Event Notification Report for May 13, 2024

EN Revision Imported Date: 5/13/2024

EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE TO AN EMBRYO / FETUS

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

"The Agency was contacted on April 30, 2024, by Advocate Illinois Masonic Medical Center in Chicago, IL, to advise a patient was administered a therapeutic dose of iodine-131 on March 7, 2024, and was confirmed pregnant on April 29, 2024. The licensee estimates the pregnancy began 3-7 days after the iodine administration. Negative pregnancy test results were confirmed prior to the administration. Both the patient and the referring physician were notified on April 29, 2024. Using dose modeling [published by the International Commission on Radiological Protection] (ICRP-88) methodology, and assuming conception was 3 days post-administration, the Agency estimates dose to the embryo/fetus over the term of the pregnancy to be 19.8 rem. This is based on an effective half-life of 5.5 days over the 3 days from administration. The patient has had a thyroidectomy which complicates the use of available biokinetic models, but likely also alters the effective half-life. The licensee is researching to determine an appropriate value for the effective half-life (which may range down to 14.4 hours and result in a 900 mrem effective dose).

"Agency inspectors will conduct a reactionary inspection, and this report will be updated as additional information becomes available."

IL Report Number: IL240010

* * * RETRACTION ON 5/10/24 AT 1630 EDT FROM GARY FORSEE TO TENISHA MEADOWS * * *

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

"Agency inspectors performed a reactive inspection on 5/3/24. The licensee and involved physicians performed a detailed literature and patient review (remnant thyroid) and concluded 9.4 to 56.4 hours was the range of applicable effective half-lives. The licensee asserts, given the patient's sex, age, recombinant human thyroid stimulating hormone (rhTSH) treatment status, weight, renal function and disease burden; that 14.4 hours is the appropriate effective half-life to utilize. Empirical calculation using whole body counts was no longer viable due to decay/clearance. Based on a review of available literature and previous incidents, the Agency would concur that 14.4 hours is an appropriate value for a patient having undergone a thyroidectomy. Estimates on the date of conception relative to the date of administration were confirmed by the licensee and a range of 3/10/24 to 3/18/24 provided. The 3/10/24 date was utilized (as a means of conservation) which results in a 0.9 rem (9 mSv) dose to the embryo using the afore mentioned ICRP 88 methodology. The licensee submitted their written report and assessment on 5/10/24. The licensee consulted the I-131 package insert for tissue-specific dose conversion factors. Consistent with ICRP 88, the dose to the patient's uterus was used as representative of that to the embryo. While relying on dose conversion factors differing from those in ICRP 88, the licensee calculated a 5.19 mSv embryonic exposure. Notwithstanding the variation between the licensee's 5.2 mSv vs. the Agency's 9 mSv dose estimate; the dose falls beneath the reportable criteria."

Notified R3DO (Ruiz), NMSS Regional Coordinator (Riveria-Capella), and NMSS Events Notification via email.

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.

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 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

AGREEMENT STATE REPORT - STUCK SHUTTERS

The following information was provided by the Arkansas Department of Health, Radiation Control Section (ADH) via email:

"On 4/25/2024, [the licensee] notified ADH by phone that, during semi-annual routine inspection, five Berthold process nuclear gauges were either stuck/seized or difficult to operate. All affected gauges were stuck in the open/operate position. A representative from Berthold reported to the site on 4/30/2024 and successfully cleaned/lubricated all shutter/operating mechanisms restoring normal operation to the affected gauges.

"The following gauges were affected:
"Berthold Model LB 7440-D-CR: SN 37624-12090: Cs-137 50 mci: (Unknown License)
"Berthold Model LB 330: SN 2868-11-89: Cs-137 24 mci: (Unknown License)
"Berthold Model LB 300L: SN 6001: Co-60 4.1, 0.7, 0.2 mci: (General License)
"Berthold Model LB 300: SN 7687: Co-60 1.8, 0.5, 0.2 mci: (Specific License)
"Berthold Model LB 300L: SN 17729-1396-10023: Cs-137 24 mci: (General License)

"Licensee corrective actions included flagging the gauges locally, involving management, notifying their safety department, and suspending any activity that would require access to the gauges until they were repaired.

"The licensee is evaluating disposal of the gauges and possible replacement.

"The licensee confirmed at 1020 CDT on 5/06/2024, that one LB 300 gauge shown above is a specific license gauge.

"The investigation is ongoing, and reporting will proceed in accordance with SA-300."

Arkansas Event Number: AR-2024-003

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."

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 - 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

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.

ACTUATION OF REACTOR PROTECTION SYSTEM and EMERGENCY FEEDWATER SYSTEM

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

"At 1655 CDT, Waterford Steam Electric Station, Unit 3 was in Mode 3 with all control rod element assemblies (CEA) fully inserted with reactor trip circuit breakers closed and individual CEA disconnects open for plant startup. During the performance of emergency feedwater surveillance testing, reactor protection system (RPS) trip set point and emergency feedwater actuation system (EFAS) initiation set point for steam generator level low was exceeded for steam generator 1.

"Preliminary evaluation indicates that all plant systems functioned normally. The unit is currently stable in Mode 3. All control rods remain fully inserted.

"This event is being reported as a eight-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the RPS and emergency feedwater systems. The NRC Resident Inspector has been notified."

OFFSITE NOTIFICATION

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

"At 2030 CDT on May 11, 2024, Arkansas Nuclear One, Unit 1 (ANO-1) determined that the State of Arkansas should be notified after greater than 100 gallons of refueling canal water overflowed from the borated water storage tank (BWST) onto the ground inside the protected area outside the ANO-1 Auxiliary Building. The activity for transferring water from the ANO-1 refueling canal to the BWST was stopped and the tank level was lowered to stop the overflow. None of the spilled liquid was introduced into a storm drain or other pathway to Lake Dardanelle. This condition did not exceed any NRC regulations or reporting criteria.

"Arkansas Nuclear One, Unit 2 (ANO-2) was unaffected by this event.

"This notification is being made as a four-hour, non-emergency notification for a notification of other government agency in accordance with 10 CFR 50.72(b)(2)(xi).

"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 area where the liquid spill occurred is being controlled and a spill remediation plan is in progress.

AUTOMATIC REACTOR TRIP

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

"At 1641 CDT on May 12, 2024, with Unit 2 in Mode 1 at 15 percent power, the reactor automatically tripped due to a unit auxiliary transformer lockout. During the trip, all control rods fully inserted. The cause of the transformer lockout is currently unknown. Emergency diesel generator (EDG) 21 and 23 actuated and all three engineered safety feature (ESF) busses were energized.

"All equipment responded as expected except for steam generator power operator relief valve (PORV) 2C which failed to open when required in automatic, and the load center (LC) E2A output breaker which failed to close automatically but was closed manually. Steam generator PORV 2C did open when placed in manual, although it subsequently failed to full open and was then closed. Primary system temperature and pressure are currently being maintained at 567 degrees/2235 psig following start of reactor coolant pumps 2A and 2D.

"Due to the reactor protection system actuation (RPS) while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the emergency diesel generators. There was no impact to 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:

South Texas Project Unit 2 was in Mode 1 at 15 percent power due to performance of testing and analysis on the main turbine prior to the RPS actuation.