Event Notification Report for April 22, 2024

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following is a summary of information received from the Alabama Office of Radiation Control via email:

On April 11, 2024, at 1500 CST, a device (Ohmart/Vega, SH-F1, Model A-2102, Source SN 9254GK, 100 mCi Cs-137) was discovered to have a stuck open shutter during routine shutter checks. The device is in place and operational. The area around the vessel on which the device is mounted has been barricaded and marked for no entry. The licensee's plan is to replace the source holder with a new one. The licensee is getting a quote for replacement and installation with an estimated repair date of May 10, 2024.

AGREEMENT STATE - MEDICAL UNDERDOSE

The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."


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 - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Two SRB Technologies exit signs, model number: BX10GY, containing 10 curies each, of tritium (20 curies total) were determined to be lost by the licensee.

Colorado event number CO240010


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 REPORT - BROKEN LOCK ON RADIOGRAPHY CAMERA

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

"This letter is serving as notification of an equipment failure under [Colorado Regulation] Section 4.52.2.3 and 5.38.1.3. A QSA Global 880 Delta camera was received from Source Production and Equipment Company, Inc. (SPEC), after being resourced. During the check-in procedure and mechanism check, it was discovered that the lock that controls access to the pigtail attachment was broken in the locked position. The camera was tagged out until it could be sent to Industrial Nuclear Company (INC), for repairs on 04/04/2024. The lock was repaired at INC, and the camera was returned to the licensee on 04/10/2024 with no issues."

Colorado Event Report ID: CO240011

AUTOMATIC ACTUATION OF EMERGENCY DIESEL GENERATORS

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

"At 0704 CDT on 4/20/24 with Unit 1 in Mode 1 at 100 percent power, an actuation of the emergency AC power system, specifically the Division 1 and Division 3 emergency diesel generators (EDGs) occurred during an unexpected loss of the Unit 1 system auxiliary transformer (SAT). The cause of the emergency AC power system auto-start was an unexpected loss of the Unit 1 SAT during switchyard maintenance. Bus 141Y did not fast transfer as designed resulting in the actuation of the Division 1 EDG. Division 3 EDG actuation is expected for this condition. The Division 1 and Division 3 EDGs automatically started as designed when the emergency AC power system valid actuation signal was received.

"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 emergency AC power system.

"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:

Division 1 and Division 3 EDGs will remain in operation and loaded until the Unit 1 SAT is restored. This event resulted in the plant entering an unplanned 72 hour limiting condition for operation (LCO) in accordance with technical specification 3.8.1. The licensee is investigating the cause of the unexpected loss of the Unit 1 SAT and the failure of the bus 141Y fast transfer.