Event Notification Report for March 18, 2024

EN Revision Imported Date: 3/18/2024

EN Revision Text: LOSS OF REACTOR BUILDING VENTILATION

The following information was provided by the licensee via email:

"At 1045 EST, on 2/19/2024, during a maintenance activity, a loss of all reactor building ventilation occurred on Unit 2. With no flow past the ventilation radiation monitors, the radiation monitors were inoperable to support their ability to perform primary and secondary containment isolation functions or start the standby gas treatment system. Reactor building ventilation was restored within 15 minutes. Due to this inoperability, the radiation monitor system was in a condition that could have prevented 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).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector will be notified."

* * * RETRACTION ON 3/15/24 AT 1315 EDT FROM BILL LINNELL TO ADAM KOZIOL * * *

"Upon further investigation, it was verified that the reactor building and the refueling floor radiation monitors are not needed to control the release of radiation for events described in chapter 14 of the updated Final Safety Analysis Report. For the analyzed loss of coolant accident (LOCA), the primary and secondary signals for this purpose were available and unaffected by this event. The radiation monitors provide a tertiary redundant method that is not credited within the station analysis. For all other analyzed accidents, the signal provided by the radiation monitors is not needed, as the secondary containment isolation function and start of the standby gas treatment system are not credited. Additionally, the fuel handling accident was not credible during the time of the event because no activities were in progress on the refueling floor. Therefore, the threshold for reporting the issue as an event or condition that could have prevented the fulfillment of a safety function was not met.

"The NRC Resident Inspector has been notified."

Notified R1DO (Jackson)

AGREEMENT STATE REPORT - DAMAGED GAUGES

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"On March 7, 2024, the Agency was notified of equipment damage at Alton Steel in Alton, IL, that exposed two sealed radioactive sources. The licensee reported that molten steel flowed over Berthold Technologies source housings (source housing serial numbers 1197-10-21 and 601-05-12) and, despite trying to cool the steel, it damaged the source housings and exposed the sources. The Berthold Technologies sources are Co-60 and have an activity of 2.3 mCi each (source serial numbers 1200-10-21 and 600-05-12). The sources were removed from the housings by a licensed service provider and placed in secured storage. Leak tests are pending. The licensee determined there were no exposures to any personnel and that the incident does not pose a risk to any members of the public. Licensee surveys indicated no contamination, and radiation levels from these sources were comparable to those from an undamaged source. The Agency plans to conduct a reactionary inspection to verify the lack of contamination/exposure and accountability of licensed materials. This is a reportable event in accordance with 32 Ill. Adm. Code 340.1220(c)(2)."

Illinois Item No.: IL240008

* * * UPDATE ON 3/13/24 AT 1625 EDT FROM GARY FORSEE TO ADAM KOZIOL * * *

"[On 3/8/24], another email update was received in which Alton Steel's licensed contractor advised another portion of the source rod had been located and was actively being cut from the molten steel. A conference call was immediately scheduled and the following information noted: The incident had actually taken place on 2/22/24 with no notification to the Agency. It was stated that the licensee's authorized user removed the damaged sources using pliers and placed them in secured storage but did not follow their approved emergency procedures to cease work and rope off the area at 20 feet. The licensee contacted their consultant (R.M. Wester), and they were on-site the same day. R.M. Wester personnel surveyed the area and assumed there was no contamination because they were getting the expected radiation levels. At that time, the consultant recommended that the licensee contact the manufacturer (Berthold) to come out and further evaluate the sources and devices. The manufacturer was on-site on 3/7/24 and discovered that two source rods were damaged. The manufacturer's rep advised a call to the State was needed. He noted one source rod had been damaged to the point the internal Co-60/nickel wire was exposed. On the afternoon of 3/8/24, Alton Steel's licensed consultant surveyed the mold lid and found what they assumed to be the remaining portion of the source (exposure rate of 50 mR/hour). On 3/8/24, Alton Steel personnel used a torch to cut that portion of the source from the lid of the mold. This piece was also placed in secured storage. The lid was then surveyed by the consultant which he stated evidenced no further radioactive material. The two damaged sources, as well as the source rod fragment, are pending disposal. The Agency has requested that the lid and mold be held for surveys when Agency staff are on-site. Agency staff plan to be on-site 3/13/24 to further investigate. Leak tests from the consultant did not evidence removeable contamination in excess of 0.005 uCi. At this time, there is no indication of risk to workers or the public as all sources are in secured storage. The investigation is ongoing and updates will be provided as available.

"On Monday, 3/11/24, Agency staff conducted interviews with the Berthold service representative which conducted the service call. Information from that call indicated the licensee had cut through a source with a torch. At this point, Agency staff responded that morning to take surveys and interview Alton Steel staff. Survey readings were taken with a microR meter, which lacked the necessary sensitivity and were inconclusive due to [naturally occurring radioactive material] NORM and refractory material. Investigation findings indicate the licensee failed to follow emergency procedures, failed to follow operating procedures, failed to adhere to license conditions, received inadequate and incorrect training, improperly handled and manipulated sealed sources, failed to perform surveys, and failed to make timely notification to the Agency. The licensee's consultant also failed to notify the Agency, lacked sufficient knowledge of the sealed source and performed inadequate surveys. Additionally, it was discovered the licensee had used a 4 inch die grinder on one source, cut through another with an oxygen lance, had a practice of handling unshielded source assemblies and an inadequate radiation safety program.

"Agency staff arrived at the licensee's site again on 3/13/24 to perform additional surveys. Upon arrival, the licensee stated they had found yet another piece of the Co-60 rod source under the spray booth that washes down the cast billets. This was reportedly the area below where the source was first cut with a torch. The Agency confirmed the licensee was aware of the source when using the torch and did not perform surveys or alter operations. The second source which was found to be damaged had also been inadvertently withdrawn from its shielded housing when the molten steel overflowed atop the mold cap. However, the second source immediately fell into two pieces, apparently suffering damage within the housing. That source was reportedly burnt/melt and would not fit into the shield. A licensee gauge user then used a 4 inch angle grinder to smooth out the source so it would fit back into the shield. Agency staff investigated all areas accessible (some areas were inaccessible due to molten steel). A portable germanium spectrometer was employed to discern if elevated count rates were from NORM or Co-60 contamination. Preliminary findings indicate at least two areas adjacent to the vise (where grinding had occurred) had Co-60 contamination. Samples were collected for lab analysis and additional area surveys performed. The [Illinois Emergency Management Agency - Office of Homeland Security] IEMA-OHS lab reported on the afternoon of 3/13/24 that samples did evidence Co-60 contamination. The Agency covered the contaminated area and required it to be posted. Additional surveys will be taken once accessible, to include the wash-down water sedimentation areas. A full survey and remediation plan will be required by the end of the month. Decontamination efforts will be undertaken by a qualified contractor and the Agency will perform verification surveys to support release. Updates will be provided as they become available."

Notified R3DO (Hills), IR MOC (Crouch), NMSS (Williams), NMSS Events (email)
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), Nuclear SSA (email), FEMA NWC (email), CWMD Watch Desk (email)

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 - STUCK SHUTTER

The following was received from the Texas Department of State Health Services (the Department) via email:

"On March 11, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that an event at the facility resulted in molten metal being spewed out from the furnace. Some of the molten metal landed on the housing cover of a Berthold LB 300 gauge containing a 2.5 curie (original activity 3 years ago) source. The licensee was able to remove the cover and inspected the gauge. The licensee found that some of the molten metal had leaked on to the shutter operator for the gauge, preventing the shutter from closing. The RSO stated they were able to remove the gauge from the vessel and place in a storage area. The RSO stated the room has been locked and posted to prevent inadvertent entry. The RSO stated they had performed radiation surveys outside the storage room and readings obtained were less than 2 millirem per hour. The RSO stated no individual received any radiation exposure that would have exceeded any limit. The RSO stated they have contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10094

Texas NMED No.: TX240009

AGREEMENT STATE REPORT - MISSING SOURCE

The following information was received from the Wisconsin Department of Health Services (the State) via email:

"On March 11, 2024, a contracted service provider was on-site to dispose of 6 sources housed in a Kevex Model 6700 Analyst. It is a 2000 Series Spectrometer, Serial Number A011E, Bench Number 5026. The Analyst [device], has been in the possession of the scrap facility for at least a decade but was never utilized. The device was identified in November 2023, as a device which contained radioactive material. At that point the State was notified, and plans were initiated to dispose of the material. The State was unable to determine who previously possessed the device, or to whom it was initially distributed.

"The device should have contained 3 Cd-109 pellets of 7 mCi each, and 3 Am-241 pellets of 7 mCi, each. The source serial number indicated on the labeling is 4047, Model 0202. The assay date was December 1, 1992. When the service provider disassembled the device to reach the source housing, no sources were present within the device. The service provider performed confirmatory surveys to ensure that no sources were present. Apparently, the sources were removed prior to the scrap yard receiving the device.

"Without knowing the provenance of the device, it is unclear whether the sources were ever properly disposed of, therefore, it is being reported as missing material."

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 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)

MANUAL REACTOR TRIP DUE TO MAIN FEEDWATER AND MAIN STEAM ISOLATIONS

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

"At 1449 CDT, Waterford 3 Steam Electric Station was operating at 100 percent power when a manual reactor trip was initiated due to main feed isolation valve (FW-184B) and main steam isolation valve (MS-124B) going closed unexpectedly.

"Emergency feedwater (EFW) was automatically actuated. Preliminary evaluation indicates that all plant systems functioned normally after the reactor trip. The unit is currently stable in Mode 3. All control rods fully inserted as expected.

"This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour nonemergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW system.

"The NRC Resident Inspector has been notified."

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

Decay heat is being removed through the turbine bypass valves and the atmospheric dump valve on loop '2'. There is no primary to secondary system leakage. The cause of the isolations is still being investigated.

MANUAL REACTOR TRIP DUE TO MAIN FEEDWATER PUMP TRIP

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

"On March 17, 2024, at 1515 CDT, the Comanche Peak Unit 2 reactor was manually tripped due to an anticipated automatic trip due to lo-lo steam generator (SG) water levels. Prior to the trip, main feedwater pump '2B' tripped and an auto runback to 700 MW (60 percent power) 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.

"Unit 2 is being maintained in hot standby (Mode 3) in accordance with integrated plant operating procedures IPO-007B. 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 '2B' main feed pump trip was due to loss of primary and redundant power to the servo control valve. The loss of power to the servo control valve is under investigation.