Event Notification Report for March 12, 2025

EN Revision Imported Date: 3/12/2025

EN Revision Text: PART 21 - INTERIM REPORT FOR REGULATING TRANSFORMER

The following is a synopsis of information provided by AMETEK Solidstate Controls Inc. (AMETEK) via email:

During regulating transformer system operations, the transformer may be experiencing short circuiting between coils to ground.

Visual inspection for severe darkening or charring of coils, magnetic shunts, or core, and/or the use of thermal probes or infrared guns monitoring for excessive temperatures greater than 180 degrees Celsius or 355 degrees Fahrenheit may detect affected regulating transformer systems.

Affected systems exhibit signs of transformer insulation system deterioration, increased audible noise from the units, blackening on any areas of the transformer, or signs of electrical shorting between windings or coil to core.

The cause of the short circuiting is unknown. Component failure impact analysis and regulating transformer system electrical testing are in progress.

Recommend all units currently in service with internal components, which include but are not limited to capacitors, wire harnesses, and transformer materials, with temperatures in excess of 180 degrees Celsius or 355 degrees Fahrenheit be removed from service.

COMPONENT DESCRIPTION:
The AMETEK SCI model numbers listed are for regulating transformers that are intended to take in AC power at 460 VAC plus or minus 10 percent and output AC power at 120 VAC plus or minus 2 percent with low harmonic distortion.

Models: 85-IS0075-12 and 85-IS0150-14

AFFECTED PLANTS:
Southern Nuclear Company - Vogtle
Constellation Energy - Ginna

* * * UPDATE ON 03/11/25 AT 1530 EDT FROM ZACHARY RUMORA TO KERBY SCALES * * *

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

Test were performed on both models (85-IS0075-14 and 85-IS0075-12).

Model 85-IS0075-12 was found to be functioning as expected during testing and did not present a failure mode. Therefore, Ginna is not affected by this component.

Regarding model 85-IS0075-14, dielectric testing was performed and the apparent source of the failure was a short-circuit between the secondary coil of the transformer and the magnetic shunts and center leg of the transformer core. The suspected cause of this short circuit is the design of the magnetic shunt. Various actions are being reviewed to enhance model 85-IS0150-14 specifically regarding the insulation system of the transformer around the coils and magnetic shunts. An updated report is expected to be completed in May/June.

Notified R1DO (Schussler), R2DO (Pearson), Part 21 Group (email)

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On February 28, 2025, the radiation safety officer (RSO) at Keck Hospital of University of Southern California, contacted the Los Angeles County Radiation Management office to report a possible medical event that occurred on February 27, 2025, during a Y-90 Therasphere radioembolization treatment of a liver cancer patient. The RSO indicated that due to abnormally high readings from the waste container associated with one of two dosage vials, he was unable to confirm the dosage administered to the patient. He sent the waste container to the vendor, Boston Scientific, for evaluation, in order to determine the administered dosage.

"On March 3, 2025, [the RSO] reported via e-mail that the patient was prescribed a total dose of 1300 Gy, but only 695.5 Gy was delivered during the treatment, which was attributed to the dosage from one of two dosage vials being stuck in the tubing. The underdosage meets the criteria for a reportable medical event. The incident did not cause any harm to the patient. Further analysis will be conducted by Boston Scientific to determine the reason for the dosage being stuck in the tubing."

CA Event Number: 022825

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.

EN Revision Imported Date: 3/12/2025

EN Revision Text: AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"The BRC received notification from Central Florida Testing Laboratories at 1500 EST 03/04/2025 of a missing Troxler soil moisture density gauge (8 mCi Cs-137, 40 mCi Am-241/Be). The transporter was returning to the storage location from a worksite when they were notified by another driver at a stoplight that something fell out of the vehicle. When [the transporter] turned around to see what had fallen, they noticed the gauge was no longer in the back of the vehicle. [The transporter] retraced their steps, returning to the worksite, and could not locate the gauge. The last confirmed possession of the gauge was at approximately 1030 EST on 03/04/2025."

Florida incident number: FL25-021

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 IODINE-125 SEED

The following information was provided by the Wisconsin Department of Health Services, Radiation Protection Section (the Department), via phone and email:

"On February 7, 2025, the Department received a notification that Gundersen Clinic, Ltd (the licensee) was unable to locate a radioactive seed containing a maximum of 100 microcuries of iodine-125. The seed was identified by the licensee as missing on February 4, 2025. The licensee completed an investigation by February 7, 2025, and submitted a written report to the Department. The licensee determined that the seed was likely disposed of as non-radioactive waste following the successful implantation of other seeds. The exact date of the disposal is unknown, but the licensee determined it occurred between November 20, 2024, and February 4, 2025, which are dates when the licensee's seed inventory was fully reconciled. The Department performed a reactive inspection on February 27, 2025, and considers this event closed. The seed is an IsoAid model IAI-125A from lot number 95130; the seeds are not assigned individual serial numbers."

Wisconsin event report ID: WI250002

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 - ELUATE EXCEEDED PERMISSIBLE CONCENTRATION

The following information was summarized from an email submitted by the Kentucky Department of Radiation Control:

An eluate exceeded the permissible concentration listed in 10 CFR 35.3204(a) at the time of generator elution. The permissible concentration cannot exceed a ratio of 0.15 microcuries of molybdenumm-99 per millicurie of technetium-99m. The eluate measured 34.6 microcuries Mo-99 to 16.6 millicuries Tc-99m which is a ratio of 2.1.

No doses went out to patients from this elution. The generator had been eluted earlier in the week without incident.

The manufacturer of the generator (Curium, lot number 914-025-023) was notified. The generator has been segregated awaiting return to Curium.

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the Massachusetts Division of Radiation Control, Bureau of Climate and Environmental Health (the Agency), via email:

"On 3/5/2025 at 1549 EST, QSA Global, Inc. notified the Agency that a source imported from India was leaking. QSA Global performed two leak tests on the source upon receipt. The results of the leak tests were 0.008 micro-curies and 0.004 micro-curies. QSA Global confirmed that no contamination exists outside of the container where the source is stored."

"Isotope: Co-60
"Source model number: A424-13
"Source serial number: 102732(B)
"Form: sealed source
"Activity: 13 Ci

"The reporting requirement is immediate [per] 105 CMR 120.288, reports of leaking or contaminated sources."

AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

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

"On March 5, 2025, the Department was notified by Honeywell International Inc (the licensee) that prior to performing maintenance on a vessel, it was found that the shutter on an Ohmart model SH-F2 gauge was stuck in the open position. Open is the normal position for the gauge. The gauge contains a 375 millicurie (original activity) cesium-137 source. The licensee reported that a service provider has been contacted, and the gauge should be repaired by March 7, 2025. The licensee reported the area around the vessel the gauge is mounted to has been isolated and posted 'No Entry'. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."

Texas incident number: 10178
NMED number: TX250015