Event Notification Report for March 13, 2024

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.

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 - 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.

CONTAMINATION IN RESTRICTED AREA

The following is a summary of information provided by the licensee via telephone:

On March 6, 2024, around 0600 CST, a technician found loose molybdenum (Mo-99) / technetium (Tc-99m) contamination inside a restricted area. Prior to the discovery, a production hot cell inside the restricted area had been deep cleaned as part of the regular maintenance program.

A thorough investigation of the area was conducted which revealed additional loose contamination on the lab floor. Surveys of surrounding areas did not reveal any spread of contamination outside of the restricted lab area.

Due to (1) the existing access controls, (2) personal protective equipment requirements for lab access, and (3) the absence of contamination identified by body scans of personnel exiting the lab; the licensee does not suspect any spread of contamination outside of the restricted area or personnel intake. Biological samples will be collected to confirm that no intake occurred.

The highest contamination level identified was 260 mrem/hr on contact and 2.3 mrem/hr at 1 foot. The contamination has been remediated to below licensee action levels. Overall, 2.4 mCi of Mo-99 was identified outside of the production hot cell. The 10 CFR 20 Appendix B limit for Mo-99 is 1 mCi. The licensee is investigating the root cause of this event.

MANUAL REACTOR TRIP

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

"On March 11, 2024, at 1337 EDT, with Unit 1 in Mode 1 at 35 percent power performing power ascension activities, the reactor was manually tripped due to the 'A' reactor feed pump (RFP) tripping on low suction pressure. Due to the power level at the time, the 'B' RFP had not been placed in service. Closure of containment isolation valves (CIVs) in multiple systems and actuation of high-pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) occurred as a result of reaching the actuation setpoint on reactor water level as designed. The trip was not complex, with all safety systems responding normally post-trip. Operations responded and stabilized the plant. The 'B' RFP was placed in service and is controlling reactor water level. Decay heat is being removed by discharging steam to the main condenser using turbine bypass valves. Unit 2 is not affected.

"Due to the emergency core cooling system (ECCS) discharging into the reactor, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). Also, the Reactor Protection System actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, it is reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of CIVs, RCIC and HPCI.

"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 cause of the 'A' RFP is under investigation. The reactor electric plant remains in a normal lineup with both emergency diesel generators available. There were no temperature or pressure technical specification limits approached.

EN Revision Imported Date: 3/13/2024

EN Revision Text: AUTOMATIC REACTOR TRIP

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

"On March 12, 2024, at 0816 CDT, Comanche Peak Unit 2 reactor automatically tripped on lo-lo level in the 2-03 steam generator (SG). Prior to the trip, main feedwater pump (MFP) 2A speed reduced and a manual runback to 700 MW (60 percent) was in progress. Both motor driven auxiliary feedwater pumps and the turbine driven auxiliary feedwater pump started due to lo-lo level in all SGs.

"Concurrent with the loss of speed on MFP 2A, a servo filter swap was in progress on MFP 2A.

"Unit 2 is being maintained in hot standby (Mode 3) in accordance with integrated plant operating procedure IPO-007A. The emergency response guideline network has been exited. Decay heat is being rejected to the main condenser via the steam dump valves."

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

The cause of the loss of the MFP is under investigation. Unit 1 was unaffected.

EN Revision Imported Date: 3/14/2024

EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE

The following information was provided by the South Carolina Department of Health and Environmental Control [the Department] via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone at 1515 EDT on 06/22/23, that during the commissioning of a new device [at their Gaston S.C. facility] the strip source of the fixed gauging device was stuck between the source housing and dip-tube. The licensee is reporting that the fixed gauge is a Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device, housing a Cs-137 Berthold Technologies USA, LLC., sealed source Model BT-MPLM. The licensee is reporting that no immediate health and safety concerns have been identified. The licensee is reporting that a consultant has been contacted to perform the repair. A department inspector will be dispatched to the facility to conduct an on-site investigation. This event is still under investigation by the Department."

* * * UPDATE ON 7/21/2023 at 1058 EDT FROM KORINA KOCI TO SAMUEL COLVARD * * *

"A Department inspector was dispatched to the facility on June 23, 2023. The licensee submitted their 30-day written report on July 14, 2023. The licensee is reporting that the serial number of the Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device is 40876-01-10009. The licensee also reports that the serial number of the sealed source containing 0.74 GBq (20 mCi) of Cs-137, (Model BT-MPLM) is G0990_22. The device was removed from service by a licensed contractor and will remain in the site's radiation storage room until the licensee and manufacturer determine the best option moving forward. The licensee reports that no regulatory exposure limits were exceeded as a result of this event, and that the sealed source remained housed for the duration of this incident. This event is still under investigation by the Department."

Notified R1DO (Carfang) and NMSS Events Notification via email.

* * * UPDATE ON 3/13/24 AT 1530 EDT FROM KORINA KOCI TO ADAM KOZIOL * * *

"The licensee disposed/transferred the model BT-MPLM sealed source (serial number G0990_22) on 12/13/23. The Berthold Technologies USA, LLC., LB 300 IRL Type III Series source holder (serial number 40876-01-10009) was also disposed. This event is considered closed."

Notified R1DO (Jackson) and NMSS Events (email)

EN Revision Imported Date: 3/14/2024

EN Revision Text: UNANALYZED CONDITION - INADEQUATE FUSES FOR FUEL POOL COOLING

The following information was provided by the licensee via email:

"On 2/9/24 at 1322 EST, it was determined that the unit was in an unanalyzed condition. A review of DC feeder circuit protection schemes identified a circuit for the fuel pool cooling system is uncoordinated due to inadequate fuse sizing. This results in a concern that postulated fire damage in one area could cause a short circuit without adequate protection, leading to the unavailability of equipment credited for in 10 CFR 50 Appendix R, Fire Safe Shutdown. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"The postulated event affects the following fire zones: fire areas 6S and 6N (within the Unit 2 reactor building). Compensatory actions for affected fire areas have been implemented. An extent of condition review is being performed.

"The NRC Senior Resident Inspector has been notified."

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

Fire watches have been established in the affected areas. These will be maintained until the protection scheme is revised.

* * * UPDATE ON 03/08/24 FROM PAUL BOKUS TO TOM HERRITY * * *

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

"On 03/08/24 at 1418, extent of condition reviews identified circuit(s) in the Units 2 and 3 Reactor Protection Systems (RPS) which are also uncoordinated due to improper fuse sizing. These circuits are not bounded by existing design and licensing documents for 10 CFR 50 Appendix R Fire Safe Shutdown and, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel.

"The postulated event affects the following fire areas: 32, 33, 38 and 39 (Units 2 and 3 Switchgear Rooms). In accordance with procedural requirements, compensatory actions for the affected fire areas have been implemented and will remain until the condition is resolved.

"The NRC Senior Resident Inspector has been notified."

Notified R1DO (Arner)

* * * UPDATE ON 3/13/2024 AT 1538 FROM TROY RALSTON TO SAM COLVARD * * *

"On March 13, 2024, at 1350 EDT, extent of condition reviews identified a circuit in the Unit 2 reactor protection system (RPS) which is also uncoordinated due to improper fuse sizing. This circuit is not bounded by existing design and licensing documents for 10 CFR 50, Appendix R, Fire Safe Shutdown, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel.

"The postulated event affects fire area 57 (Switchgear Corridor, common to Units 2 and 3). In accordance with procedural requirements, compensatory actions for the affected fire areas have been implemented and will remain until the condition is resolved.

"Additionally, it was previously reported that fire area 6N contained a circuit which was not bounded by the Fire Safe Shutdown analysis; however, after further review it has been determined that compliance is maintained in this fire area and is therefore retracted from the scope of this report.

"The NRC Senior Resident Inspector has been notified."

Notified R1DO (Jackson)

AGREEMENT STATE REPORT - SOURCE DISCONNECT

The following is a synopsis of information received via email from the Alabama Department of Public Health, Office of Radiation Control:

On the evening of March 6, 2024, the licensee experienced a source disconnect at a job site in Russellville, Alabama. The source connector appeared to have not been connected properly, and the source apparently disconnected from the drive cable while outside the exposure device (camera). The source was retrieved and secured in a 650L model source changer about 45 minutes later when a source retrieval team arrived on site. The two source retrieval personnel received 45 milliroentgens and 15 milliroentgens of exposure respectively. The radiography crew dosimetry had not yet been retrieved for emergency processing at the time of the report.

The camera and source information is as follows: Sentinel 880D, D1120, about 78.9 curies of iridium-192 in a model A424-9 source.

Alabama Incident Number: TBD

LOSS OF POWER TO CONTAINMENT RADIATION MONITORS

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

"On March 12, 2024, at 2111 EDT, a valid containment ventilation isolation train 'A' and 'B' signal was received due to a spurious loss of power to 1EMF-38 (containment particulate radiation monitor) and 1EMF-39 (containment gas radiation monitor). The power to 1EMF-38 and 1EMF-39 was restored.

"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:

There were no plant evolutions ongoing at the time of the event and the cause of the loss of power is under investigation. There was no impact to Unit 2.

* * * RETRACTION ON 3/13/2024 AT 1436 EDT FROM JASON MOORE TO SAM COLVARD * * *

"After further review of the event, it was determined the actuation of the associated containment ventilation isolation train 'A' and 'B' was not valid. This is due to the loss of power being associated with the control room modules for 1EMF-38 and 1EMF-39, and not a result of an actual sensed parameter or plant condition. Therefore, this event notification is being retracted.

"The NRC Resident Inspector has been notified."

Notified R2DO (Miller)