Event Notification Report for January 05, 2024

EN Revision Imported Date: 1/5/2024

EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE RACK

The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:

"The IEMA-OHS Operations Center was contacted at 1712 CDT on December 17, 2023, by the radiation safety officer for Sterigenics to report a stuck source rack. The rack reportedly became stuck around 2300 on December 16, 2023, with approximately 10 percent of the sources above the pool level. The area was isolated with an additional restricted area established to maintain occupational exposures within limits. At this time, no public or occupational exposures above regulatory limits have been reported. This matter has a 24-hour reporting requirement under 32 Ill. Adm. Code 346.830 which was met by the licensee. IEMA-OHS inspectors will arrive at the facility on 12/18 to evaluate timelines for corrective action and the efficacy of safety systems. Staff will also evaluate the site and review staff dosimetry, potential impacts to source capsule integrity, any anticipated heat impacts, and plans for quality assurance of the impacted system(s)."

Source type: sealed source irradiator
Radionuclide: Co-60
Activity: 24 MCi (888 PBq)
Model no.: C-188

Illinois report no.: IL230036

* * * UPDATE FROM WHITNEY COX TO DAN LIVERMORE ON 12/19/23 * * *

The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:

"Agency staff arrived at the site on 12/18/23 and surveys indicate no public or occupational exposure levels above normal operation. The source rack is still stuck in the unshielded position. The Agency continues to monitor the situation and will update when additional information is available."

Notified R3DO (Edwards), NMSS (email).

* * * UPDATE FROM GARY FORSEE TO IAN HOWARD ON 1/4/24 * * *

The following information was received from the Illinois Emergency Management Agency (IEMA-OHS) via email:

"The Licensee reports 18 modules (3 rows), constituting 626,000 curies of Co-60, in the B/C cell remain stuck in the unshielded position due to product carts impeding travel of the rack. The sources are below the point of product cart impact. A second IEMA-OHS inspection was conducted to increase coordination on response activities and obtain additional data on the following: security requirements (all operational), radiation levels (700 microR/hour maximum reading), dosimetry procedures (transitioned to digital dosimetry which is read daily and employed at a 40 mrem/day investigational level), total occupational doses to date (20 mrem), exposure rate maps including access points used for radiation hardened cameras, personnel access, pool conductivity (within specifications), updated operations and emergency procedures (confirmed), on site staff and safety culture (satisfactory, additional manufacturer health physics staff brought in to assist), fire hazards (none at this time), status of deionizer (satisfactory), and mitigation planning.

"The Licensee is awaiting cameras and remote vehicles capable of withstanding radiation levels and manipulating product totes. The facility was confirmed to be in a safe and stable condition and ongoing response operations will be coordinated with IEMA-OHS. IEMA-OHS has now transitioned to weekly inspections until the incident is remedied.

"Updates will be provided as they become available."

Notified R3DO (Stoedter), NMSS (email).

FOUND DEPLETED URANIUM PROJECTILE

The following information was provided by the licensee via email:

"In accordance with 10 CFR 20.2201 (a)(1)(ii), the US Army is (telephone) reporting the recovery of a 120 mm depleted uranium (DU) projectile from a landfill in York, PA. [10 CFR 20.2201(a)(1)(ii) - Within 30 days after the occurrence of any lost, stolen, or missing licensed material becomes known to the licensee, all licensed material in a quantity greater than 10 times the quantity specified in appendix C to Part 20 that is still missing at this time.]

"An M829 120 mm DU projectile has 4000 grams of DU, which equates to approximately 1,520 microcuries of U-238. The M829 DU projectile was manufactured in the 1970's - 1980's.

"The Part 20 App C limit for U-238 is 100 microcuries. 100 microcuries times 10 equals 1,000 microcuries.

"The specifics on retrieving the 120 mm DU projectile are as follows:

1. A military explosive ordnance disposal (EOD) team was contacted (Nov 28) and requested to respond to a possible unexploded ordnance (UXO) device at the York County Resource Recovery Center, York, Pennsylvania.
2. The EOD team arrived (Nov 28) and identified the UXO as a 120 mm DU projectile (projectile with tailfin, no propellant, no cartridge case, no explosives, no tracer).
3. EOD placed the item in an ammo storage container and transported the item to Joint Base McGuire-Dix-Lakehurst, New Jersey for safe storage.
4. US Army Joint Munitions Command DoD Low Level Radioactive Waste (LLRW) Lead Agent was notified on or about December 1.
5. A member of the LLRW team is at Joint Base McGuire-Dix-Lakehurst on December 27-28 to package and ship the DU projectile to our Morris Consolidation Facility (NRC License 12-00722-15), Rock Island Arsenal, Rock Island, IL, for safe storage and eventual disposal.
6. At this time, we have no further information or evidence to determine how the item arrived at the Pennsylvania landfill.
7. There are no clear identification markings that we have viewed on pictures (so far) that will help us to determine where the device was stored or possessed. We will conduct a more thorough visual exam once we have the item in our possession at our Rock Island Arsenal facility (Morris Consolidation Facility).

"In accordance with 10 CFR 20.2201 (b), a written report will be provided to the NRC within 30 days after making the telephone report."

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

Swipe test of the ordinance revealed no loose contamination. Dose rate on contact is 1-2 mrem/hr, so exposure exceeding limits to public is unlikely.

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

EN Revision Imported Date: 1/5/2024

EN Revision Text: UNANALYZED CONDITION

The following information was provided by the licensee via email:

"Plant alignment caused an unanalyzed condition regarding unit 1 and unit 2 Appendix R procedures.

"[Watts Bar Nuclear] (WBN) unit 1 and unit 2 Appendix R procedures require manual operator action times including [volume control tank] (VCT) isolation. They are calculated with an assumed hydrogen cover gas constant at 20 psig. This is to preclude hydrogen ingestion into the charging pumps with an operator action time of 70 minutes. Due to recent lower hydrogen concentration in the [reactor coolant system] (RCS), [unit 2] VCT hydrogen regulator set point was increased to 28 psig. This increased pressure set point invalidated the initial assumptions made in the Appendix R calculations for manual operator action times.

"WBN unit 1 VCT hydrogen regulator was also verified high out of band at 22 psig.

"WBN has restored unit 1 and unit 2 VCT hydrogen regulators to the required specification.

"The NRC Resident Inspector has been notified of this condition."

* * * RETRACTION ON 1/4/24 AT 1556 EST FROM JARRETT K. LAVASSEUR TO OSSY FONT * * *

The following information was provided by the licensee via email:

"In accordance with NUREG-1022, Section 2.8 and Section 4.2.3, WBN is retracting the previous report in EN 56910 pursuant to 10 CFR 50.72(b)(3)(ii)(B). An analysis of the postulated Appendix R Fires that could cause ingestion of cover gas into the charging pumps would be mitigated through current plant processes and procedures and therefore does not present a significant threat to fire safe shutdown. Based on sufficient margin and existing operator actions, the event does not represent a condition that significantly degrades plant safety under 10 CFR 50.72(b)(3)(ii)(B). Therefore EN 56910 is being retracted.

"The NRC Resident Inspector has been notified of this retraction."

Notified R2DO (Miller).

AGREEMENT STATE REPORT - UNDERDOSE

The following information was provided by the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) via email:

"A medical administration of Y-90 microspheres that took place on 12/29/23. Advocate General Hospital in Park Ridge, IL, failed to deliver nearly 100 percent of the intended dose. There was no patient impact and the treatment will be rescheduled.

"The radiation safety officer (RSO) for Advocate General Hospital, contacted the IEMA-OHS Operations Center on 12/29/23, to report the above described medical underdose. The patient had been prescribed two administrations of Theraspheres Y-90 microspheres. The first administration went without issue. The second administration (from a separate written directive) called for 3.5 GBq to segment 8 of the liver. Post-administration surveys indicated that nearly 100 percent of the microspheres were still contained within the delivery tubing. The patient and referring physician were immediately notified. The RSO and the authorized user (AU) believed that the time between dose preparation and delivery may have been a contributing issue, but the investigation is ongoing. This matter is reportable by the next calendar day. The licensee met reporting requirements. Inspectors will not be dispatched until next week as there is no immediate radiation safety concern. This report will be updated as additional information becomes available."

Illinois Event Number: IL230037

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.

PRESSURE BOUNDARY DEGRADED / BOTH TRAINS OF HIGH PRESSURE SAFETY INJECTION INOPERABLE

"At 1257 EST on January 3, 2024, it was determined that a class 1 system barrier had a through wall flaw with leakage. The leakage renders both trains of high pressure safety injection inoperable. The unit is being cooled down to cold shutdown to comply with technical specifications.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A) and 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."

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

At the time of the discovery, the unit was shutdown in mode 3. The unit was experiencing signs of reactor coolant system leakage and a shutdown was initiated in order to search for possible sources. The unit is currently cooling down and proceeding to mode 5, where the safety function is not required.

PART 21 - EMD CYLINDER LINER WITH BORE DEFICIENCY

The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax:

An edge or lip in the bore of an EMD (Brand name: Electro-Motive Diesel) cylinder liner prevented successful installation of the corresponding power assembly on an emergency diesel generator set. The lip is located axially at the bottom of the inlet ports and is present around the circumference of the bore. The EMD model 645E4 is a 2-stroke engine with air inlet ports in the wall of the cylinder liner. As the piston travels below the inlet ports, air box pressure scavenges and replenishes air to the power assembly.

Installation of the power assembly requires lowering the piston through the liner in order to secure the connecting rod to the crankshaft. During this process the piston could not be lowered below the inlet ports due to the piston rings catching on the lip. The power assembly was not installed and therefore there was no safety hazard; however, if the defect had gone undetected there was the potential to damage engine components and possibly reduce load carrying capacity of the engine.

The extent of the condition is this single cylinder liner, P/N 9318833, S/N 20M0938 used in the power assembly at Tennessee Valley Authority (TVA) - Sequoyah Nuclear Plant, Serial Number: 23H1306.

Corrective Actions:
For TVA-Sequoyah:
No action required; the power assembly has been returned to ESI.
For ESI:
To prevent reoccurrence, ESI has revised the dedication package to include verification that bore machining is continuous along the entire length and no edges or lips are present. The revision was implemented on December 6, 2023.