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.