Event Notification Report for December 16, 2024

EN Revision Imported Date: 12/16/2024

EN Revision Text: TECHNICAL SPECIFICATIONS VIOLATION

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

"At approximately 1100 CST on December 15, 2023, the facility was discovered to be in violation of a Limiting Condition of Operation (LCO) according to Technical Specification 3.3.2.2, which requires that the static pressure measurement in the confinement exhaust system measure -0.1 inches of water or less during operation. It was discovered that this plant variable was not tied to the PANALARM trip for 'Building Pressure', nor was the sensor output value available in the control room to be checked by operators. The PANALARM trip for 'Building Pressure' was set to a different variable not related to the LCO required value. This condition has existed since 2006.

"The reactor was not in operation at the time of the discovery, and the situation creating this LCO violation is being corrected prior to the next reactor startup."

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

The issue was discovered by the vendor when a controller board was being replaced after damage from a power outage.

* * * RETRACTION ON 12/15/2024 AT 2233 EST FROM JERE JENKINS TO IAN HOWARD * * *

The following information was provided by the licensee via email:

"This event report is hereby withdrawn. The reactor was not operated in contravention with the LCO. The confinement pressure was maintained."

Notified NRR (Boyle) and NRR (Waugh)

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the New Jersey Department of Environmental Protection via email:

"On December 5, 2024, the licensee became aware of a shutter that could not fully close but was able to return to the fully open, operative position. The shutter failure was identified while performing a routine six-month fixed gauge shutter check. The fixed gauge is located eight feet above a walking platform which is only accessible to licensee staff via ladder, scaffolding or other means. No members of the public have access to this location.

"The shutter is currently in its normal, open position. No maintenance activities are scheduled which would require closure of the shutter.

"The licensee has a contract with the manufacturer and has scheduled them to assess this situation and make any necessary repairs.

"The shutter holder contains a Cs-137 sealed source (model A-2102) with maximum activity of 300 mCi.

"This event is reportable under 10 CFR 30.50(b)(2) [NJAC 7:28-51.1]"

Equipment information:
Model number: SH-F2
Serial number: 0362CG
Manufacturer: Vega Americas, Inc.

New Jersey Event Report ID number: To be determined

AGREEMENT STATE REPORT - STUCK SOURCES

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

"On December 5, 2024, two 1.53 mCi Co-60 sources were removed from their casting molds for an outage and placed into shielded source holders. At that time, it was discovered that one source could not be fully placed into its shielded configuration. The cause was believed to be a bend or steel prohibiting the source from being fully inserted. The active portion of the source was shielded, but the inactive portion extended beyond the shutter. It was also discovered that the shutter for the second source was inoperable.

"The sources were oriented to minimize exposure rates and secured in the licensee's source storage room. Exposure rates within the source storage room were 2 mR per hour and the exterior wall (unrestricted area) was maximumly 1.6 mR/hour. These measurements were confirmed by Chase Environmental consulting staff on December 6, 2024.

"The Agency staff will respond to the facility and assess the sources and shields when being removed for use on Monday, December 9, 2024.

"There are no anticipated exposures in excess of regulatory limits as a result of this incident. The matter is reportable to the Agency under 32 Ill. Adm. Code 340.1220(c)(2)."

Equipment information:
Device: Gauge shutter
Manufacturer: Berthold
Model number: LB 300 IRL ML

Illinois Item Number: IL240031

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On December 4, 2024, while administering Y-90 microspheres to a patient for radioembolization of the liver, a portion was shunted to the gastrointestinal tract. The shunting was not identified in the licensee's pre-administration macroaggregated albumin (MAA) mapping. The shunting is estimated to have resulted in approximately 100 cGy (rem) to the patient's stomach. The patient and physician have been notified. The licensee has not been reachable for additional details and a site visit is being coordinated."

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 TROXLER GAUGE

The following report was received by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"On September 16, 2024, one of the licensee's portable gauge users was performing a measurement on asphalt using a Troxler 3430 moisture density gauge (serial number 25688) containing a cesium-137 source (serial number 75-8566, presumably 8 mCi) and an americium-241 source (serial number 47-22058, presumably 40 mCi). The operator had his back to the paving vehicle, and the vehicle did not have a functioning back-up alarm. The vehicle struck the operator in the shoulder, and the vehicle's right rear tire impacted and damaged the gauge. The operator sustained minor injuries, but the gauge suffered serious damage. The licensee's radiation safety officer (RSO) surveyed the vehicle's right rear tire using a calibrated instrument and found no evidence of contamination. The highest exposure rate reading from the damaged gauge was approximately 1 mR/hr at 1 meter from the gauge. The RSO was able to return the source rod to the shielded position, secure the damaged source rod from moving using duct tape, and place the gauge in the transportation case. The transport index of the transport case with the damaged gauge inside was 0.3. The RSO contacted Troxler for instructions to return the gauge to Troxler and to order a replacement gauge.

"This event was discovered during a routine license inspection by the Division on December 6, 2024. At the time of the inspection the transport case with the damaged gauge was still in the licensee's possession."

INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

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

"This 60-day optional telephone notification is being made in lieu of a licensee event report (LER) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 1917 Eastern Standard Time (EST) on November 3, 2024, an invalid actuation of group 6 primary containment isolation valves (PCIVs) (i.e., containment atmospheric control/monitoring (CAC/CAM) and post accident sampling system (PASS) isolation valves) occurred. Reactor building ventilation isolated and standby gas treatment started, per design.

"The group 6 isolation resulted from a spurious signal from the reactor building ventilation radiation monitor `A' channel. No manipulations associated with the isolation or reset logic were ongoing at the time, and no abnormalities were noted in the reactor building ventilation radiation values. The readings for both reactor building ventilation radiation monitor channels remained consistent with each other, with no readings approaching the isolation setpoint.

"The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.

"During this event the PCIVs functioned successfully, and the actuations were complete. This event did not result in any adverse impact to the health and safety of the public."