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Event Notification Report for October 11, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/10/2024 - 10/11/2024

EVENT NUMBERS
57329 57362 57364 57370 57372 57373
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
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: 10/10/2024
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
EN Revision Imported Date: 10/11/2024

EN Revision 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

* * * RETRACTION ON 10/10/24 AT 1513 EDT FROM CHASE WILLIAMS TO KAREN COTTON * * *

The following information was provided by the licensee via email:

"On September 18, 2024, Columbia Generating Station notified the NRC (event notification 57329) under 10 CFR 50.72(b)(2)(xi) of an offsite notification for potential oil release to the plant service water system and potentially the Columbia River.

"Further troubleshooting efforts refuted the possibility of leakage from the heat exchanger to the plant service water system. Engineering determined the most likely path of oil leakage was through a seal in the reactor feed turbine 'A' pump. This leakage would exit with seal water leak-off into the marine oil separator into collection barrels which are collected and processed.

"Since troubleshooting efforts determined oil leakage was not from the heat exchanger to the plant service water system, the offsite notification retractions were completed as of October 10, 2024, and therefore event notification 57329 is being retracted."

The NRC Resident Inspector was notified.

Notified R4DO (Gaddy).


Hospital
Event Number: 57362
Rep Org: Christiana Hospital
Licensee: Christiana Hospital
Region: 1
City: Newark   State: DE
County:
License #: 07-12153-02
Agreement: N
Docket:
NRC Notified By: Carol Wen
HQ OPS Officer: Natalie Starfish
Notification Date: 10/04/2024
Notification Time: 09:16 [ET]
Event Date: 10/03/2024
Event Time: 10:00 [EDT]
Last Update Date: 10/04/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
MEDICAL EVENT - Y-90 UNDERDOSE

The following information was provided by the licensee via phone:

A medical event involving Y-90 TheraSpheres occurred on 10/03/2024 at approximately 1000 EDT. A patient received an underdose of about 67 percent due to leakage at a connection point to the catheter.

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

The leak appears to be caused from a crooked connection. Modifications are being made to the procedure to review the connections from different angles to assure alignment.

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
Event Number: 57364
Rep Org: MA Radiation Control Program
Licensee: QSA Global
Region: 1
City: Burlington   State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Sam Colvard
Notification Date: 10/04/2024
Notification Time: 14:33 [ET]
Event Date: 10/04/2024
Event Time: 12:44 [EDT]
Last Update Date: 10/08/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS)
Grant, Jeffery (IR)
Smith, Todd (INES)
Event Text
AGREEMENT STATE REPORT - MISSING CATEGORY 2 SOURCE

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via phone and email:

"On 10/4/2024, at 1244 EDT, QSA Global, Inc. (license number 12-8361) was notified that a package containing a 109.1 Ci Ir-192 sealed source in a type B package was missing in transit and notified the Agency at 1315 EDT on the same day. The following information was provided at the time of notification:

"Isotope: Ir-192
Source Serial Number: 97855M
Form: Sealed source
Activity (at time of shipment): 109.1 Ci
Container Model Number: 650L
Container Serial Number: 1063
Transportation Index: 0.6
Shipping Date: 9/13/24
Last Known Location: [Common carrier] hub in Memphis, TN

"The reporting requirement is immediate and is required by 105 Code of Massachusetts Regulations (CMR) 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

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

The last physical scan was on 9/17/24, at 1403 EDT, in Memphis, TN. The recipient reached out to the common carrier on 10/1/24 asking to track the package. The response from the common carrier was that they were experiencing high volume and the package was waiting to be cleared in customs. The recipient followed up again on 10/4/24, at 0928 EDT, asking for an update, and received an update at 1108 EDT stating that they could not locate the package. The Agency has contacted the State of Tennessee regarding this event.

Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email).

* * * UPDATE AT 1308 EDT ON OCTOBER 8, 2024 FROM BOB LOCKE TO BRIAN P. SMITH * * *

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via email:

"At 1108 EDT on October 8, 2024, the missing package was delivered undamaged to the intended recipient. The Agency considers this event closed."

Notified R1DO (Arner), IR (Grant), NMSS (Fisher), ILTAB (Brown), INES (Smith), NMSS Events Notification.

Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email).

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Part 21
Event Number: 57370
Rep Org: North Anna Power Station
Licensee: North Anna Power Station
Region: 2
City: Mineral   State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Robert Page
HQ OPS Officer: Kerby Scales
Notification Date: 10/09/2024
Notification Time: 17:07 [ET]
Event Date: 10/08/2024
Event Time: 17:53 [EDT]
Last Update Date: 10/09/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Suber, Gregory (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 - DEGRADED VOLTAGE DUE TO A LOOSE TERMINAL CONNECTION SCREW

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

"This is a non-emergency notification submitted in accordance with 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 20 days.

"On October 8, 2024, North Anna Power Station (NAPS) determined a manufacturing defect affecting the normal AC supply molded case switch for the Unit 1, 1-IV battery charger was reportable under Part 21. On July 29, 2024, the 1-IV battery charger was declared inoperable due to the AC input voltage reading approximately 250 VAC on the B-C phases and A-C phases. The A-B phase voltage was normal at 480 VAC. Troubleshooting determined the normal AC supply molded case switch was the cause of the degraded voltage due to a loose terminal connection screw on the 'C' phase load side of the contacts.

"The NRC Senior Resident Inspector has been notified."

Battery Manufacturer: Ametek Solidstate Solutions
Switch Manufacturer / Model: Eaton / J250K

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

The licensee plans to inspect all battery chargers on both units to verify they don't have loose terminal screws. They are unaware of this issue affecting any other site.


Power Reactor
Event Number: 57372
Facility: Calvert Cliffs
Region: 1     State: MD
Unit: [2] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ryan Baker
HQ OPS Officer: Natalie Starfish
Notification Date: 10/10/2024
Notification Time: 08:45 [ET]
Event Date: 10/10/2024
Event Time: 05:57 [EDT]
Last Update Date: 10/10/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Arner, Frank (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby
Event Text
AUTOMATIC REACTOR TRIP DUE TO TURBINE GENERATOR LOSS OF FIELD

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

"At 0557 EDT on 10/10/2024, with Unit 2 in mode 1 at 100 percent power, the reactor automatically tripped due to turbine generator loss of field. The trip was not complex with all systems responding normally post-trip. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Operations responded using EOP-0, post trip immediate actions, and stabilized the plant in mode 3. Decay heat is removed by discharging steam to the main condenser using the turbine bypass valves.

"Unit 1 is not affected.

"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 exciter is suspected to being the cause and is under investigation. All control rods fully inserted.


Power Reactor
Event Number: 57373
Facility: Davis Besse
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Michael Boles
HQ OPS Officer: Kerby Scales
Notification Date: 10/10/2024
Notification Time: 11:39 [ET]
Event Date: 10/10/2024
Event Time: 10:45 [EDT]
Last Update Date: 10/10/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
Orlikowski, Robert (R3DO)
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
UNANALYZED CONDITION

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

"On October 10, 2024, at 1045 EDT, it was determined that an additional failure mechanism existed for a previous issue with the emergency diesel generator (EDG) speed switches. As a result, for some initiating events such as a fire or high energy line break potentially causing a ground on the negative buses on both trains of the station direct current (DC) system, both EDG speed switches could have been affected, resulting in a failure of the EDGs to function.

"This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel, as the EDG speed switches were replaced in January 2022 with a different design that is not susceptible to grounds on the station DC system. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."