Event Notification Report for June 13, 2025

AGREEMENT STATE REPORT - SOURCE UNABLE TO BE RETRIEVED

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

"On June 5, 2025, LDEQ was notified by CF Industries Nitrogen, LLC that, while retracting the source cable during an outage, one source came off the cable and remains inside the reactor. The facility was retracting a Berthold Model P2608-100, serial number LB 7674, with three cobalt-60 sources on the cable. Two sources were retracted and secured. One source came off the cable and remains inside the reactor. There were no radiation exposures to personnel.

"Berthold has been called to perform a source retrieval for the source inside the reactor. The facility is in a shutdown and there is a lockout tag-out in place until the source is retrieved. The disconnected source activity is one of either three sources: 197.3 mCi, 120.3 mCi, or 106.8 mCi. The source serial numbers are 41-01-15, 42-01-15, and 43-01-15."

Louisiana Event Number: LA20250004

AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following is a summary of information provided by the Kentucky Department of Radiation Control (the Department) via email:

The Nelson County Emergency Management Agency reported that two blue containers were discovered in a rural location with radioactive material markings. The Department investigated and found the containers were lead pigs from August 6, 2024 which held decayed F-18 positron emission tomography doses. The containers were assayed, and no removable contamination was found on the packages. All radiation readings showed no levels above background.

The Department took custody of the materials and will investigate both the vendor listed on the package as well as the hospital. Local fire and law enforcement responded to the incident.

AGREEMENT STATE REPORT - STUCK OPEN GAUGE

The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:

"The licensee informed the Department via telephone on June 5, 2025, that a fixed gauging device was disabled or failed to function as designed. The licensee reported that a sealed source was stuck (exposed) in a dip tube assembly that was attached to a process vessel. The licensee reported that a representative from a licensed service provider was on-site and was able to remove the sealed source from the dip tube assembly and place the sealed source into a transport shield.

"The sealed source is a 9 millicurie cobalt-60 Berthold Technologies USA, LLC Model P2608-100.

"The licensee did not report any overexposures or ongoing health/safety concerns.

"This event is still under investigation by the Department."

South Carolina Event Report ID Number: TBD

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via phone and email from the South Carolina Department of Health and Environmental Control (the Department):

"The licensee informed the Department via telephone on June 6, 2025, that a medical event had occurred on June 5, 2025. The licensee reported that a Y-90 microsphere procedure resulted in 71 percent of the prescribed dose being administered to a patient (a difference of 29 percent), and that a spill also occurred during the administration. The licensee is reporting that the spill originated from the delivery system and likely caused the medical event.

"The licensee reported that the spill in the administration area was cleaned, and the area was released. The licensee is not reporting any overexposures or ongoing health or safety concerns. The referring physician was notified on June 6, 2025. This event is still under investigation by the Department."

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.

South Carolina Event Report ID Number: TBD

MEDICAL EVENT

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

On June 6, 2025, a technologist injected Tc-99m Pertechnetate into the nebulizer instead of Tc-99m DTPA (diethylene-triamine-pentaacetate) for a lung perfusion ventilation study. The patient was an 11-year-old child with a weight of 61 lbs. (27.72 kg). The nuclear medicine technologist grabbed the wrong syringe and did not verify the information on the label before injecting into the nebulizer. The technologist has been advised by the physician on the need to ensure the labeling is correct prior to injection or use and to verify that it contains the correct compound for the correct study. The patient's family and the referring physician have been notified.

Initial indications of patient dose was 63.9 rem whole body (due to Tc-99m pertechnetate) with an initially prescribed activity of 18 mCi (Tc-99m DTPA) to the lungs. No indication of acute blood changes or radiation sickness. The licensee does not intend to call REAC/TS.

* * * RETRACTION ON 06/10/25 AT 1435 EDT FROM DAVID RHOE TO KERBY SCALES * * *

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

"The original dosimetry estimate has been revised and indicates no organ dose exceeds the 50 rem limit or the 5 rem effective dose. The dose that was reported as 63.9 Rem was meant to be for an organ dose and not whole body. After much assistance from the NRC staff, a revised dosimetry estimate has been performed.

"The estimate was performed using the MIRDcalc program with the dose of 18 mCi Tc-99m for a 10-year-old female."


Notified R1DO (Warnek), NMSS (Allen), and NMSS Events Notification via email.

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.

PART 21 - THERMAL SLEEVE DEFECT

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

The affected component is the thermal sleeve in the control rod drive mechanism (CRDM) penetration tube in the replacement Reactor Vessel Closure Head (RVCH) provided to the Callaway plant in 2014. The reportable defect is the unanticipated wear rate of the CRDM thermal sleeve flanges supplied to Callaway as part of the replacement RVCH that was installed in the fall of 2014.

During the Callaway refueling outage in the spring of 2025, the thermal sleeve at location H08 was found resting on the upper internals. A ring shaped remnant of the thermal sleeve flange had become separated and was present in the CRDM adapter.

Measurements were performed on the remaining CRDM thermal sleeves to determine the amount of thermal sleeve descent from the nominal design configuration. Descent distances ranged from 0.03 to 1.7 inches, with four thermal sleeves having descent of 0.9 inches or more.

The failure of a thermal sleeve resulting in a detached flange segment can impact the performance of the corresponding CRDM with the potential to impede or prevent control rod insertion. This issue was first reported under 10 CFR 21 by Westinghouse.

Since the identification of the thermal sleeve flange wear issue by Electricite de France (EdF) in 2018, Framatome is unaware of any instances of a control rod failing to insert due to CRDM thermal sleeve events, even at plants which have experienced multiple locations with complete thermal sleeve flange separation.

Framatome is conservatively making this notification because the undetected simultaneous failure of multiple thermal sleeves could potentially create a safety hazard if multiple control rods fail to fully insert.

Although the causal analysis in still in process, Framatome has reviewed the other replacement RVCHs supplied by Framatome to the US fleet and have not identified any other plants which contain an equivalent combination of conditions that would indicate the potential for accelerated thermal sleeve flange wear.

For the other US plants with Framatome supplied replacement RVCHs with thermal sleeves, Framatome will provide a notification to continue using the current and future inspection guidance published by industry bodies.

Affected plants: Callaway Energy Center

Framatome Contact Information:

Gayle Elliott
Director, Licensing Regulatory Affairs
Framatome Inc.
gayle.elliott@framatome.com