Event Notification Report for February 18, 2025

EN Revision Imported Date: 2/18/2025

EN Revision Text: PART 21 INTERIM REPORT - TORQUE SWITCH FAILURES

The following is a summary of information provided by the licensee via phone and email:

During installation of a replacement torque switch into a SMB-00 actuator at Beaver Valley Nuclear Power Station, technicians reported that the roller subassembly which connects the torque switch to the actuator drive train was loose and easily removed from the torque switch. The condition was identified on a quantity of two torque switches. Investigations by Flowserve indicate that the torque switch assemblies contain a manufacturing error resulting in the torque switch roller pin to be improperly secured in the tripper arm. This condition can potentially result in the roller subassembly becoming detached from the torque switch rendering the torque switch assembly non-functional. However, none of the components were installed in plant equipment.

The extent of condition investigation of the issue is ongoing and the expected date of completion is on or before 2/28/25.

Known plant affected: Beaver Valley Nuclear Power Station

Contact information:

Chris Shaffer, Global Quality Manager - ACV for
Arie van Eyk, Director, Plant Manager
Flowserve US Inc.
5114 Woodall Road
Lynchburg VA 24502
(434) 258-5074
cshaffer@flowserve.com

* * * UPDATE ON 2/14/2025 AT 1501 EST FROM KYLE SAWYER TO ERNEST WEST * * *

The following is a synopsis of information received via phone and email:

Flowserve completed their final report pertaining to SMB-00 torque switch assemblies. Flowserve identified replacements parts under Limitorque part number 11501-010 are affected as well as original equipment switches contained in new SMB/SB-00 actuators.

Flowserve also provided an updated list of affected power plants. All affected plants have been notified by Flowserve.

Updated known affected U.S. nuclear power plant sites:
Beaver Valley
Watts Bar
Sequoyah
McGuire
Catawba
Point Beach

Notified R1DO (Henrion), R2DO (Penmetsa), R3DO (Orlikowski), and Part 21/50.55 Reactors (email)

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received by the Ohio Department of Health via email:

"On February 7, 2025, the Ohio Department of Health was notified of a medical event involving Y-90 TheraSpheres. Two patients were scheduled to receive treatment on February 7, 2025, however, patient 'A' received the dose prescribed to patient 'B'. The written directive stated patient 'A' was to receive 160 Gy (47 mCi) but instead received 92 Gy (27 mCi), resulting in an underdose of 43 percent. The apparent cause was due to transposing the vial lot numbers when entering the information into the hospital's patient tracking system. The hospital caught the error before patient 'B' was treated, and patient 'B' received the dose prescribed in the written directive. Patient 'A' and his physician were notified. The patient will be evaluated to determine if additional treatment is required. An investigation of this event is pending."

Ohio Item Number: OH250002

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 - RADIATION WORKER EXCEEDED 5 REM ANNUAL LIMIT

The following information was provided by the Louisiana Department of Environmental Quality (LDEQ) via email:

"On February 6, 2025, LDEQ was notified by Source Production and Equipment Company, that a radiation hot cell worker exceeded the annual occupational dose limit for adults. [A radiation worker] reported for December 2024 a year-to-date exposure of 5,292 mrem."

Louisiana Event Report ID No.: LA20250001

AGREEMENT STATE REPORT - LOST EXIT SIGN

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"NYSDOH received a phone call from the general manager of AMC Theatres 8, to report a missing tritium exit sign. The device was no longer functioning and was removed for replacement on or about December 4, 2024. The sign was set aside for pick up by the contractor. On February 10, 2025, at approximately 1100 EST, the general manager discovered the sign was missing. The make/model/serial number of the sign is unknown. However, the theater is attempting to gather additional information.

"No further information on the device, source, or incident is available at this time.

"It is suspected that the tritium exit sign may have been disposed of in the regular trash, but AMC Theatres is investigating the potential whereabouts and causes for this lost device. It is not believed that the tritium exit sign is damaged and/or leaking and it is not believed that this event led to any exposure or dose to members of the public.

"Given the normal activity of these devices and the 12.3-year half-life, it is suspected that the quantity of H3 exceeds the reportability threshold required by 10 CFR 20.2201(a)(1)(i).

"NYSDOH is monitoring this event and has assigned NYSDOH Incident No. 1515 to internally track this event."

Event Report ID No.: NY-25-02

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

AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR

The following report was received via phone and email from the Texas Department of State Health Services (the Department):

"On February 11, 2025, the Department received a notification from the licensee of a lost general licensed device. The device, a P-2021-5432 static eliminator containing a 10 mCi (original activity from May 2023) Po-210 (Polonium) source, was used in a controlled cleanroom environment as an ion gun for removing micro-particles from semiconductor machine components. The licensee stated the device was erroneously disposed of by a facilities technician during a preventative maintenance exercise on cleanroom air guns conducted on December 2, 2024. The licensee stated that to prevent a future recurrence of this incident, all facilities technicians have been trained on the proper identification, restrictions, and regulatory disposal requirements of these devices.

"Additional Information will be provided in accordance with SA 300 Requirements"

Texas Incident Number: 10167
Texas NMED Number: TX250009

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

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Minnesota Department of Health, Radioactive Materials Unit via email:

"During the licensee's semi-annual wipe and shutter check for their fixed gauges, the licensee identified a radiation source with a shutter that is stuck in the [open] position. The device is a Vega/Omart SHF1-45 containing 2 mCi of Cs-137. The gauge is not readily accessible."

Minnesota Event Report ID number: MN250001

TECHNICAL SPECIFICATION DEVIATION

The following is a summary of information obtained from the licensee by phone:

On February 13, 2025, at 1009 EST, the licensee violated Technical Specification 3.2.3 when conducting a $2.00 reactor pulse while one of the required reactor power measurement channels was in bypass, therefore, the pulse power was not recorded. The pulse was completed per procedure, and the reactor was shutdown and secured. The incident was reported to supervision, and the pulse data was reviewed. The peak observed temperature during the pulse aligned with the expected peak temperature for the conducted pulse, but the peak power was not captured by the system. After review of the data, continued operation was authorized. There is no assessed safety impact due to this event.

Training will be conducted to clarify the Technical Specification requirements to prevent this issue in the future.

NRC Project Managers have been notified.

MANUAL REACTOR SCRAM DUE TO DEGRADING CONDENSER VACUUM

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

"On February 15, 2025 at 2240 CST, Grand Gulf Nuclear Station (GGNS) was operating in mode 1 at 84 percent reactor power when a [manual] reactor protection system (RPS) actuation (scram) occurred due to degrading condenser vacuum. All control rods inserted, there were no complications, and all plant systems responded as designed. Immediately after the scram, an expected reactor water level 3 isolation signal was received.

"Reactor pressure is being maintained via the main turbine bypass valves. Reactor level is being maintained via condensate and main feedwater. GGNS is currently in mode 3. No radiological releases have occurred due to this event.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A), as an event or condition that results in actuation of the RPS when the reactor is critical and as a specified system actuation due to the expected reactor water level 3 isolation signal immediately following the reactor scram.

"The NRC Senior Resident Inspector has been notified."

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

The loss of condenser vacuum was due to loss of power to the seal steam controller.