Event Notification Report for June 24, 2024

EN Revision Imported Date: 6/24/2024

EN Revision Text: PART 21 - DEFECT WITH EMERGENCY DIESEL GENERATOR VOLTAGE REGULATOR

The following information was provided by Paragon Energy Solutions, LLC via email:

"Paragon has identified a defect in one voltage regulator supplied to AEP DC Cook with serial number NLI-3S7950GR751A1-1007.

"Pursuant to 10CFR Part 21  21.21(d)(3)(i), Paragon is providing initial notification of a defect associated with the emergency diesel generator (EDG) voltage regulator. The voltage regulator was refurbished under the client purchase order 01600229, project number 351030025. Part of the refurbishment involved complete replacement of the units wiring, physical inspection and testing of the unit to Paragon approved acceptance testing instructions. The refurbished unit was supplied to the customer in December 2023. Prior to installation (March 2024), the unit successfully passed bench testing at the plant. During post installation testing, the EDG was started, and the output voltage pegged high and was not controllable. DC Cook subsequently removed the voltage regulator and documented the non-conformance. DC Cook troubleshooting determined the unit was mis-wired. The unit [voltage regulator] was returned to Paragon, and inspection confirmed the plant's diagnosis. The identified mis-wire affects the system circuitry by placing silicon controlled rectifier 5CD in a reverse biased position. The reversed biased rectifier blocks the flow of current which creates an open circuit condition. This open circuit condition causes the output voltage to max out, and does not allow the output voltage to be adjusted. This condition, if left uncorrected, could contribute to a substantial safety hazard and is reportable in accordance with 10CFR Part 21.

"Date of Discovery: May 9, 2024

"Reportability Determined: May 23, 2024

"Paragon has entered this condition in our corrective action program, and we have custody of the effected unit. The extent of condition is limited to this unit supplied to DC Cook. Paragon has determined there is no action necessary for DC Cook at this time."

Affected plant: DC Cook

* * * UPDATE ON 06/21/2024 AT 1655 EDT FROM RICHARD KNOTT TO ROBERT THOMPSON * * *

Paragon Energy Solutions submitted a final report for this event documenting the cause of the mis-wire and corrective actions to prevent recurrence.

Paragon contact: Richard Knott, Vice President Quality Assurance, Paragon Energy Solutions, LLC, 7410 Pebble Drive, Ft. Worth, TX 76118, 817-284-0077, rknott@paragones.com.

Notified R3DO (Havertape), R4DO (Josey), and Part 21 (email).

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"On June 14, 2024, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge secured in the trunk, was stolen earlier that day. Local police are aware of the incident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.

"Manufacturer and Model Number: Troxler Electronic Laboratories
"Model Number: 3440
"Serial Number: 35459
"Isotope and Activity: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries."

PA Event Report ID No: PA240012

Surrounding States and the Pennsylvania emergency response team have been notified.

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

PART 21 - BURNABLE POISON ROD ASSEMBLY MISLOAD

The following is a synopsis of information provided by Framatome, Inc. (Framatome) via email:

During startup testing at the affected plant, unexpected high reactor peaking factor readings resulted from an incorrect boron concentration of Al2O3-B4C pellets in two burnable poison rod assemblies (BPRAs). The cause of the issue was due to 0.2 percent boron concentration Al2O3-B4C pellets inadvertently combined with the intended 2.0 percent boron concentration Al2O3-B4C pellets, which were then placed back into inventory labeled as 2.0 percent.

This issue was determined to be a 10 CFR 21 Defect on June 21, 2024.

Corrective actions are that Framatome replaced the two affected BPRAs with BPRAs fabricated correctly and a root cause analysis has been initiated by Framatome which is scheduled for completion by July 31, 2024.

The affected plant is Oconee Unit 3.

The name and address of the individual reporting this information is:
Gayle Elliott
Director, Licensing & Regulatory Affairs
Framatome Inc.
Office 434 832-3347
Mobile 434 841-0306
3315 Old Forest Road
Lynchburg, VA 24501
gayle.elliott@framatome.com

MANUAL ACTUATION OF REACTOR PROTECTION SYSTEM (RPS)

The following information was provided by the licensee via email:

"At 0728 EDT on 06/22/2024, with Unit 2 in Mode 3 at zero percent power and the reactor trip breakers closed, a manual actuation of the RPS was initiated during the withdrawal of the shutdown rods in preparation for Mode 2. This was procedurally directed due to a shutdown rod being misaligned from the other rods in the bank due to a malfunction.

"Units 1, 3 and 4 were not affected.

"Due to the manual actuation of the RPS, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 6/25/2024

EN Revision Text: MANUAL REACTOR TRIP

The following information was provided by the licensee by email:

"On 06/18/2024 at 0317 EDT with Unit 2 at 18 percent power, the reactor was manually tripped due to elevated secondary chemistry levels (sodium and chlorides).

"The trip was uncomplicated with all systems responding normally post trip. Operations stabilized the plant in Mode 3. Decay heat is being removed by auxiliary feedwater and atmospheric dump valves.

"St. Lucie Unit 1 was unaffected and remains at 100 percent power.

"This event is being reported pursuant 10CFR 50.72(b)(2)(iv)(B).

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All rods fully inserted. An investigation is underway to determine the root cause of the elevated chemistry levels.

* * * RETRACTION ON 6/24/2024 AT 1315 FROM BOB MURRELL TO ADAM KOZIOL * * *

The following retraction was provided by the licensee via email:

"The purpose of this notification is to retract a previous report made on 06/18/2024 at 0652 (EDT) (EN# 57177). Notification of the event to the NRC was initially made because of inserting a manual reactor trip due to elevated secondary chemistry levels (sodium and chlorides).

"After the initial report, Florida Power and Light has concluded that the event did not meet the reporting requirements on 10 CFR 50.72(b)(2)(iv)(B) since it was part of a normal plant shutdown.

"Therefore, this event is not considered an unplanned scram and is not reportable to the NRC as a Licensee Event Report per 10 CFR 50.73.

"The NRC Senior Resident Inspector has been notified."

AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

The following information was provided by the Arkansas Department of Health, Radiation Control, Radioactive Materials Program (the Agency) via email:

"The Agency was notified by the Radiation Safety Officer (RSO) for the University of Arkansas for Medical Sciences on Friday afternoon, June 7, 2024, to advise of a possible Y-90 TheraSphere misadministration where the patient did not receive all the prescribed dose. The administration was two doses to segment 5 of the patient's liver. The discovery was made when the tubing and waste from the procedure was surveyed after it was returned to the lab.

"The written report was received on Friday afternoon, June 14, 2024. On June 17, 2024, the Agency reviewed the information provided and determined that this event is a misadministration due to the following:

"The administered doses both differed from their respective prescribed doses by more than 0.5 Sv (50 rem) to an organ. The delivered dose of 95 Gy (9500 rem) was 198 Gy (19800 rem) less than the [prescribed] dose of 293 Gy (29300 rem) for dose number one; the delivered dose of 105 Gy (10500 rem) was 21 Gy (2100 rem) less than the [prescribed] dose of 126 Gy (12600 rem) for dose number two.

"[For] dose number one only, the total dose delivered differs from the prescribed dose by twenty percent or more. Dose number one was outside the treatment prescription range; 68 percent of the prescribed dose was not received. Therefore, [dose] number one is considered to be a misadministration in accordance with current emerging medical technology licensing guidance.

"Dose number two was just inside the treatment prescription range; 17 percent of the prescribed dose was not received.

"The referring physician and [the] patient were notified, and the patient has been scheduled for an additional treatment.

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

Arkansas Event number: AR-2024-004

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.

AGREEMENT STATE REPORT - DAMAGED GAUGE

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

"Alton Steel Inc. contacted the Agency on June 17, 2024, to advise of an incident in which molten steel impacted and damaged a 2.3 mCi Co-60 sealed source. This incident reportedly occurred on June 14, 2024, and results from the same ongoing conditions (source susceptible to molten steel flowing down the dip tube) identified in the licensee's March 2024 incident (refer to EN 57016). The licensee is still working with the source manufacturer to identify an engineered solution.

"The source and casting mold lid were collectively moved into a restricted area under the oversight of the radiation safety officer. The damaged source was then secured pending a site visit by the source manufacturer's authorized representative on June 18, 2024. The licensee missed the reporting timeline (24 hours). Agency staff will be on site the morning of June 20, 2024, for a reactive inspection. That inspection will assess contamination potential, discuss reporting timelines (reportedly missed due to multiple heat injuries and facility damage), address ongoing susceptibility of sources to damage, review contaminated area remediation timelines, and address proposed corrective actions for the April 19, 2024, Notice of Violation.

"Based on the information available at this time, there does not appear to be any impact to public health and safety. A description of the event indicates licensed material was not dispersed or incorporated into any product. This will collectively be assessed and this report [will be] updated thereafter."

Illinois Item Number: IL240014

THIS MATERIAL EVENT CONTAINS A 'Not Recorded' LEVEL OF RADIOACTIVE MATERIAL

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The following information was received from the Georgia Radioactive Material Program (the Department) via email:

"A report was received from the radiation safety officer (RSO) at Applied Technical Services, LLC. on June 21, 2024, concerning the most recent dosimeter badge report which indicated a whole body dose of over 5,000 mrem for the month of April 2024 for an employee. The RSO has notified their upper management and the employee is suspended from all radiation work as of June 20, 2024, until further investigation. The employee is in the process of writing a detailed statement. The licensee is currently reviewing all utilization logs and will notify the Department once the investigation is complete. Further investigation is ongoing to determine root cause and a follow-up report will be provided within 30 days."

Georgia Incident Number: 85