Event Notification Report for February 28, 2024

EN Revision Imported Date: 4/30/2024

EN Revision Text: AGREEMENT STATE - STUCK SHUTTER

The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The radiation safety officer (RSO) for INspec Ethylene Oxide and Specialities (INEOS), IL-01337-01, contacted the Agency on 2/28/24, to advise that a fixed gauge was found to have a shutter stuck in the `open' position. The impacted gauge is a Ronan Engineering model X90-SA1-F37, serial number M7388 containing 40 mCi of Cs-137. The device shutter is normally in the `open' position and was only found to be `stuck' during the routine six-month shutter checks. It had likely been in this condition for at least six months. The product vessel that it faces is full of commodity and will remain full for the foreseeable future. Aside from being full of commodity, the vessel is also equipped with locking mechanisms preventing any personnel access.

"Agency staff will be on site in the coming weeks."

NMED Item Number: IL240006

* * * UPDATE ON 4/30/24 FROM W. COX TO T. HERRITY * * *

Agency inspector was on site 3/20/24 while Ronan was there to repair the gauge. The gauge was successfully repaired. This matter is now closed.

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

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was provided by the North Dakota Department of Health (the Department) via email:

"On February 28, 2024, EMCOR Facilities Services, Inc. reported that nine (9) single-face tritium exit signs belonging to The Church of Jesus Christ of Latter-Day Saints were removed and improperly disposed of by an electrical subcontractor (Feininger Electric Works). The make, model, and serial numbers of these tritium exit signs are unknown.

"North American Signs was contracted by EMCOR Facilities Services, Inc. on November 02, 2023 to complete the scope of work on behalf of the Church. In turn, North American Signs subcontracted the work to be completed by Feininger Electric Works.

"North American Signs informed EMCOR Facilities Services, Inc. on February 6, 2024, that a Feininger Electric Works technician mistakenly discarded 9 tritium exit signs before they could be catalogued, packed, and shipped out for proper disposal. The signs were presumably collected from a general waste receptacle and could not be recovered.

"The Department is attempting to gather more specific information from the entities involved. Typically, each of these signs initially contain tritium in amounts greater than one (1) curie. As such, we are reporting this event under 10 CFR 20.2201(a)(1)(i)."

NMED Event Number: ND240001

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

AUTOMATIC REACTOR SCRAM

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

"At approximately 0839 [CST] with Unit 1 in Mode 1 at 100 percent power, the reactor automatically scrammed due to the depressurization of the SCRAM air header caused by an invalid signal that [occurred] during system testing. The SCRAM was uncomplicated with all systems responding as expected. The cause and details of the event are under investigation. Containment isolation valves actuated and closed on a valid Group 2 signal.

"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), and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group 2 isolation signal.

"Operations responded using the emergency operating procedure and stabilized the plant in Mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. State as well as Wright and Sherburne Counties will be notified."

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

The Anticipated Transient Without Scram (ATWS) circuit was being tested when an invalid signal was sent to depressurize the SCRAM air header.

SPECIFIED SYSTEM ACTUATION - AUTOMATIC START OF EMERGENCY DIESEL GENERATORS

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

"At 1350 EST on 2/28/2024, with Calvert Cliffs Unit 1 in Mode 5 at 0 percent power and Unit 2 in Mode 1 at 65 percent power, an actuation of the '1A' and '2A' emergency diesel generators' auto-start occurred due to an undervoltage condition on the number 11 and number 21 4kV buses which are fed from the number 11 13kV bus. The '1A' and '2A' emergency diesel generators automatically started as designed when the 4kV buses' undervoltage signals were received.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the '1A' and '2A' emergency diesel generators.

"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:

The undervoltage condition was caused by the feeder breaker to the number 11 13 kV bus opening during electrical maintenance.

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following summary of information was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email:

On March 1, 2024, the Department was notified of a medical misadministration that occurred on February 28, 2024. The misadministration was that of Ga-68 Dotatate (5.24 millicuries) being administered instead of F-18 FDG (Fludeoxyglucose). The licensee proceeded with the scan having an incomplete scan description on an outside physician's order. The signed order received only asked for "PET-CT Scan (Base of Skull to Thigh)." An unsigned order/history form, clearly designating a Ga-68 Dotatate scan, was filled out by the outside clinic's medical staff and included with the physician's order. The licensee proceeded with scan as directed using the elaboration of the unsigned order/history form as designation of the specific scan ordered.

The patient was notified of the incident and will receive the appropriate scan the following week. Investigation in to how this situation can be avoided in the future has been conducted by the licensee.

WA Event Number: WA-24-0007

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.

* * * UPDATE ON 3/14/24 AT 1538 EDT FROM BORIS TSENOV TO ADAM KOZIOL * * *

The following was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email:

The licensee provided a written report to the Department identifying root causes and corrective actions. The report also calculated an effective dose estimate of 498 mrem and the highest expected effective organ dose to the spleen of 5.47 rem.

Notified R4DO (Werner) and NMSS Events (email)