Event Notification Report for May 10, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
05/09/2024 - 05/10/2024

Agreement State
Event Number: 57100
Rep Org: WA Office of Radiation Protection
Licensee: U of Washington
Region: 4
City: Seattle   State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Mark Hernandez
HQ OPS Officer: Thomas Herrity
Notification Date: 05/02/2024
Notification Time: 16:16 [ET]
Event Date: 04/26/2024
Event Time: 00:00 [PDT]
Last Update Date: 05/02/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LEAKING ELECTRON CAPTURE DEVICE

The following was received from the Washington State Department of Health via email:

"The University of Washington has indication that an electron capture device (ECD) containing nickel-63 (Ni-63) is leaking.

"The ECD (G1223A, serial number F7283) had been removed from the gas chromatograph (Hewlett Packard 5890) for disposal. Previous leak testing had been performed with the ECD installed in the GC, and no contamination had been identified that required reporting. The ECD contains Ni-63 that is plated onto an inner surface of the cell body. The current activity is approximately 11.9 millicuries.

"On April 26, 2024, a health physicist performed a leak test by taking a wipe sample on the detector inlet. The wipe from the detector inlet showed contamination of 44,536 dpm using a machine calculated efficiency of approximately 72 percent. The detector inlet indicates a contamination level of 44,536 dpm or approximately 742 Bq (0.02 microcurie). This value exceeds the limit of 185 Bq (0.005 microcurie).

"The ECD will be returned for recycling/disposal of the source."

Washington Incident Report No.: WA-24-011


Agreement State
Event Number: 57101
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush-Presb.-St. Luke's Med Center
Region: 3
City: Chicago   State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Bill Gott
Notification Date: 05/03/2024
Notification Time: 10:27 [ET]
Event Date: 05/01/2024
Event Time: 00:00 [CDT]
Last Update Date: 05/03/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The Agency was contacted on 5/2/24 to advise that a patient who was administered Y-90 TheraSpheres on 5/1/24 received an underdose of approximately 23.6 percent. Both the patient and the referring physician were notified. There is no anticipated adverse impact to the patient and retreatment will not be necessary. The root cause has yet to be identified, and Agency inspectors will perform a reactive inspection the week of 5/6/24. This report will be updated as additional information becomes available."

IL Event Number: IL240011

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.


Non-Agreement State
Event Number: 57102
Rep Org: P4 Production, LLC
Licensee: P4 Production, LLC
Region: 4
City: Soda Springs   State: ID
County:
License #: 11-27361-01
Agreement: N
Docket:
NRC Notified By: David Matyus
HQ OPS Officer: Ian Howard
Notification Date: 05/03/2024
Notification Time: 11:49 [ET]
Event Date: 04/30/2024
Event Time: 10:00 [MDT]
Last Update Date: 05/03/2024
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_Events_Notification, (EMAIL)
Event Text
STUCK SHUTTER

The following information was provided by the licensee via phone:

The radiation safety officer (RSO) attempted to actuate air to close the shutter on a 2003 Vega source holder, model SH-F2, serial number 2791CG, containing 500 mCi of Cs-137. The source turns into the source holder like it normally does, however, radiation levels are the same as when the shutter is open. The RSO is in contact with Vega to schedule a technician to service the shutter. The shutter is normally in the open position and there has been no additional exposure to personnel or the public due to the position of the shutter.


Agreement State
Event Number: 57106
Rep Org: SC Dept of Health & Env Control
Licensee: Carolina Canners, Inc.
Region: 1
City: Cheraw   State: SC
County:
License #: GL-0084
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Ian Howard
Notification Date: 05/03/2024
Notification Time: 17:21 [ET]
Event Date: 04/15/2024
Event Time: 00:00 [EDT]
Last Update Date: 05/03/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST NUCLEAR GAUGES

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via phone and email:

"The Department was notified via telephone on 5/3/2024, that four fixed gauging devices were unaccounted for by the general licensee. The general licensee is reporting that four Industrial Dynamics fixed gauging devices (model number FT 50) containing 100 mCi (3.7 GBq) of americium-241 each, for a total of 400 mCi (14.8 GBq), were sent to a recycling facility on 3/8/2024. The serial numbers for the four fixed gauging devices were as follows: 112531, 112532, 112533, 112534. The general licensee is reporting no immediate health and safety concerns, or ongoing emergencies. Department inspectors will be dispatched. This event is still under investigation by the Department. No internal event identification number has been assigned to this 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


Non-Power Reactor
Event Number: 57113
Facility: Oregon State University (OREG)
RX Type: 1100 Kw Triga Mark Ii
Comments:
Region: 0
City: Corvallis   State: OR
County: Benton
License #: R-106
Agreement: Y
Docket: 05000243
NRC Notified By: Steve Reese
HQ OPS Officer: Adam Koziol
Notification Date: 05/08/2024
Notification Time: 14:30 [ET]
Event Date: 05/07/2024
Event Time: 14:28 [PDT]
Last Update Date: 05/08/2024
Emergency Class: Non Emergency
10 CFR Section:
Non-Power Reactor Event
Person (Organization):
Waugh, Andrew (NRR)
Balazik, Michael (NRR)
Miller, Andrew (NRR)
Event Text
TECHNICAL SPECIFICATION VIOLATION

The following information was provided by the licensee via phone:

Per the licensee's Technical Specifications (TS) 6.1.3.a, "The minimum staffing when the reactor is not secured shall be: . A reactor operator or the senior reactor operator on duty in the control room."

On May 7, 2024, following the reactor shutdown, there was an indication that one control rod was not fully inserted. Both the reactor operator and reactor engineer left the control room to investigate and discovered that one control rod was not fully inserted. The reactor operator leaving the control room violated the minimum control room staffing requirements of TS 6.1.3.a.

On May 8, 2024, the licensee determined that the cause for the control rod not being fully inserted was a dislodged plastic buffer at the bottom of the control rod barrel.

The NRC Project Manager has been notified.


Power Reactor
Event Number: 57115
Facility: Beaver Valley
Region: 1     State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Shawn Snook
HQ OPS Officer: Sam Colvard
Notification Date: 05/09/2024
Notification Time: 11:48 [ET]
Event Date: 05/09/2024
Event Time: 08:00 [EDT]
Last Update Date: 05/09/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
50.72(b)(3)(ii)(B) - Unanalyzed Condition
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel
Person (Organization):
Young, Matt (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
Event Text
CONTAINMENT BYPASS CONDITION DUE TO DEGRADED RIVER WATER PIPING

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

"At 0800 EDT on May 9, 2024, it was identified during leak rate testing that through-wall flaws existed on 'reactor plant river water' piping inside the containment building. This determination resulted in a containment bypass condition such that a gaseous release could have occurred at a location not analyzed for a release in the loss of coolant accident dose consequence analysis. This condition is not bounded by existing design and licensing documents. Evaluation of the condition of the piping is ongoing to support repair prior to startup.

"With the plant currently in cold shutdown, the containment, as specified in Technical Specification 3.6.1, is not required to be operable. There was no impact on the health and safety of the public or plant personnel.

"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A), 10 CFR 50.72(b)(3)(ii)(B), and 10 CFR 50.72(b)(3)(v)(C).

"The NRC Resident Inspector has been notified."


Fuel Cycle Facility
Event Number: 57116
Facility: Framatome ANP Richland
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
Region: 2
City: Richland   State: WA
County: Benton
License #: SNM-1227
Docket: 07001257
NRC Notified By: Brandon Hanson
HQ OPS Officer: Natalie Starfish
Notification Date: 05/09/2024
Notification Time: 12:57 [ET]
Event Date: 05/07/2024
Event Time: 10:15 [PDT]
Last Update Date: 05/09/2024
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
CONCURRENT REPORT FOR OFFSITE NOTIFICATION

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

"In accordance with 10 CFR 70, Appendix A(c) concurrent reporting, this notification is being made because a plant condition required reporting to the Washington State Department of Health (WDOH). At approximately 1015 PDT on 5/7/2024, three items were found in a storage area.

"Those items were:
1. A metal table that had been used in contaminated areas.
2. A cart that had been used in contaminated areas to transport material, with an additional weight standard stored on it.
3. An out-of-service overpack, designed to transport pellet sintering boats between buildings.

"The items were removed and sent to an outside waste area for gamma spectrometry measurement. The gamma spectrometry results at 1445 PDT on 5/7/2024, indicated that less than 8 grams of uranium were present in the transfer vault. This is more than the annual portion quantity of the building containing the storage area. The limit per stack license for Emission Unit 1511 is 1 gram of uranium.

"The other items were found to not be contaminated. There was no removable contamination on the items as measured by health and safety technicians."


Part 21
Event Number: 57117
Rep Org: Engine Systems, Inc.
Licensee: Fitzpatrick
Region: 1
City: Rocky Mount   State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Thomas Herrity
Notification Date: 05/09/2024
Notification Time: 14:42 [ET]
Event Date: 02/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 05/09/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Young, Matt (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 - EMERGENCY DIESEL GENERATOR CYLINDER LINER LEAK

The following is a synopsis of information provided by Engine Systems, Inc. (ESI) via fax and email:

On February 22, 2024, an EMD brand cylinder liner developed a jacket water leak following installation on an emergency diesel generator set. The leak occurred at a brazed joint and was detected after post-installation engine testing. Had the leak gone undetected, jacket water may have accumulated in the combustion chamber or airbox and potentially contaminated the engine's lubricating oil. Jacket water intrusion into any of these areas is undesirable and could lead to failure of the diesel engine and therefore failure of the emergency diesel generator set.

The extent of condition is a single cylinder liner, P/N 9318833, S/N 20D6294 used in the power assembly shown below.
Customer: Constellation - Fitzpatrick
Customer PO: 703, release 13498
ESI Sales Order: 3021545
Part Number Ordered: 40124898 (Blade Power Pack)
Serial Number: 20L0603
ESI C-of-C Date: April 1, 2021

The corrective action:
For Fitzpatrick: No action required; the power assembly has been returned to ESI for replacement.
For ESI: ESI will revise the dedication package to include additional verifications to prevent reoccurrence. The revision will be implemented within 30 days.

Name and contact information:
Dan Roberts, Quality Manager
Engine Systems Inc.
175 Freight Rd.
Rocky Mount, NC 27804

John Kriesel, Engineering Manager
Engine Systems Inc.
175 Freight Rd.
Rocky Mount, NC 27804


Power Reactor
Event Number: 57120
Facility: FitzPatrick
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Michael Lewis
HQ OPS Officer: Natalie Starfish
Notification Date: 05/09/2024
Notification Time: 21:10 [ET]
Event Date: 05/09/2024
Event Time: 16:29 [EDT]
Last Update Date: 05/09/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Young, Matt (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
HIGH PRESSURE COOLANT INJECTION INOPERABLE

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

"At 1629 EDT on 05/09/2024, the high pressure coolant injection (HPCI) system was declared inoperable due to a pinhole through-wall leak identified on the seal drain line for 23HOV-1 (HPCI trip throttle valve) downstream of the restricting orifice 23RO-137A. The location of the defect is in the class 2 safety related piping. HPCI is a single train safety system and this notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D).

"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:

This pinhole leak was discovered during normal operator rounds. Although HPCI is inoperable and in a 14 day limited condition of operation, the system function remains available. In addition, all other ECCS systems are currently operable. Compensatory measures (walkdowns) have been implemented to ensure the leak rate does not significantly increase.