Event Notification Report for September 20, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
09/19/2024 - 09/20/2024

EVENT NUMBERS
57320 57326 57328 57329 57330
Agreement State
Event Number: 57320
Rep Org: New Mexico Rad Control Program
Licensee: Lovelace Medical Center
Region: 4
City: Albuquerque   State: NM
County:
License #: 210-132
Agreement: Y
Docket:
NRC Notified By: Victor Diaz
HQ OPS Officer: Ernest West
Notification Date: 09/12/2024
Notification Time: 11:28 [ET]
Event Date: 07/18/2024
Event Time: 00:00 [MDT]
Last Update Date: 09/12/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - Y-90 DOSE MISADMINISTRATION

The following is a summary of information that was provided by the New Mexico Radiation Control Program via phone and email:

At approximately 1830 MDT on September 10, 2024, the licensee's radiation safety officer discovered that on July 18, 2024, a dose of 0.2 Gbq of yttrium-90 was prescribed for delivery to a patient, but the patient received a reported dose of 0.25 Gbq. The cause for the discrepancy between the prescribed and delivered dose is unknown. The licensee has been instructed to provide a complete written report.

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.


Power Reactor
Event Number: 57326
Facility: Vogtle 3/4
Region: 2     State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Jason Hayes
HQ OPS Officer: Sam Colvard
Notification Date: 09/17/2024
Notification Time: 04:48 [ET]
Event Date: 09/17/2024
Event Time: 01:27 [EDT]
Last Update Date: 09/19/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(2)(iv)(A) - ECCS Injection
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Suber, Gregory (R2DO)
Crouch, Howard (IR)
Russell Felts (NRR EO) (NRR EO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Safe Shutdown
Event Text
EN Revision Imported Date: 9/20/2024

EN Revision Text: AUTOMATIC REACTOR TRIP AND MANUAL SAFEGUARDS ACTUATION

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

"At 0127 EDT on 9/17/2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped due to the passive residual heat removal heat exchanger outlet flow control valve failing open. A manual safeguards actuation was initiated due to the lowering pressurizer water level resulting from the reactor coolant system cooldown that was caused by the passive residual heat removal heat exchanger outlet flow control valve failing open. The trip was not complex, with all safety systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by the passive residual heat removal heat exchanger. Units 1, 2, and 4 are not affected.

"Due to the core makeup tank actuation, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). The reactor protection system actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, this event is reportable per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid containment isolation actuation and a valid passive residual heat removal heat exchanger actuation.

"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 failure of the control valve does not inhibit the residual heat removal system from functioning as it is passive. The reactor coolant system maximum allowable cooldown rate was exceeded (Technical Specification 3.4.3). The limit is 100 degrees F per hour above 350 degrees F. The maximum observed cooldown rate was 226 degrees F per hour. At time 0458 EDT, reactor coolant system temperature is 369.1 degrees F, reactor pressure is 900 psig. Currently, the plant is cooling down and proceeding toward placing shutdown cooling online.


Power Reactor
Event Number: 57328
Facility: Summer
Region: 2     State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: Lauren Anderson
HQ OPS Officer: Tenisha Meadows
Notification Date: 09/17/2024
Notification Time: 23:38 [ET]
Event Date: 09/17/2024
Event Time: 20:05 [EDT]
Last Update Date: 09/18/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Suber, Gregory (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 91 Power Operation 91 Power Operation
Event Text
STEAM PROPAGATION DOOR INOPERABLE

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

"At 2005 EDT on 9/17/2024, it was discovered that steam propagation door DRCB/501 would not latch properly; thus making the door inoperable. Door DRCB/501 is required as a steam propagation barrier to protect both trains of engineered safety feature equipment from effects of a postulated steam line break. Due to this inoperability, the plant was in a condition that could have prevented the 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 has been notified.

"Steam propagation door DRCB/501 was repaired and maintained in the closed and latched position at 2032 EDT on 9/17/2024."


Power Reactor
Event Number: 57329
Facility: Columbia Generating Station
Region: 4     State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: Matthew Pace
HQ OPS Officer: Adam Koziol
Notification Date: 09/18/2024
Notification Time: 13:31 [ET]
Event Date: 09/18/2024
Event Time: 08:15 [PDT]
Last Update Date: 09/18/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Azua, Ray (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
Event Text
OFFSITE NOTIFICATION FOR OIL RELEASE

The following information was provided by the licensee via email:

"On September 18, 2024, Columbia Generating Station determined that lubricating oil was likely released into the plant service water system due to a failed heat exchanger on the reactor feed turbine alpha. Isolation of the heat exchanger from the plant service water system is in progress. The plant service water system returns water to a water basin that contains, at a minimum, 300,000 gallons of water. The water basin is connected to the Columbia River via a blowdown line. The blowdown line was secured at 0739 PDT on 9/18/2024. A visual inspection of the basin did not identify any oil sheen or film, but a sample downstream of the affected heat exchanger revealed an oily sheen in the sample bottle. It does not appear the oil released poses a threat to human health or the environment. However, there could have been a discharge of an unknown quantity of oil into the Columbia River, this matter is immediately reportable under Revised Code of Washington 90.56.280 to the U.S. Coast Guard National Response Center, Washington State Department of Ecology, and to the Energy Facility Site Evaluation Council per National Pollutant Discharge Elimination System (NPDES) permit section S3.F.2.b.i.

"This condition is being reported pursuant to 10 CFR 50.72(b)(2)(xi) for notification of other government agencies concerning an event related to the health and safety of the public or protection of the environment. Notifications to off-site agencies were performed at 0850 PDT on 9/18/2024. The NRC Resident Inspector has been notified."

United States Coast Guard National Response Center Incident Report #141183
Washington State Department of Ecology #733853


Power Reactor
Event Number: 57330
Facility: Point Beach
Region: 3     State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Bob Murrell
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/18/2024
Notification Time: 13:30 [ET]
Event Date: 09/17/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/18/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Ziolkowski, Michael (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
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
2 N Y 96 Power Operation 96 Power Operation
Event Text
PART 21 REPORT - DEFECTIVE RELAY IDENTIFIED DURING PRE-INSTALLATION TESTING

The following information was provided by NextEra Energy Point Beach, LLC (NextEra) via phone and email:

"NextEra makes the following notification under 10 CFR 21.21(d)(3)(i) of a defect found in a Westinghouse relay, model NBFD31S, during pre-installation bench testing. Specifically, the relay was found to not function as required due to its internal plunger not operating properly. This malfunctioning caused the plunger to not fully extend and cause the normally open contacts to remain closed. Investigations completed by Westinghouse determined that the plunger would not function properly because its kickout spring was misaligned due to human error. This relay was procured from Westinghouse for safety related nuclear applications.

"NextEra has concluded that this defect constitutes a substantial safety hazard (SSH). A SSH exists because of the nature of the defect was such that the relay would not be able to perform its safety function if installed, and would result in a loss of redundancy in a safety related system, in this case, the reactor protection system.

"On September 17, 2024, the Point Beach Site Vice President was notified of the requirement to report this event under 10 CFR 21.21. This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3(ii) will be provided within 30 days.

"Since this defect was discovered prior to installation, in accordance with station requirements for bench testing, and the vendor has concluded that this event is an isolated case, there were no actual impacts on safety related equipment.

"The NRC Resident Inspector has been notified."

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

Responsible corporate officer:
Michael Durbin
Site Vice President
(920) 755-7854