Event Notification Report for February 23, 2024

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

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

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.

EN Revision Imported Date: 2/26/2024

EN Revision Text: 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."

The NRC Resident Inspector had been notified.

EN Revision Imported Date: 2/26/2024

EN Revision Text: 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."

The NRC Resident Inspector had been notified.

EN Revision Imported Date: 2/26/2024

EN Revision Text: 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."

FUEL CYCLE FACILITY - UNPLANNED MEDICAL TREATMENT WITH CONTAMINATION

The following information was provided by the licensee via email:

"On February 17, 2024, a Honeywell employee experienced a non-work-related medical condition that required off site medical support. The incident occurred at approximately 2140 CST in the Feed Materials Building at the Metropolis facility. Due to the nature of the employee's condition, the individual was transported to [Massac Memorial Hospital in Metropolis, IL]. Honeywell health physics staff accompanied the injured employee, provided guidance to emergency room personnel, and controlled the facilities prior to decontamination. A whole-body survey of the employee and plant clothing was performed; the maximum amount of contamination present on the employee's coveralls was 65,500 disintegrations per minute (dpm) per 100 centimeters squared. All contaminated clothing was removed from the employee and an additional whole-body survey was performed; no contamination above background levels was detected. An emergency medical technician's (EMT) pants leg, boot, and the gurney wheels were found to be contaminated. The maximum amount of contamination present was 13,000 dpm per 100 centimeters squared. The EMT's pants leg, boot, and gurney were decontaminated to background levels. Following medical evaluation, hospital facilities were monitored and found to be free of contamination prior to release for unrestricted use. All contaminated materials from the hospital and injured employee were returned to the Metropolis facility.

"The NRC Fuel Facility Inspector has been notified."


The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The contamination was reported as: uranium ore concentrate.
The employee had fallen unconscious. They have been released from the hospital after recovering.

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following was received from the the Virginia Office of Radiological Health, Radioactive Materials Program via email:

"At approximately 1743 EST, on 2/16/2024, the Virginia Office of Radiological Health was notified of an incident involving a portable nuclear gauge. At approximately 1600 EST, a Troxler gauge; Model 3430, containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be, was struck by a dump truck on a building construction site located in Chester, VA. The authorized user notified the radiation safety officer (RSO) who arrived on site and then he notified the Virginia Emergency Management's Operations Center at approximately 1630 EST.

"Per the RSO, the gauge was sitting on soil with the source in the retracted, shielded position when it was run over by a dump truck. The source remained in the shielded position, but the handle was bent slightly. He did not attempt to turn it on or extend the rod for any reason. He obtained survey readings of 2.5 mR/h at 12 inches and 0.1 mR/h at 3 feet from the gauge. The gauge was placed in its transportation box, secured in the back of a pickup truck, and transported back to the licensee's office for secure storage. The gauge will be sent to the manufacturer for assessment.

"The Radioactive Materials Program will follow up with an investigation."

Virginia Report Number: VA240002

AUTOMATIC START OF EMERGENCY DIESEL GENERATOR

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

"At 0219 CST on February 24, 2024, Browns Ferry Unit 3 was shut down in a refueling outage, while closing 4 kV shutdown board breaker 3EB-9, the 4 kV shutdown board normal feeder breaker tripped open resulting in a valid 4 kV bus under-voltage condition. Due to the under-voltage condition, the 3B emergency diesel generator (EDG) auto started and tied to the board. The cause of the breaker tripping open is unknown and an investigation is in progress.

"All systems responded as expected for the loss of voltage. This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A). There was no impact to 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:

No other safety related equipment was affected. The 3B EDG continues to supply the shutdown board pending further investigation.

MANUAL REACTOR TRIP DUE TO STEAM GENERATOR 22 FEED PUMP TRIP

The following information was provided by the licensee via email:

"At 1546 EST, with unit 2 at 100 percent power, the reactor was manually tripped due to the '22' steam generator feed pump tripping. The trip was uncomplicated with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Operations responded using emergency operation procedure EOP-0, Post Trip Immediate Actions and EOP-1, Uncomplicated Reactor Trip and stabilized the plant in mode 3. Decay heat is removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 is not affected.

"ESFAS [engineered safety features actuation systems] actuation (auxiliary feedwater manual actuation) is reportable under 10 CFR 50.72(b)(3)(iv)(A) 8-hour report. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

PART 21 - AIR START VALVE (BENT BOTTOM STEM)

The following is a summary of the information provided by Fairbanks Morse Engine via email:

Prairie Island Nuclear Generating Plant (PINGP) was conducting a planned replacement of emergency diesel generator air start solenoid valves when it discovered that the bottom stem appeared to be bent and observed air leakage. PINGP returned five valves to Fairbanks Morse, and they returned them to the manufacturer, ASCO. ASCO reassembled one valve and confirmed there was air leakage through the valve. The leakage path was from the air supply port to the exhaust port when the valve was in the de-energized normally open state. ASCO functionally tested the remaining four valves and found a second valve that also leaked.

ASCO and Fairbanks Morse have implemented corrective actions to address this issue. Fairbanks Morse will notify PINGP and Limerick Generating Station.

Affected plants with potentially defected parts: Prairie Island Nuclear Generating Plant and Limerick Generating Station.

Point of Contact:
Martin Kurr
Quality Assurance Manager
Fairbanks Morse
608-364-8247
Martin.Kurr@fmdefense.com

Fairbanks Morse Notification Report Number: 23-01

PART 21 - MINI-GEN SIGNAL GENERATOR DEFECT

The following is a summary of the information provided by Fairbanks Morse Engine via email:

Arkansas Nuclear One (ANO) Unit 2 had a failure of a mini-gen signal generator on the opposed piston emergency diesel generator. Bench testing after removal from the engine showed an erratic signal, and this was confirmed by Fairbanks Morse. Fairbanks Morse destructive analysis revealed wear of the dynamic surface on the stator bushing inside diameter. The cause of the worn stator bushing is most likely due to inadequate lubrication on the dynamic surfaces, outside diameter of the shaft and inside diameter of the stator bushing. Possible causes of inadequate lubrication could be failure to apply enough lubrication to the dynamic surfaces during the manufacturing process or deterioration/evaporation over time.

Fairbanks Morse has implemented corrective actions to address this issue, and they are estimated to be completed by May 23, 2024.

Affected plants with potentially defected parts: Arkansas Nuclear One, Edwin I. Hatch Nuclear Plant, Joseph M. Farley Nuclear Generating Station, Limerick Generating Station, and Prairie Island Nuclear Generating Plant.

Point of Contact:
Martin Kurr
Quality Assurance Manager
Fairbanks Morse
608-364-8247
Martin.Kurr@fmdefense.com

Fairbanks Morse Notification Report Number: 23-02