Event Notification Report for March 03, 2025

EN Revision Imported Date: 3/3/2025

EN Revision Text: PART 21 INTERIM REPORT - POTENTIAL DEFECT WITH CIRCUIT BOARD

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

The licensee received two alarms due to direct current (DC) output voltage fluctuating between 127.4 to 131.3 volts. After troubleshooting, the DC output voltage fluctuations were caused by the battery charger printed circuit board. The part has been sent to the vendor, Ametek, for evaluation. Catawba is the only plant known to have this issue at this time.

The evaluation is expected to be completed on January 31, 2025.

Catawba condition report number: 02526388

Ametek Part Number: 80-921-4031-90
Ametek failure analysis number: 24-006

* * * UPDATE ON 01/31/25 AT 1548 EST FROM ETHAN SALSBURY TO KAREN COTTON * * *

Ametek is continuing its evaluation of the circuit boards. The original evaluation completion date was January 31, 2025. Ametek is extending the evaluation completion date to February 28, 2025. Remaining steps include completing the cause analysis, identifying all affected equipment, finalizing any corrective action measures, and determining actions required.

Notified R2DO (Suggs), Part 21 Group (email)

* * * UPDATE ON 02/28/25 AT 1509 EST FROM ETHAN SALSBURY TO ERNEST WEST * * *

The following is a synopsis of the information provided from Ametek:

AMETEK has submitted their final report for the evaluation of the circuit boards in question. AMETEK identified two failed capacitors on a charger control printed circuit board with part number: 80-9214031-90. The two failed capacitors are C35 (part number: 03-010003-00) and C36 (part number: 03-011006-00). These capacitors have been identified to fail prematurely prior to the 10-year replacement schedule in a few identified cases. AMETEK will be conducting further design evaluations on printed circuit board (PCB) 80-9214031-90 and considering design and/or component changes that will further enhance the reliability of the charger control board.

AMETEK reviewed the last 10 years of jobs and identified the following potentially affected U.S. nuclear power plants:

Farley
Braidwood
Byron
Dresden
Fitzpatrick
Ginna
Nine Mile Point
Quad Cities
Millstone
North Anna
Surry
Catawba
Robinson
Harris
McGuire
Oconee
Beaver Valley
Davis Besse
Columbia Generating Station
Arkansas Nuclear One
Grand Gulf
River Bend
Waterford
Hatch
Vogtle Unit 1 and Unit 2
DC Cook
Seabrook
Turkey Point
Point Beach
Diablo Canyon
Sequoyah
Watts Bar
Comanche Peak
Prairie Island
Palisades (ISFSI)
Three Mile Island (ISFSI)


Notified R1DO (Defrancisco), R2DO (Penmetsa), R3DO (Feliz-Adorno), R4DO (Roldan-Otero), Part 21 Group (email)

AGREEMENT STATE - STUCK OPEN SHUTTER

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On February 20, 2025, the Department was notified by the licensee that the shutter on a Vega SH-F2 nuclear gauge containing a 800 millicurie (original activity) Cs-137 source was found stuck in the open position during routine testing. Open is the normal position for the shutter. The licensee will try to close the shutter on February 21, 2025, when temperatures are above 32 degrees Fahrenheit to [determine whether] cold temperatures were a factor. It is a possibility that water was in the internals of the source holder, the water became ice, and then caused the shutter to not function as designed. If it is not a temperature issue, the licensee will pursue other options to repair or replace the source holder. The licensee stated there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this shutter mechanism failure. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10170
Texas NMED number: TX250011

* * * UPDATE ON 02/21/25 AT 1508 EST FROM ART TUCKER TO KAREN COTTON * * *

"On February 21, 2025, the licensee stated the gauge shutter was tested and the shutter operated as designed. The licensee reported, 'There must have been ice inside the source holder.' The Department has requested additional information."

Notified R4DO(Dixon) and NMSS Events (email)

AGREEMENT STATE - STUCK OPEN SHUTTER

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On February 21, 2025, the Department was notified by the licensee that on February 20, 2025, the shutter of a Ronan SA-1 nuclear gauge containing a 20 millicurie (original activity) cesium-137 source was found stuck in the open position during routine testing. Open is the normal position of the shutter. The licensee stated there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this shutter mechanism failure. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: 10171
Texas NMED number: TX250012

AGREEMENT STATE REPORT - UNPLANNED EXPLOSION AND CONTAMINATION

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

"On 2/19/2025, Agency staff conducted a routine inspection at Hot Shots NM, LLC. At the time of inspection, it was discovered that on 5/28/2024, a pharmacist used a standard hot plate in lieu of a heat block in order to tag 2 curies of Tc-99m to Sestamibi. The heating caused the glass vial to explode, resulting in a major spill. The event resulted in contamination of the clean room and contamination to (2) individual's face and hair.

"The matter was discussed the next day [2/20/2025] with supervisory staff, and it was determined that the licensee failed to report the event as required under [32 Illinois Administrative Code] 340.1220(c)4 and likely 340.1220(b)2, both requiring notification to the Agency within 24 hours. This matter is reportable to the U.S. NRC within 24 hours.

"Due to a lack of records or licensee evaluation of dose from absorption through skin required under 32 Illinois Administrative Code 340.220(d), there is no current estimate to the amount of occupational exposure to the contaminated workers. Inspectors are actively gathering survey readings, specific activity, and variables that may allow an estimation of potential dose to workers. No workers reported to the hospital as a result of the incident. The investigation is ongoing, and updates will be provided as they become available."

Illinois Reference Number: IL250009

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY EQUIPMENT

The following information was provided by the California Department of Public Health via email:

"Mistras Group was performing radiography at a temporary job site outside of a water tank. The radiographer was using a manned lift to perform the radiography at the 50-foot level. The Industrial Nuclear Company (INC) IR 100 exposure device number 4435 with an Ir-192 model 32, serial number 003J with 37.3 curies was resting inside an I-beam trough and secured to the tank using magnets. The source crank assembly was 35 feet long. During the eighth exposure, the radiographer felt the magnets holding the exposure device to the tank pull off, and he immediately cranked the radiography source into the exposure device, which fell approximately 45 feet to the ground level. The radiographer returned to ground level and surveyed the exposure device with his survey meter and found that it was at the normal range.

"Upon examination of the radiography equipment, the radiation safety officer discovered that the swedge end of the Ir-192 source pigtail was damaged during the fall. The exposure device will not be used again and will be returned to the manufacturer, INC, for source removal and any needed repairs.

"There was no exposure to any radiography personnel or members of the public."

California 5010 Number: 022125

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the Maryland Department of the Environment (MDE) via email:

"On February 20, 2025, an incident involving a sealed radioactive source [leaking source] at the PET/CT Department of Johns Hopkins Imaging, Bethesda was reported to the MDE. The issue was identified during a routine leak test conducted by the facility's health physics consultant, Krueger Gilbert Health Physics. The sealed vial source, Cs-137 (Serial Number 16694, activity 0.199 mCi as of March 1, 2002), was used for quality control of the Capintec CRC dose calibrator.

"Upon detection of the issue, the sealed source was immediately withdrawn from service, placed in a polythene zip-lock bag, and securely stored in the hot lab. A comprehensive contamination survey was conducted by collecting wipe samples from the dose calibrator, handling tools, storage container, storage area, and other relevant locations. The survey results confirmed no detectable radioactive contamination.

"As a precautionary measure, the licensee was instructed to maintain the sealed source in double-sealed polythene packaging within a secure container. The licensee is currently awaiting a return kit for the proper disposal of the source through an authorized agency or supplier. Upon completion of the disposal process, all relevant documentation will be submitted to MDE.

"MDE will provide follow up to this reactive investigation until the source is securely disposed."

AGREEMENT STATE REPORT - MEDICAL EVENT

The following summary was received via phone from the Nebraska Division of Radioactive Materials (DHHS-NE):

At 0830 CST on February 24, 2025, DHHS-NE was notified by the licensee of a medical underdose occurring during the morning of February 21, 2025. A patient received a Y-90 treatment of 47.25 mCi intended for the right lobe of the liver. However, only 74 percent of the intended dose reached the right lobe of the liver. DHHS-NE is continuing to follow up on the event.

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.

* * * RETRACTION FROM BRYCE DAVIDSON TO BRIAN P. SMITH AT 1657 EST ON FEBRUARY 25, 2025 * * *

DHHS NE informed the Headquarters Operations Center that upon further review the Y-90 treatment that underdosed the patient involved shunting and therefore is not a medical event. The event thus is not reportable.

Notified R4DO (Roldan-Otero) and NMSS Events Notification (email)

FITNESS FOR DUTY

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

A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

MAIN STEAM ISOLATION VALVE FAILED TO CLOSE

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

"At 0101 EST on 03/01/25, while shutting down for entry into a scheduled refueling outage, the station discovered that a single main steam isolation valve '4A MSIV' did not fully close on demand. All other equipment operated as expected.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v).

"The NRC Resident Inspector has been notified."

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

Unit 4 will remain in mode 4 until corrected. The MSIV was closed by isolating instrument air.