Event Notification Report for April 14, 2025

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

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

"On April 4, 2025, the Department was notified by the licensee of a telephonic overexposure report they received from their dosimetry provider. The licensee radiation safety officer stated the report had one of their employees with an exposure of 7.7 rem for the month of February 2025. The licensee had other readings (pocket dosimeters) that did not match this level of exposure. The licensee removed the employee from the work environment until the dose can be confirmed. The employee affected is an assistant, and neither of the other two radiographers had any exposure near this level. The licensee is still investigating.

"More information will be made available according to SA-300 requirements."

Texas incident number: 10189
NMED number: TX250022

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the North Carolina Radioactive Materials Branch via email:

On April 4, 2025, Y-90 SIR-spheres therapeutic split dose administration resulted in a patient being underdosed per the written directive. One of three doses administered was 27 percent or less of the prescribed dose. The referring physician and patient were notified on the same day of treatment. The cause of the underdose was a catheter clog or kink. Corrective actions consisted of retraining of personnel.

NC Event Number: 250004

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.

STUCK OPEN GAUGE SHUTTER

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

The licensee discovered a stuck-open shutter during routine checks on a gauge with a normally open shutter. The gauge is a Berthold model LB444 with a 500 mCi Cs-137 source. The area around the gauge has been flagged and there are no concerns about radiation exposure. The manufacturer will be contacted to repair the gauge.

* * * UPDATE ON 04/09/2025 AT 1257 EDT FROM DUSTIN SMITH TO JORDAN WINGATE * * *

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

The licensee has been in contact with Berthold technologies, who will be sending a technician to repair the gauge. A finalized date has not yet been confirmed. Additional information will be provided as it becomes available.

Informed R1DO(Schussler) and NMSS Events Notifications (email).

UNPLANNED CONTAMINATION EVENT

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

During an ongoing inspection, the licensee determined that the following event had not been previously reported.

On March 29, 2024, at approximately 1800 EDT, a rejected batch of individual lead pots containing glass vials of Pluvicto (Lu-177) solution was being logged into the waste room. Each dose of Pluvicto was 5ml with an activity between 7 to 12 GBq.
An individual handling the lead pots accidentally lifted a lead pot by the lid instead of the bottom. The lead pot was taped shut but the tape failed, and the vial was dropped, breaking on the floor of the waste room. The individual's clothes were contaminated but no skin contamination occurred. Based on dosimetry records the individual has a current lifetime exposure of 1 mrem of deep-dose equivalent, 2 mrem of lens dose equivalent, 2 mrem of shallow-dose equivalent, and 11 mrem to the extremity.
The spread of contamination was limited to the radioactive waste room and the individual's clothing. The radiation safety officer secured access to the radioactive waste room for approximately 48 hours while room decontamination efforts were in progress.

UNUSUAL EVENT - LOSS OF ALL BUT ONE AC POWER SOURCE TO EMERGENCY BUSES

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

"On 4/10/2025, Unit 1 was defueled at 0 percent power. The `A' train class bus was being powered by the `A' diesel generator (DG) and the `B' train bus was out of service for maintenance. Additionally, the `A' train offsite power transformer is currently out of service for maintenance. Abnormal indication was observed on the `A' DG with lowering voltage and the decision was made to manually trip the `A' DG.

"Power was restored to the `A' class bus by crosstieing `B' train offsite power via engineering safety feature transformer NBN-X04. This resulted in a loss of all but one AC power source to emergency buses for 15 minutes or longer which is an Unusual Event (UE) CU2.1. It is currently not known at this time what caused the abnormal voltage indications on the `A' DG."

State and local agencies were notified. The NRC Resident Inspector has been notified.

Notified DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC, DHS Nuclear SSA (email), CWMD Watch Desk (email).

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

Palo Verde Units 2 and 3 were not affected by this event. The licensee restored spent fuel pool cooling.

* * * UPDATE ON 4/10/2025 AT 1701 EDT FROM TANNER GOODMAN TO SAMUEL COLVARD * * *

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

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to the event or alters the information being provided at this time, a follow up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"Train `A' emergency diesel generator (DG) was supplying power to PBA-S03 bus. At 0658 MST on April 10th, 2025, train `A' DG was exhibiting erratic and degraded voltage and was placed in emergency stop, which caused a loss of power to PBA-S03.

"When the `A' DG was stopped, train `A' balance of plant engineered safety features actuation system (BOP ESFAS) detected the loss of power condition on PBA-S03, and sent an emergency start signal to the train `A' DG. Train `A' DG did not respond as it was placed in emergency stop. Operators restored power to PBA-S03 at 0703 MST. At the time of the [loss of power], the reactor was defueled with the core offloaded to the spent fuel pool. Unit 2 and Unit 3 are not impacted by this event and remain in Mode 1, 100 percent power. Unit 1 is still currently in Unusual Event, CU2.1

"This [update] is in addition to the event reported at 1029 EDT EN 57659. The original EN reported an Emergency Classification definition as a loss of all but 1 AC power source to emergency buses for 45 minutes. The correct time is 15 minutes.

"The NRC Senior Resident Inspector has been notified of the update."

[This update is an 8-hour, non-emergency, 10 CFR 50.72(b)(3)(iv)(A) report of a valid specified system actuation due to the BOP ESFAS attempting to start 'A' DG upon loss of the PBA-SO3 bus during the initial event.]

Notified R4DO (Vossmar).

* * * UPDATE ON 4/10/2025 AT 2245 EDT FROM NGOC NGUYEN TO SAMUEL COLVARD * * *

The following information was provided by the licensee via phone:

On 4/10/2025, at 2224 EDT, Palo Verde Unit 1 terminated the Unusual Event. Restoration of 'A' DG was made by swapping to its redundant automatic voltage regulator and performance of a functional startup. This restores two sources of power to the class 1E bus: offsite power and 'A' DG in a standby configuration. The redundant automatic voltage regulator was tested in surveillance in the previous cycle and remains operable. The issues that led to the declaration of Unusual Event with 'A' DG have been entered into the corrective action program.

State and local authorities have been notified. The NRC Resident Inspector has been notified.

Internal notifications: R4DO (Vossmar), NRR EO (Felts), IR MOC (Crouch), R4 RA (Monninger), NRR (King), R4 PAO (Dricks), and NSIR (Erlanger)
External notifications: DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC, DHS Nuclear SSA (email), CWMD Watch Desk (email)

FITNESS FOR DUTY

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

"On April 10, 2025, at 1124 CDT, a licensed operator at Arkansas Nuclear One, Unit 1, had a confirmed positive result for alcohol during random testing per the Entergy fitness for duty (FFD) program. The individual's unescorted access has been terminated. This event is being reported under 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been informed."

SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS

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

"During a planned shutdown at Columbia Generating Station for a refueling outage, pressure boundary leakage was identified from the bonnet vent line of loop `B' discharge motor operated isolation valve during a drywell inspection. Leakage was initially identified during a drywell entry at 15 percent [reactor] power and identified as pressure boundary leakage during a subsequent entry in mode 3. The leak exceeds technical specification (TS) 3.4.5 'RCS Operational Leakage' of no pressure boundary leakage. TS action `C' was entered, requiring [the plant to be in] mode 3 in 12 hours and mode 4 in 36 hours. Columbia Generating Station was in mode 3 at time of determination for [entering TS] 3.4.5. Therefore, the event is reportable within 4 hours per 10 CFR 50.72(b)(2)(i) due to the initiation of a plant shutdown required by the plant's TS.

"The event is also reportable within 8 hours per 10 CFR 50.72(b)(3)(ii)(A) due to an event that resulted in the condition of the nuclear power plant, including principal safety barriers, being seriously degraded."

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

The NRC Resident Inspector has been informed. Columbia Generating Station estimates the leak rate to be less than 0.2 gallons per minute. Columbia Generating Station expects to enter mode 4 within the required 36 hours.