Event Notification Report for February 21, 2025

EN Revision Imported Date: 2/20/2025

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
River Bend
Calvert Cliffs
Limerick


Notified R1DO (Henrion), R2DO (Penmetsa), R3DO (Orlikowski), R4DO (Dixon), and Part 21/50.55 Reactors (email)

EN Revision Imported Date: 2/20/2025

EN Revision Text: AGREEMENT STATE REPORT - LOST THEN FOUND RADIOACTIVE MATERIAL SHIPMENT

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

"Advanced Accelerator Applications (AAA) in Millburn, New Jersey, reported that a shipment of Lu-177 radiopharmaceutical was lost and subsequently recovered en route to another AAA facility in Indianapolis. The package was found on the side of the road near the Pittsburgh airport. A common carrier driver noticed it and called the police, who then called a local hazmat team to make sure it was safe. The hazmat team subsequently called the Chemical Transportation Emergency Center (CHEMTREC), who proceeded to give it to another common carrier at the Pittsburgh airport because they thought they were the courier by mistake. CHEMTREC notified AAA, who confirmed the package as their own, and sent one of their couriers to retrieve it. The courier returned the shipment back to AAA's facility in Millburn."

The activity of the Lu-177 was not provided in the initial report, but it was identified as being less than IAEA category 2.


* * * UPDATE ON 02/20/25 AT 1148 EST FROM K.J. KARAUSKY TO JOSUE RAMIREZ * * *

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

"According to the licensee's report, the radioactive-labeled package containing 460 mCi of Lu-177 was displaced from the private courier's vehicle when the driver stopped to rearrange some packages. Police found the package on the side of the road who contacted Advanced Accelerator Applications, and the package was returned to the licensee the same day. The package remained intact and was [reading] <0.5 mR/hr on contact and consistent with background at 1 meter. There was no suspected exposure to members of the public.

"To avoid these incidents in the future, vehicles and package storage will be standardized, permissions must be requested before handling packages, and drivers will be retrained.

"This incident is now closed."

Notified R1DO (Deboer) and NMSS Events (email).

New Jersey Incident Number: C933984

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 - MEDICAL EVENT

The following information was provided by the Georgia Radioactive Materials Program via email:

"On February 11, 2025, the radiation safety officer reported a misadministration which occurred on February 10, 2025 at Northside Hospital Gwinnett in Lawrenceville, Georgia. A patient was prescribed a reduced dose of 160 mCi of lutetium-77 under the brand name Pluvicto, used for the treatment of metastatic prostate cancer, but the regular dose of 200 mCi was accidentally administered rather than the lower dose. The referring physician was notified, and the patient will be seen before the end of the week to ensure that no adverse effects have been caused by the higher dosage."

NMED Incident number: 91

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 - MEDICAL EVENT

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

"On 02/13/25, at 1138 EST, the licensee, Beth Israel Deaconess Medical Center (Massachusetts license number: 60-0432) reported a medical event involving yttrium-90 Theraspheres (Manufacturer: Nordion BWXT ITG Canada, Inc.; Model: TheraSphere Y-90 glass microsphere system; sealed source and device registration number: NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.

"The medical event occurred on 2/11/25. The activity delivered was calculated to be 45.5 percent of the prescribed activity (prescribed activity: 4.13 GBq, delivered activity: 1.88 GBq). The event was identified on 2/12/25. The licensee reported that there was no adverse effect on the patient. The authorized user, referring physician, and patient have been notified.

"MRCP will follow up with the licensee's radiation safety officer (RSO) to determine event cause and corrective actions. The device has been taken out of service while the investigation remains open.

"The MRCP considers this event open. The MRCP will follow up with a special inspection of the licensee."

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 - LOST I-125 SEED

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

"The Agency was contacted on 2/13/25, by the University of Chicago to report the inadvertent disposal of a an I-125 brachytherapy seed down the facility's sink drain. The loss is believed to have occurred during sterilization prior to implant on 2/5/25. Five extra sterilized and packaged I-125 seeds were brought to the facility's radiation oncology department in the event they were needed for the procedure. The extra seeds were not needed and the unopened package was taken to the source storage room. It is unclear if surveys of the unused seeds were performed as required. On 2/12/25, the package believed to contain the five I-125 seeds was opened and found to be empty.

"Radiation safety staff surveyed applicable areas and located four of the five seeds in the sterilization area's sink drain. The fifth seed was not located and is being reported as lost, with the likely disposition of being inadvertently disposed of via the sanitary sewer.

"The brachytherapy seed has decayed to approximately 0.344 millicuries and would have an exposure rate of just over 2 millirem per hour at six inches. [The original activity of the I-125 brachytherapy seed was 0.405 millicuries.] The loss is reportable to the U.S. NRC within 30 days. Agency inspectors will conduct a reactive inspection to determine root cause and measures taken to prevent a recurrence. This report will be updated as additional information becomes available."

Illinois Item Number: IL250006

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 provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The Agency was contacted on 2/14/25 by representatives for ExxonMobil Oil Corp. (IL-01742-01) in Joliet, IL, to report a fixed gauge shutter stuck in the open position. The 20 mCi Cs-137 source is oriented into a process vessel that will not be entered. The gauge is normally in the `open' position and the vessel remains in use and full of commodity.

"The manufacturer's representative is being contacted to coordinate a site visit and make appropriate repairs. There are no exposures reported or anticipated as a result of this issue. The shutter condition was discovered [on 2/14/25] and reporting requirements were met. Inspectors are coordinating a site visit to gather supporting details. This matter is reportable within 24 hours under 32 Illinois Administrative Code 340.1220(c)(2). Updates will be provided as they become available."

Illinois Item Number: IL250007

AGREEMENT STATE REPORT - LOST SOURCE

The following information was received from the Wisconsin Department of Health Services (the Department) via email:

"On January 22, 2025, the Department received a telephone notification that the licensee was unable to locate a vial containing (as of January 1, 2025) 167 microcuries of cesium-137. The source was transferred to the licensee's possession with the return of a leased positron emission tomography-computed tomography (PET/CT) coach on January 25, 2024 and was stored on the coach. The licensee subsequently decommissioned and sold the coach and believed they had removed the source as part of the decommissioning. On January 10, 2025, the licensee's radiation safety officer observed that the source was not listed on inventory records. The licensee contacted the transferor of the source, the new purchaser of the vehicle, and searched their facility. Neither the licensee, transferor, nor the transferee could locate the source. On January 20, 2025, the licensee declared the source lost.

"The Department performed a reactive inspection on February 7, 2025. The vial source is an Eckert and Ziegler model RV-137-200U with serial number 1896-16-16 and contained 201 microcuries at manufacture on January 1, 2017."

WI Event Report ID No: WI250001.

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

PART 21 - EDG ROOM VENTILATION FAN CONTROLLER FAILURE

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

"Catawba Nuclear Station has determined that a defect associated with Love Controllers identified with Limpet supplier part number 54-834-838-8187-8160-8134-8174 is reportable under 10 CFR Part 21.

"The subject parts were procured as commercial grade items and dedicated by Duke Energy, Inc., solely for use at Catawba Nuclear Station. Manufacturer circuit board workmanship issues associated with the Love controller resulted in a failed controller installed in Catawba's 2A1 emergency diesel generator room ventilation train and resulted in Catawba submitting licensee event report 2024-001-00. The loss of one emergency diesel room ventilation fan, under certain conditions, could cause a loss of safety function at elevated outside air temperatures and could result in a substantial safety hazard. All other Love controllers installed and in Duke Energy's warehouse were subsequently inspected for similar workmanship issues [with no issues found].

"The NRC Senior Resident Inspector has been notified. No other nuclear plants were affected as the part has not been sold or transferred to another facility."

Notified by:

Scott Milton
Nuclear Support Services Manager
Catawba Nuclear Station
Desk: 803-701-3488

TWO OF THREE ECCS TRAINS DECLARED INOPERABLE

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

"On 02/18/2025, at 0400 CST, train `C' essential cooling water was declared inoperable for scheduled maintenance. This cascades down to train `C' emergency core cooling system (ECCS), rendering it inoperable. Train `C' essential cooling water was declared operable on 02/18/2025, at 1207; however, train `C' essential chiller remained inoperable due to ongoing maintenance, which renders train `C' ECCS inoperable.

"On 02/19/2025, at 0324, train `B' ECCS was declared inoperable due to challenging control room habitability. The mitigating strategy of placing high head safety injection pump `1B' in pull to lock was completed at 0749 on 2/19/2025.

"On 02/19/2025, at 0324, Technical Specification 3.5.2 action `b' was entered due to two trains of ECCS being inoperable. This action requires that at least two trains of ECCS are restored to operability within 1 hour or apply the requirements of the CRMP (Configuration Risk Management Program).

"On 02/19/2025, at 0424, the CRMP was entered based on two ECCS trains remaining inoperable for longer than 1 hour.

"This condition resulted in the inoperability of two of the three safety trains required for the accident mitigating function including: high head safety injection, low head safety injection, and containment spray. This is an 8-hour reportable condition per 10CFR50.72(b)(3)(v)(D) because it could affect the ability to mitigate the consequences of an accident.

"Unit 1 remains in mode 1 at 100 percent power. The NRC Resident Inspector has been notified."

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

With two ECCS trains inoperable, the licensee will enter a shutdown technical specification action statement on 3/13/2025.