Event Notification Report for February 22, 2024

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

AGREEMENT STATE REPORT - LOST SOURCE

The following information was provided by the New York State Department of Health (the Department) via fax:

"The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at [the Plainview facility], RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause.

"Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements."

New York State Event Report Number: NY-24-01



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: 2/22/2024

EN Revision Text: ACTUATION OF EMERGENCY DIESEL GENERATOR SYSTEM

The following information was provided by the licensee via email:

"At 2224 EST on February 15, 2024, with both units 1 and 2 in mode 1 at 100 percent power, an actuation of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The reason for the emergency diesel generator system auto-start was clearance removal sequencing errors. The emergency diesel generator system automatically started as designed when the common emergency start 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 diesel generator system.

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

* * * RETRACTION ON 2/21/2024 AT 1549 EST FROM TYSON JONES TO KAREN COTTON * * *

The following information was provided by the licensee via email:

"In accordance with NUREG-1022, Section 2.8 and Section 4.2.3, Watts Barr is retracting the previous report EN 56970 pursuant to 10 CFR 50.72(b)(3)(iv)(A). The start signal for the 1A-A, 1B-B, and 2B-B emergency diesel generators (EDG)s was from activation of the common emergency start of the 2A-A EDG. The actuation was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design safety function.

"The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system. Since the starts were not initiated via an automatic signal from a LOOP, SI, or traditional operator action, the signal is not a valid actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A). Therefore, EN 56970 is being retracted.

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

Notified R2DO (Miller)

FITNESS FOR DUTY

The following is a synopsis of information that was provided by the licensee via email and phone call:

A non-licensed supervisor had a confirmed positive during a fitness for duty test. The supervisor's access to the plant has been terminated.

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

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

"On February 1, 2024, a patient was receiving a lutetium-177 (Lutathera) treatment. The written directive, signed by the authorized user (AU), was for 200 mCi of Lu-177. However, the treating medical oncologist signed a 100 mCi dose alteration treatment plan order on the same day as the procedure. The patient received the 200 mCi dose that was recorded in the written directive instead of what was intended. It is believed that miscommunication occurred between the two, and a full investigation into the cause of the event is underway by the licensee. The AU and the patient have been notified. No harmful effects are expected to patient. The Department will update this event as soon as more information is provided."

PA NMED Event Number: PA240005

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 - SHUTTER STUCK IN SHIELDED POSITION

The following information was provided by Texas Department of State Health Services (the Department) via email:

"On February 16, 2024, the Department was contacted by the licensee's radiation safety officer (RSO) that the source in a Mark 1 irradiator could not be raised or lowered. The device contains a 10,000-curie cesium-137 source (original activity manufactured 6/25/1986). The source problem was discovered when a researcher was attempting to irradiate a few mice and the source would not raise. The RSO stated they inspected the device and found a fuse that controlled the source's movement both up and down had failed. The RSO stated they had contacted a service company to repair the device. The source is in the fully shielded position. No individuals received any exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas NMED number: TX240006

INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

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

"This 60-day optional telephone notification is being made in lieu of a Licensee Event Report (LER) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 2333 EST on January 1, 2024, an invalid actuation of group 6 primary containment isolation valves (PCIVs) (i.e., containment atmospheric control/monitoring (CAC/CAM) and post-accident sampling system (PASS) isolation valves) occurred. Reactor building ventilation isolated and standby gas treatment started per design. No manipulations associated with the isolation or reset logic were ongoing at the time.

"Troubleshooting determined that the group 6 isolation signal resulted from spurious relay contact actuation in the main stack radiation high-high isolation logic due to relay contact oxidation. The main stack radiation monitor is a shared component that sends isolation signals to Unit 1 and Unit 2. There were no Unit 1 actuations. Only the relay contacts associated with Unit 2 actuated. The relay has been replaced.

"The actuation was not initiated in response to actual plant conditions. It was not an intentional manual initiation and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.

"During this event the PCIVs functioned successfully, and the actuations were complete. This event did not result in any adverse impact to the health and safety of the public."

INVALID ACTUATION OF EMERGENCY DIESEL GENERATORS

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

"This 60-day optional telephone notification is being made in lieu of a Licensee Event Report (LER) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 0815 EST on December 28, 2023, an invalid actuation of the four emergency diesel generators (EDGs) occurred. It was determined that this condition was likely caused by spurious operation of the undervoltage relay for the startup auxiliary transformer feeder breaker to the `1D' balance of plant bus which was being fed by the unit auxiliary transformer at the time, per the normal lineup. This non-safety related EDG actuation logic was disabled, and additional investigation is planned during the upcoming refueling outage.

"The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.
"During this event, the four EDGs functioned successfully, and the actuations were complete. All emergency buses remained energized from offsite power and, therefore, the EDGs did not tie to their respective buses.

"This event did not result in any adverse impact to the health and safety of the public."

ACCIDENT MITIGATION - HIGH PRESSURE COOLANT IINJECTION DECLARED INOPERABLE
The following information was provided by the licensee via email:

"At 1103 CST on February 22, 2024, a potential through-wall steam leak was identified on the high pressure coolant injection (HPCI) steam supply 1-inch drain line. As a result, HPCI was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the 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)(D). Reactor core isolation cooling (RCIC) and low pressure emergency core cooling systems (ECCS) remain operable.

"Additional investigation is in progress.

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