Event Notification Report for June 25, 2024

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