Event Notification Report for April 29, 2024

EN Revision Imported Date: 4/29/2024

EN Revision Text: UNPLANNED CONTAMINATION

The following information was provided by the licensee via telephone:

On March 27, 2024, at 1101 EDT, a sample containing 20.3 mCi of carbon-14 (C-14) in 1,3-Dichloropropene liquid form (348 microliters) was dropped when being removed from a storage container. The authorized user immediately called for assistance and restricted access to the laboratory where the spill occurred. Decontamination efforts began immediately after the incident, and it was confirmed that the contamination was contained to the laboratory where the spill occurred. It was determined on March 28, 2024, at 1025 EDT that restrictions would remain in place greater than 24 hours, and that this incident was reportable under 10 CFR 30.50(b)(1).

Following the spill, a nasal swab was taken of the worker with no detectable activity, however, a urine bioassay taken the following day indicated a potential internal dose of 213 mrem. No other staff were exposed, and there was no risk to public safety or the environment.

The applicable 10 CFR 20 Appendix B annual limit for intake for C-14 is 2000 microcuries.

Decontamination efforts will continue until detectable surface contamination is less than 1000 dpm/100 square centimeters.

* * * UPDATE ON 4/26/24 AT 1609 EDT FROM KELLY WEGENER-GAVE TO ADAM KOZIOL * * *

The licensee submitted a 30-day written report for this event.

Notified R3DO (Betancourt-Roldan) and NMSS Events (email).

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."


* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

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

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.


PA Event Number: PA240008

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 - MEDICAL EVENT

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

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."


* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

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

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.


PA Event Number: PA240009

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 - MEDICAL EVENT

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

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."


* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

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

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.


PA Event Number: PA240010

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 PARTIALLY OPEN

The following was received from the Iowa Department of Public Health - Bureau of Radiological Health (Iowa HHS) via email:

"Arconic Davenport possesses an IMS Measuring System (model 5221-02 profile thickness gauge) for measuring thickness of aluminum on the production line. The C-frame gauge contains five independent source housings, with each housing containing a 5 curie, americium-241, sealed source. The C-frame gauge is constructed from steel and is suspended from a monorail which allows the device to be moved offline to a restricted access calibration area. The shutter [on each source] is opened and closed by a pneumatic cylinder that is controlled from a remote location.

"On the morning of April 22, 2024, it was determined that shutter number 1 of the C-frame gauge B had failed to fully close. This was determined [during] an automated attempt to close all 5 shutters on the gauge, and the computer indicated that shutter number 1 was not fully closed. Per the licensee's procedures, the C-frame gauge was removed from the line using the monorail to the secured calibration house. Radiation surveys of the outside wall adjacent to the shutter 1 position were above background with a maximum dose rate of 0.1 mR/hr.

"The licensee has contacted their service provider to perform repair work (identify and fix the equipment problem) which is tentatively scheduled for same day or April 23, 2024. No reported overexposures have occurred because of this incident, no release or contamination of radioactive material occurred because of this incident (most recent negative leak test was November 2, 2023), and Iowa HHS will update this report once additional information is provided (cause, corrective actions, etc.)."

IA Event Number: IA240002

EN Revision Imported Date: 4/29/2024

EN Revision Text: PART 21 - FUEL ASSEMBLY SPACER RELOCATION

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

Global Nuclear Fuel discovered instances of GNF3 fuel assembly spacers relocating within the fuel bundle. A safety communication was issued in 2022 following the discovery of a raised water rod (WR) at Grand Gulf Nuclear Station. Shutdown inspections in February 2024 at Lasalle identified five spacers out of position. Shutdown inspections at Limerick in April 2024 identified four spacers out of position. Those discoveries prompted this Part 21 report. An evaluation concluded that the relocated spacers could result in a degraded critical power margin, but the evaluation of this condition indicates it will not compromise or greatly reduce protection to public health and safety.

Plants with suspect bundles installed:
Grand Gulf Nuclear Station (Raised WR but no defective spacers)
Lasalle (1 bundle with 5 relocated spacers found)
Limerick (1 bundle with 4 relocated spacers found)
Nine Mile Point (No defects found)
Fermi (No defects found)
Peach Bottom (Shutdown scheduled in Fall 2024)
Fitzpatrick (Shutdown scheduled in Fall 2024)

* * * UPDATE ON 4/26/24 AT 1220 EDT FROM LISA SCHICHLEIN TO ADAM KOZIOL * * *

Updated to correct administrative errors in the summary of defects. Corrections were made above.

Notified R1DO (Werkheiser), R3DO (Betancourt-Roldan), R4DO (Warnick), Part 21/Reactor Group (email)

AUTOMATIC REACTOR SCRAM WITH ECCS ACTUATION

The following information was provided by the licensee via email:

"On 4/24/2024 at 2215 CDT, Browns Ferry Unit 1 experienced an automatic reactor scram. The cause of the scram is currently under investigation. The main steam isolation valves (MSIVs) remain open with the main turbine bypass valves controlling reactor pressure. The reactor feedwater pumps are in service to control reactor water level.

"Primary containment isolation systems (PCIS) Groups 2, 3, 6, and 8 isolation signals were received. Upon receipt of these signals, all components actuated as required. Following the reactor scram, due to reactor water level reaching minus 45 inches, both high pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) initiation signals were received, and both initiated as designed. All safety systems operated as expected.

"This event requires a 4-hour report per 10 CFR 50.72(b)(2)(iv)(A), `Any event that results or should have resulted in emergency core cooling system (ECCS) discharge into the reactor coolant system as a result of a valid signal except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'

"This event requires a 4-hour report per 10 CFR 50.72(b)(2)(iv)(B), `Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'

"This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A), `Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B): 1) Reactor protection system (RPS) including: reactor scram or reactor trip. 2) General containment isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs). 4) ECCS for boiling water reactors (BWRs) - high-pressure coolant injection (HPCI). 5) BWR reactor core isolation cooling system (RCIC).'

"All safety systems operated as expected. At no time was public health and safety at risk. The NRC resident inspector has been notified."

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

Units 2 and 3 were not affected.

INVALID ACTUATION OF AUTOMATIC TURBINE DRIVEN AUXILIARY FEEDWATER PUMP

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

"This report is being made in accordance with 10 CFR 50.73(a)(2)(iv)(A), under the provision of 10 CFR 50.73(a)(1), detailing the event in which an unplanned actuation of the turbine driven auxiliary feedwater pump (TDAFP) at the Callaway plant occurred in response to an invalid actuation signal.

"The actuation occurred at 2056 [CDT] on 3/21/2024 during restoration from maintenance on the NN12 inverter. The actuation signal was received while closing breaker NK0211 (for connecting the inverter to its associated 125-VDC bus). In response to the TDAFP actuation, operators closed the flow control valves and reduced turbine load by approximately 10 MW electrical. Initial investigation showed that a spurious manual actuation signal had been received and cleared 5 seconds later.

"The direct cause of the event was due to a voltage transient generated on the NK02 125-VDC bus during closure of the NK0211 breaker. The actuation occurred due to degradation of a 48-VDC power supply (PS1) within engineered safety features actuation system (ESFAS) logic cabinet SA036C. The power supply exhibited elevated ripple during testing as part of troubleshooting efforts, which was indicative of degradation of the regulation circuitry within the supply. This degradation prevented the power supply from sufficiently filtering the transient that occurred on the 125-VDC bus associated with the NN12 inverter. The power supply was replaced."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee originally submitted this event under 10 CFR 50.72(b)(3)(iv)(A) in EN 57043. The licensee has retracted EN 57043.

CONFIGURATION OF 'B' AND 'C' RESIDUAL HEAT REMOVAL LOOPS IN AN UNANALYZED CONDITION

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

"On April 25, 2024, it was determined that between March 25, 2024, 2015 [EDT] and March 30, 2024, 2024 [EDT], the condensate transfer and storage system was employed as a method of alternate keepfill in place of the installed residual heat removal (RHR) system's waterleg pump for RHR system loops `B' and `C'. This condition is not bounded by existing design and licensing documents.

"Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."