Event Notification Report for February 21, 2024

AGREEMENT STATE - SHUTTER STUCK OPEN

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

"On January 18, 2024, the licensee's radiation safety officer (RSO) was completing shutter checks and leak tests on a Berthold fixed gauge, model number: LB-300 W, serial number 1744-11-14 containing sealed source number P-2608-100 with 8 millicuries of Co-60. During the checks, the shutter's shear pin broke, and the RSO was unable to close the shutter. The vessel that this gauge is on is not entered very often and is not readily accessible. A licensed contractor will be on site on February 13 - 14, 2024, to repair the gauge. If they are not able to repair the gauge on-site, the gauge will be placed in storage until it can be sent for repair. The DEP has been in contact with the licensee."

PA event report ID: PA240004

MEDICAL EVENT - DOSE MISADMINISTRATION

The following is a summary of information provided by the licensee via phone:

At 1110 EST on February 14, 2024, a patient was administered the wrong radiopharmaceutical. The prescribed dose was 25 mCi Tc-99m pyrophosphate, and the administered dose was 25 mCi Tc-99m sestamibi. The patient and referring physician were informed. There were no adverse effects to the patient. The total effective dose equivalent for this study was estimated to be 1,200 mrem.

* * * RETRACTION ON 2/15/24 AT 1240 EDT FROM GLADYS KAGAOAN TO ADAM KOZIOL * * *

After further review, the dose to the patient was below reporting threshold. The radiopharmaceutical was a diagnostic tracer and non-therapeutic.

Notified R1DO (Bickett), NMSS (Rivera-Capella), and NMSS Events (email).

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

AGREEMENT STATE REPORT - SHUTTER STUCK OPEN

The following is a summary of information provided by the New Mexico Radiation Control Bureau via email:

On February 14, 2024, a routine inspection discovered that a densitometer (Berthold LB8010, serial number 10377, 20 mCi of cesium-137) was missing the handle that actuates the shutter. The shutter was in the open position. The radiation safety officer packed the defective densitometer in lead pending disposal. There were no excessive exposures due to this event.

AGREEMENT STATE REPORT - STOLEN PORTABLE GAUGE

The following was received from the Colorado Department of Public Health and Environment (the Department) via email:

"On February 14, 2024, the radiation safety officer of CTL/Thompson, Inc. reported a stolen InstroTek model 3500 series portable moisture/density gauge (Serial Number 4764). The gauge user reported they loaded the gauge at their Pueblo office and stopped at their residence to retrieve their wallet. Upon returning to their truck, both chains that secured the gauge and transportation case were cut and the gauge and transportation case were stolen. The gauge contained a 10 mCi cesium-137 source (Serial Number BG1770) and a 40 mCi americium-241: beryllium source (K147/22).The licensee was instructed to file a police report. The Department is waiting for additional details regarding the event."

CO Event Number: CO240003

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

AUTOMATIC START OF EMERGENCY DIESEL GENERATOR

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

"At approximately 2325 EST on February 18, 2024, with Unit 1 in Mode 5 at 0 percent power and Unit 2 in Mode 1 at 100 percent power, emergency diesel generator 2 automatically started due to the unexpected loss of AC power to emergency bus E2 during a planned transfer of E2 DC control power from normal to alternate for the 1B-1 battery. In addition, the unexpected loss of AC power to E2 resulted in Unit 1 primary containment isolation system (PCIS) partial Group 2 (i.e., drywell equipment and floor drain, residual heat removal (RHR), discharge to radioactive waste, and RHR process sample), Group 6 (i.e., containment atmosphere control/dilution, containment atmosphere monitoring, and post accident sampling systems), and partial Group 10 (i.e., air isolation to the drywell) isolations.

"Emergency diesel generator 2 automatically started and re-energized the E2 bus as designed when the loss of E2 signal was received. The PCIS actuations were as expected for the outage plant line up on Unit 1 at the time. The cause of the loss of electrical power to emergency bus E2 is under investigation at this time.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency diesel generator 2 and PCIS.

"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:

This event will be entered into the plant's corrective action program.

EN Revision Imported Date: 2/20/2024

EN Revision Text: AUTOMATIC START OF 'B' EMERGENCY DIESEL GENERATOR

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

"On February 19, 2024, at 0236 EST, with VC Summer Unit 1 in Mode 1 at 100 percent power, an actuation of the `B' emergency diesel generator (EDG) occurred. The reason for the `B' EDG auto-start was the trip of 1 `DB' normal incoming breaker. The `B' EDG automatically started as designed when the undervoltage signal was received. The `B' emergency feedwater pump started due to the undervoltage signal and ran for approximately 1 minute and was secured by operations per procedure. Other plant equipment and systems also responded as expected. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the `B' EDG and a valid actuation of the `B' emergency feedwater pump. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

"The `A' Emergency Diesel Generator was tagged out for maintenance earlier in the shift, but maintenance has not started. The plan is to restore the `A' emergency diesel generator to an operable status and investigate the cause of the 1 `DB' normal incoming breaker trip."

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

This event resulted in the plant entering a 12 hour limiting condition for operation (LCO) in accordance with technical specification (TS) 3.8.1.1.C. due to having one operable EDG and a loss of offsite power.

LOSS OF REACTOR BUILDING VENTILATION

The following information was provided by the licensee via email:

"At 1045 EST, on 2/19/2024, during a maintenance activity, a loss of all reactor building ventilation occurred on Unit 2. With no flow past the ventilation radiation monitors, the radiation monitors were inoperable to support their ability to perform primary and secondary containment isolation functions or start the standby gas treatment system. Reactor building ventilation was restored within 15 minutes. Due to this inoperability, the radiation monitor system was in a condition that could have prevented 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).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector will be notified."