Event Notification Report for March 05, 2024

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 0132 EST, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main feedwater isolation signal which resulted in steam generator lo-level reactor trip. The reactor trip was not complex, with all systems responding normally post-trip. Operations responded and stabilized the plant. Decay heat is being removed using the auxiliary feedwater and steam dump systems. Unit 1 is not affected.

"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). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72(b)(3)(iv)(A).

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

"All control rods are fully inserted. The cause of the main feedwater isolation is being investigated."

ACCIDENT MITIGATION - LOSS OF UPS COOLING

The following information was provided by the licensee via email:

"*** 8 Hour Notification was due at 1520 CST *** Follow up discussion of conditions after recovery determined that a report is required. This report restores reporting compliance.

"On March 5, 2024, at 0720 CST, the X-02 118V uninterruptible power supply air conditioning (UPS A/C) unit tripped with the associated emergency fan coil units (EFCUs) shut down for planned maintenance in the area. The X-01 UPS A/C unit was declared inoperable upon discovery due to a scheduled outage of support systems (Unit 1 station service water) via the safety function determination process. This placed the site in technical specification 3.7.20 condition A, B, and C to restore the UPS A/C system within one hour. The EFCUs were restarted at 0729 which satisfied condition B and C, and X-01 UPS A/C unit was aligned to Unit 2 cooling water at 0801, exiting condition A. The condition that could have prevented the fulfillment of the safety function lasted for approximately nine minutes. Area temperatures had no notable change based on field observations during the condition.

"The UPS HVAC system provides temperature control for the safety related UPS and distribution rooms during all normal and accident conditions. The UPS HVAC system consists of (a) a dedicated UPS room EFCU in each safety-related UPS and distribution room, and (b) two electrically independent and redundant A/C trains either of which can support all four safety related UPS and distribution rooms; each train consists of an air conditioning unit, ductwork, dampers, and instrumentation."

The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - MISADMINISTRATION

The following information was received from the Georgia Radioactive Materials Program via email:

"The licensee reported on 3/5/24 about an incident at Piedmont Hospital with Y-90. They underdosed a patient when the catheter was put in the artery. There were vein convulsions which caused only about 30 percent of it to be administered. The licensee stated it did not cause stasis. A follow up with a report will be submitted to the Georgia Environmental Protection Division within 15 days."

Georgia Incident Number: 79

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.

EN Revision Imported Date: 4/19/2024

EN Revision Text: STUCK IRRADIATOR SOURCE

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

At 1000 MST on 3/5/24, a 10,000 Ci Co-60 source (Model 7810) became stuck in the unshielded position during operator training. The irradiator is a J.L. Shepherd, Model SDF-34-M1, panoramic dry-source storage type. Upon determining that the source was stuck, the operator attempted to manipulate the source back into the shielded position using the emergency cable, but it came loose. Site staff have secured the irradiator facility.

No personnel exposure occurred, and there are no elevated dose rates outside of the irradiator enclosure. The site has requested manufacturer support to resolve the issue.

The NRC Project Manager (O'Keefe) has been notified.

* * * UPDATE ON 4/18/24 AT 1508 EST FROM MAJ RYAN EISWERTH TO ADAM KOZIOL * * *

On 3/18/24, authorized users were able to return the source to a shielded position. A post-event inspection was scheduled during the week starting 4/22/24 with the vendor to verify operability of the irradiator.

At approximately 1000 MST on 4/18/24, while an authorized user was conducting a performance functional check in preparation for the scheduled inspection, the irradiator source again became stuck in an unshielded position.

The irradiator had not been used since the initial report on 3/5/24. No personnel exposure occurred, and there are no elevated dose rates outside of the irradiator enclosure. The site has requested manufacturer support to resolve the issue.

Notified R4DO (Young), IRMOC (Crouch), and NMSS Events (email).

AGREEMENT STATE REPORT - STUCK SHUTTER

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

"On March 5, 2024, the Department was notified by the licensee that during routine shutter testing, the shutter on a Vega SH-F2C failed to close. Open is the normal operating position for the gauge shutter. The gauge contains a 500 millicurie (original activity) cesium-137 source. The gauge is in an area that is accessed only to test the shutter as it is located 230 feet off the ground. The gauge does not present an exposure risk to any individual. The licensee has contacted a service company to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10093

NMED Number: TX240008

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following information was provided by the California Department of Public Health, Radiologic Health Branch via email:

"Isolite Corporation notified the California State Warning Center of the loss of a container containing eight tritium exit signs with a total activity of 60.8 curies of tritium (H-3). Fifty-one containers of tritium signs were to be delivered by [common carrier]. Only 50 containers of tritium exit signs were delivered, leaving one container containing the eight exit signs missing. [The common carrier] is currently conducting a search to determine the status of the missing container of exit signs. Since this exceeds the amount of H-3 by greater than 1000 times the value in Appendix C of Part 20, it constitutes a less than or equal to 24-hour reportable event."

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 EXIT SIGNS

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

Two tritium exit signs were determined to be lost by the licensee.

Manufacturer: Isolite Corporation
Number of signs: 2
Model: BX-10-BK
Activity: 9.21 Ci each, H-3

The signs were discovered missing during an annual fire inspection on 03/05/2024.

Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))

Colorado Event Report ID Number: CO240030


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