source. The area around the gauge has been flagged and there are no concerns about radiation exposure. The manufacturer will be contacted to repair the gauge.
* * * UPDATE ON 04/09/2025 AT 1257 EDT FROM DUSTIN SMITH TO JORDAN WINGATE * * *
The following is a summary of the information provided by the licensee via phone:
The licensee has been in contact with Berthold technologies, who will be sending a technician to repair the gauge. A finalized date has not yet been confirmed. Additional information will be provided as it becomes available.
Informed R1DO(Schussler) and NMSS Events Notifications (email).
The following is a summary of the information provided by the licensee via phone:
The licensee discovered a stuck-open shutter during routine checks on a gauge with a normally open shutter. The gauge is a Berthold model LB444 with a 500 mCi Cs-137 source. The area around the gauge has been flagged and there are no concerns about radiation exposure. The manufacturer will be contacted to repair the gauge.
* * * UPDATE ON 04/09/2025 AT 1257 EDT FROM DUSTIN SMITH TO JORDAN WINGATE * * *
The following is a summary of the information provided by the licensee via phone:
The licensee has been in contact with Berthold technologies, who will be sending a technician to repair the gauge. A finalized date has not yet been confirmed. Additional information will be provided as it becomes available.
Informed R1DO(Schussler) and NMSS Events Notifications (email).
Power Reactor
Event Number: 57645
Facility: North Anna
Region: 2 State: VA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Matt West
HQ OPS Officer: Ian Howard
Region: 2 State: VA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Matt West
HQ OPS Officer: Ian Howard
Notification Date: 04/04/2025
Notification Time: 06:35 [ET]
Event Date: 04/04/2025
Event Time: 00:14 [EDT]
Last Update Date: 04/04/2025
Notification Time: 06:35 [ET]
Event Date: 04/04/2025
Event Time: 00:14 [EDT]
Last Update Date: 04/04/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Franke, Mark (R2DO)
Franke, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Standby | 0 | Hot Standby |
SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"At 0002 EDT on 4/4/25, Unit 2 was in mode 3 with all three reactor coolant pumps (RCPs) running in preparation for a reactor startup when an alarm for the 'B' RCP vibration alert/danger was received due to the indication of elevated vertical proximity vibrations. At 0014, the 'B' RCP vertical proximity vibration indication exceeded the pump trip setpoint and the reactor trip breakers were manually opened, followed by the 'B' RCP being manually tripped. All rods were fully inserted prior to the reactor protection system (RPS) actuation, and all required equipment responded as designed.
"This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the RPS."
NRC Resident has been notified.
The following information was provided by the licensee via phone and email:
"At 0002 EDT on 4/4/25, Unit 2 was in mode 3 with all three reactor coolant pumps (RCPs) running in preparation for a reactor startup when an alarm for the 'B' RCP vibration alert/danger was received due to the indication of elevated vertical proximity vibrations. At 0014, the 'B' RCP vertical proximity vibration indication exceeded the pump trip setpoint and the reactor trip breakers were manually opened, followed by the 'B' RCP being manually tripped. All rods were fully inserted prior to the reactor protection system (RPS) actuation, and all required equipment responded as designed.
"This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the RPS."
NRC Resident has been notified.