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Federal

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Licensee Name

Site Name - City Name State Cd

Report Date Notification Dt Notification Time

Event Date Event Dt Event Time

Event Text

--------------------

Westinghouse Electric Corporation

Westinghouse Electric Corporation - Columbia SC

Report Date 11/02/2022 11:12:00

Event Date 11/01/2022 11:29:00

EN Revision Imported Date: 4/5/2024

EN Revision Text: UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS

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

Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.

This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.

This issue has been entered into the licensee's corrective action program as IR-2022-9728.

* * UPDATE ON 09/13/23 AT 1219 EDT FROM STEPHEN SUBOSITS TO THOMAS HERRITY * * *

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

On 9/12/2023, while offloading additional barrels of Hematite Ash from the the 2003 shipment, A URRS operator identified that the tag for a drum showed the contents have a higher enrichment than that which is recorded in the Chemical Area Manufacturing and Process System (ChAMPS) and on the original paperwork provided by Hematite Fuel Operations. The unloading activity was stopped, and URRS Management and Nuclear Criticality Safety were notified. The unopened pail was placed back in the drum and the drum was segregated from other items in the area. Environmental Health and Safety requested that the remaining seven drums be opened and the contents tag for each be checked against the information in ChAMPS and the original paperwork from Hematite Fuel Operations. This was done.

This report is conservatively being made as an update to Event Notification 56199 under reporting criterion 10 CFR 70 Appendix A (b)(1) as an event that resulted in the facility being in a state that was not analyzed in the Integrated Safety Analysis, and resulted in a failure to meet the performance requirements of 10 CFR70.61 similar to the 9 drums of Hematite Ash that were discovered in November 2022 due to it being an unanalyzed condition.

Westinghouse believes it is likely that the enrichment listed on the tag of the drum is inaccurate. The issue has been entered into the corrective action program as IR-2023-8953.

Notified R2DO (Endress) and NMSS_EVENTS via email.

* * * RETRACTION ON 04/04/24 AT 1035 EDT FROM STEPHEN SUBOSITS TO JOSUE RAMIREZ * * *

The following information was provided by the licensee via email:

"In response to the discovery of the Hematite Ash material with a U-235 enrichment that was potentially greater than 5 percent U-235, Westinghouse submitted two sequential license amendment requests which were approved by the NRC in May 2023 and October 2023, respectively. The first license amendment permitted possession and storage of the drums containing the ash material in a safe configuration. The second license amendment approved sampling, analysis, and blending, if necessary, of the ash material.

"After receipt of the second license amendment, Uranium Recovery and Recycle Services personnel sampled the drums of suspect ash material, and laboratory personnel performed the analyses of the samples taken to determine U-235 content. Analytical results were less than 4.265 percent U-235 for all of the samples taken. The results confirmed the ash materials were within the license limit for percent U-235, and as a result, blending with lower enrichment materials to meet the license limit was not necessary.

"Westinghouse is retracting Event Notification 56199 based on the sample results of the Hematite Ash material being less than 5 percent U-235 and the resultant conclusion that the facility was not in an unanalyzed condition state. 10 CFR 70.61 performance requirements were met for the Hematite Ash material based on the nuclear criticality safety controls that were documented and in place for material less than 5 percent U-235."

Notified R2DO (Miller) and NMSS_EVENTS via email.

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Exelon Nuclear Company, Llc

Dresden - Morris IL

Report Date 11/20/2023 17:53:00

Event Date 11/20/2023 9:56:00

EN Revision Imported Date: 4/8/2024

EN Revision Text: HPCI DECLARED INOPERABLE

The following information was provided by the licensee via email:

"At 0956 [CST] on November 20, 2023, accumulated gas was identified in the Dresden Unit 2 high pressure coolant injection (HPCI) system discharge header. As a result, the HPCI system was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The HPCI system was subsequently vented, and the accumulated gas has been removed, restoring the Dresden Unit 2 HPCI system to an operable status. All other emergency core cooling systems remained operable during this time period.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee administratively verified the isolation condenser was operable after declaring HPCI inoperable as required by technical specifications. The licensee stated there was no increase in plant risk. The cause of gas accumulating in the Dresden Unit 2 HPCI discharge header is under investigation, and this issue has been entered into the licensee's corrective action program.

* * RETRACTION ON 4/5/2024 AT 1544 EDT FROM JON CHAPMAN TO IAN HOWARD * * *

"Further analysis demonstrated that the Unit 2 high pressure coolant injection (HPCI) system remained operable with the level of voiding found in the HPCI discharge line. This analysis also found that the additional loads that would be present if the HPCI system were actuated with this level of voiding are within design limits of the HPCI system piping and supports.

"Based on these results, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D), `Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' Therefore, EN 56866 submitted on November 20, 2023, is being retracted.

"The NRC Resident Inspector has been notified."

Notified R3DO (Havertape)

--------------------

NRD, LLC

New York State Dept. of Health - Grand Island NY

Report Date 11/22/2023 12:17:00

Event Date 11/19/2023 0:00:00

EN Revision Imported Date: 4/12/2024

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE The following information was provided by the New York State Department of Health (the Department) via email:

"New York State (NYS) Department of Heath received an email from the radiation safety officer (RSO) of NRD, LLC regarding an employee entering a restricted zone (Silver Recovery) without use of proper personal protective equipment (PPE) and respiratory protection on Sunday, November 19, 2023. Staff at NRD were made aware of this on November 20, 2023, at 1145 EST. The individual entered the restricted area to conduct non-authorized work, which was performed for 20 minutes in a 12 DAC-hr environment based on continual air monitor (CAM) readings at this time. The individual did not wear proper respiratory equipment, nor did they use a personal (lapel) air sampler, which is a PPE requirement for this zone. The individual later donned proper PPE and respiratory protection and continued to work for a total working time of 2 hours. The nature of work that was being conducted is unknown by the Department at this time.

"As the individual did not perform nasal swabs or have personnel air monitoring estimated doses were assumed using the 12 derived air concentration-hour (DAC-hr) environments based on the CAM. The assumptions in preliminary calculations assume a 2-hour working time to be conservative, which shows 24 DAC Hours (2 percent) of intake for the most limiting isotope (Am-241). Individual has been placed on bioassay urine collection and has had authorizations and security removed. NRD will be notifying the Department of these results and more information as it becomes available. This worker has received one bioassay for urinalysis and has been terminated from employment by NRD, LLC.

"NRD, LLC contacted the Radiation Emergency Assistance Center/Training Site (REAC/TS) regarding this event as a precaution to inquire on the potential supply of Diethylenetriamine pentaacetate (DTPA) for chelation therapy. The affected individual involved in this event has apparently refused to cooperate with REAC/TS. The results of this bioassay will be used to determine if an overexposure event has occurred for this individual where possible."

* * * UPDATE ON 4/11/24 AT 1404 EDT FROM DANIEL SAMSON TO KAREN COTTON * * *

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"An individual (employed by NRD, LLC) did not wear proper respiratory equipment, nor did they use a personal (lapel) air sampler, which is a personal protective equipment (PPE) requirement for this zone. The individual later donned proper PPE and respiratory protection and continued to work for a total working time of 2 hours. The nature of work was discovered to be the removal of an induction furnace from within a glovebox previously used for precious metal recovery/recycling. The work performed was planned to be performed by NRD, LLC later in the week using pre-approved protocols and procedures. However, the individual in question decided to perform the work on the weekend without following required approved safety protocols and without the knowledge of NRD, LLC.

"Nasal swabs were not collected for the individual in question. However, a single bioassay (24-hour cumulative urine sample) was collected following NRD, LLC's awareness of the event. The 24-hour cumulative urine bioassay analysis showed undetectable levels of Am-241 and Po-210- the two target isotopes of concern during this incident. Noteworthy to the analysis of this data, only one bioassay sample was collected as the individual was terminated shortly after NRD, LLC's awareness of this event. NRD, LLC contacted REAC/TS (Radiation Emergency Assistance Center/Training Site) regarding this event as a precaution to inquire on the potential supply of DTPA (Diethylenetriamine pentaacetate) for chelation therapy. The affected individual involved in this event had apparently refused to cooperate with NRD, LLC or REAC/TS. No doses of DTPA or other chelation agents were administered to the individual following this event. However, provided the assumed intake by this individual, clinical intervention was not likely necessary.

"New York State Department of Health (NYSDOH) performed an unannounced reactive inspection on 12/13/2023 and 12/14/2023 to investigate the circumstances leading to and following this event. Since the bioassay data showed undetectable levels of both Am-241 and Po-210, a comparison to air sampling data was also conducted. Information provided (security camera footage) compared with ambient air concentration data on a continual air monitor (CAM) indicates that the average air concentration was approximately 12 DAC-hrs (assuming Am-241, most limiting ALI) for the 20-minute duration in which this individual was performing work without PPE. This would constitute approximately 100 mrem CDE to the bone surfaces for Am-241 (approximately 0.2 percent Annual Limit CDE for Am-241 to the Bone Surfaces). Since the CAM was placed next to the location where this work was conducted, a rough/conservative estimate to determine potential dose incurred by the individual assumes that there was a uniform distribution of aerosolized Am-241 in an environment 6x higher for the worker than what was recorded near the CAM based on prior lapel air sampling data for performing this type of work. From performing this work without PPE, it would be estimated that this individual could have approximately 600 mrem CDE to the bone surfaces for Am-241 (approximately 1.2 percent Annual Limit CDE for Am-241). Based on information provided and observed, this would expect to be an overly conservative assumption, as the individual appeared to minimize hands-on work during the 20-minute duration without PPE. Expected doses incurred from this intake, if any, would be expected to fall well below 600 mrem CDE to the bone surfaces-based observations by NYSDOH staff performing the reactive investigation. This is further reinforced by the single 24-hour bioassay sample, which provides some additional confidence that these estimates may be overly conservative.

"Following this event and investigation, NYSDOH made numerous attempts to contact the individual in question. All attempts by NYSDOH to contact this individual were unsuccessful.

"The reactive inspection performed by NYSDOH resulted in observations of noncompliance and notices of violation issued to NRD, LLC. NRD, LLC has and will continue to implement corrective actions following this event. NYSDOH will be evaluating all corrective actions on the next inspection.

"Given the lack of information available at the time of original notification, NYSDOH opted to report this information out of an abundance of caution in the event this individual in question may have received in intake, caused an event leading to excessive airborne or surface contamination, or participated in an event which may have met the reportability criteria to NMED. Given the information provided, NYSDOH has closed Incident No. 1464."

Notified R1DO (DeFrancisco), NMSS Day Coordinator (Roberts), and NMSS Events Notification (email)

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INEOS

Illinois Emergency Mgmt. Agency - Joliet IL

Report Date 02/29/2024 13:22:00

Event Date 02/28/2024 0:00:00

EN Revision Imported Date: 4/30/2024

EN Revision Text: AGREEMENT STATE - STUCK SHUTTER

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

"The radiation safety officer (RSO) for INspec Ethylene Oxide and Specialities (INEOS), IL-01337-01, contacted the Agency on 2/28/24, to advise that a fixed gauge was found to have a shutter stuck in the `open' position. The impacted gauge is a Ronan Engineering model X90-SA1-F37, serial number M7388 containing 40 mCi of Cs-137. The device shutter is normally in the `open' position and was only found to be `stuck' during the routine six-month shutter checks. It had likely been in this condition for at least six months. The product vessel that it faces is full of commodity and will remain full for the foreseeable future. Aside from being full of commodity, the vessel is also equipped with locking mechanisms preventing any personnel access.

"Agency staff will be on site in the coming weeks."

NMED Item Number: IL240006

* * UPDATE ON 4/30/24 FROM W. COX TO T. HERRITY * * *

Agency inspector was on site 3/20/24 while Ronan was there to repair the gauge. The gauge was successfully repaired. This matter is now closed.

Notified R3DO(Betancourt-Roldan) and NMSS Events via email.

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Kirtland Air Force Base

Kirtland Air Force Base - Albuquerque NM

Report Date 03/05/2024 14:17:00

Event Date 03/05/2024 10:00:00

EN Revision Imported Date: 4/19/2024

EN Revision Text: STUCK IRRADIATOR SOURCE

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

At 1000 MST on 3/5/24, a 10,000 Ci Co-60 source (Model 7810) became stuck in the unshielded position during operator training. The irradiator is a J.L. Shepherd, Model SDF-34-M1, panoramic dry-source storage type. Upon determining that the source was stuck, the operator attempted to manipulate the source back into the shielded position using the emergency cable, but it came loose. Site staff have secured the irradiator facility.

No personnel exposure occurred, and there are no elevated dose rates outside of the irradiator enclosure. The site has requested manufacturer support to resolve the issue.

The NRC Project Manager (O'Keefe) has been notified.

* * UPDATE ON 4/18/24 AT 1508 EST FROM MAJ RYAN EISWERTH TO ADAM KOZIOL * * *

On 3/18/24, authorized users were able to return the source to a shielded position. A post-event inspection was scheduled during the week starting 4/22/24 with the vendor to verify operability of the irradiator.

At approximately 1000 MST on 4/18/24, while an authorized user was conducting a performance functional check in preparation for the scheduled inspection, the irradiator source again became stuck in an unshielded position.

The irradiator had not been used since the initial report on 3/5/24. No personnel exposure occurred, and there are no elevated dose rates outside of the irradiator enclosure. The site has requested manufacturer support to resolve the issue.

Notified R4DO (Young), IRMOC (Crouch), and NMSS Events (email).

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Alton Steel

Illinois Emergency Mgmt. Agency - Alton IL

Report Date 03/08/2024 13:02:00

Event Date 03/07/2024 0:00:00

EN Revision Imported Date: 4/17/2024

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGES

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"On March 7, 2024, the Agency was notified of equipment damage at Alton Steel in Alton, IL, that exposed two sealed radioactive sources. The licensee reported that molten steel flowed over Berthold Technologies source housings (source housing serial numbers 1197-10-21 and 601-05-12) and, despite trying to cool the steel, it damaged the source housings and exposed the sources. The Berthold Technologies sources are Co-60 and have an activity of 2.3 mCi each (source serial numbers 1200-10-21 and 600-05-12). The sources were removed from the housings by a licensed service provider and placed in secured storage. Leak tests are pending. The licensee determined there were no exposures to any personnel and that the incident does not pose a risk to any members of the public. Licensee surveys indicated no contamination, and radiation levels from these sources were comparable to those from an undamaged source. The Agency plans to conduct a reactionary inspection to verify the lack of contamination/exposure and accountability of licensed materials. This is a reportable event in accordance with 32 Ill. Adm. Code 340.1220(c)(2)."

Illinois Item No.: IL240008

* * UPDATE ON 3/13/24 AT 1625 EDT FROM GARY FORSEE TO ADAM KOZIOL * * *

"[On 3/8/24], another email update was received in which Alton Steel's licensed contractor advised another portion of the source rod had been located and was actively being cut from the molten steel. A conference call was immediately scheduled and the following information noted: The incident had actually taken place on 2/22/24 with no notification to the Agency. It was stated that the licensee's authorized user removed the damaged sources using pliers and placed them in secured storage but did not follow their approved emergency procedures to cease work and rope off the area at 20 feet. The licensee contacted their consultant (R.M. Wester), and they were on-site the same day. R.M. Wester personnel surveyed the area and assumed there was no contamination because they were getting the expected radiation levels. At that time, the consultant recommended that the licensee contact the manufacturer (Berthold) to come out and further evaluate the sources and devices. The manufacturer was on-site on 3/7/24 and discovered that two source rods were damaged. The manufacturer's rep advised a call to the State was needed. He noted one source rod had been damaged to the point the internal Co-60/nickel wire was exposed. On the afternoon of 3/8/24, Alton Steel's licensed consultant surveyed the mold lid and found what they assumed to be the remaining portion of the source (exposure rate of 50 mR/hour). On 3/8/24, Alton Steel personnel used a torch to cut that portion of the source from the lid of the mold. This piece was also placed in secured storage. The lid was then surveyed by the consultant which he stated evidenced no further radioactive material. The two damaged sources, as well as the source rod fragment, are pending disposal. The Agency has requested that the lid and mold be held for surveys when Agency staff are on-site. Agency staff plan to be on-site 3/13/24 to further investigate. Leak tests from the consultant did not evidence removeable contamination in excess of 0.005 uCi. At this time, there is no indication of risk to workers or the public as all sources are in secured storage. The investigation is ongoing and updates will be provided as available.

"On Monday, 3/11/24, Agency staff conducted interviews with the Berthold service representative which conducted the service call. Information from that call indicated the licensee had cut through a source with a torch. At this point, Agency staff responded that morning to take surveys and interview Alton Steel staff. Survey readings were taken with a microR meter, which lacked the necessary sensitivity and were inconclusive due to [naturally occurring radioactive material] NORM and refractory material. Investigation findings indicate the licensee failed to follow emergency procedures, failed to follow operating procedures, failed to adhere to license conditions, received inadequate and incorrect training, improperly handled and manipulated sealed sources, failed to perform surveys, and failed to make timely notification to the Agency. The licensee's consultant also failed to notify the Agency, lacked sufficient knowledge of the sealed source and performed inadequate surveys. Additionally, it was discovered the licensee had used a 4 inch die grinder on one source, cut through another with an oxygen lance, had a practice of handling unshielded source assemblies and an inadequate radiation safety program.

"Agency staff arrived at the licensee's site again on 3/13/24 to perform additional surveys. Upon arrival, the licensee stated they had found yet another piece of the Co-60 rod source under the spray booth that washes down the cast billets. This was reportedly the area below where the source was first cut with a torch. The Agency confirmed the licensee was aware of the source when using the torch and did not perform surveys or alter operations. The second source which was found to be damaged had also been inadvertently withdrawn from its shielded housing when the molten steel overflowed atop the mold cap. However, the second source immediately fell into two pieces, apparently suffering damage within the housing. That source was reportedly burnt/melt and would not fit into the shield. A licensee gauge user then used a 4 inch angle grinder to smooth out the source so it would fit back into the shield. Agency staff investigated all areas accessible (some areas were inaccessible due to molten steel). A portable germanium spectrometer was employed to discern if elevated count rates were from NORM or Co-60 contamination. Preliminary findings indicate at least two areas adjacent to the vise (where grinding had occurred) had Co-60 contamination. Samples were collected for lab analysis and additional area surveys performed. The [Illinois Emergency Management Agency - Office of Homeland Security] IEMA-OHS lab reported on the afternoon of 3/13/24 that samples did evidence Co-60 contamination. The Agency covered the contaminated area and required it to be posted. Additional surveys will be taken once accessible, to include the wash-down water sedimentation areas. A full survey and remediation plan will be required by the end of the month. Decontamination efforts will be undertaken by a qualified contractor and the Agency will perform verification surveys to support release. Updates will be provided as they become available."

Notified R3DO (Hills), IR MOC (Crouch), NMSS (Williams), NMSS Events (email) Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), Nuclear SSA (email), FEMA NWC (email), CWMD Watch Desk (email)

* * UPDATE ON 3/18/2024 AT 1440 EDT FROM GARY FORSEE TO SAM COLVARD * * *

"On 3/15/2024, the Agency dispatched seven inspectors to perform comprehensive surveys of the facility, characterize exposures, and determine if additional fragments of the source remained unaccounted for. Inspection findings indicate that there is Co-60 contamination within a single room (mold repair room) at Alton Steel. The licensee has secured the room and implemented contamination control procedures. Updated procedures and training were implemented on Friday, March 15, 2024. Extensive Agency surveys of the facility and personnel performed on 3/15/2024 indicate that the contamination is not being carried offsite; nor was there any indication of public exposures. There is no contamination of water. Contamination of the product (steel) has not been identified; nor is it likely to be a concern resulting from this incident.

"Due to improper handling of sources, it is likely a gauge user received an extremity dose in excess of regulatory limits. Time-motion study will be performed to refine dose estimates and substantiate.

"ONS-RAM is investigating additional, chronic internal exposures to Co-60 which have likely occurred over many years. ONS-RAM will return to the site on 3/20/2024 to evaluate the efficacy of contamination control measures, determine the timeline for remediation activities and perform additional sampling/surveys to better quantify exposures and determine the appropriateness of bioassays. This report will be updated as additional information becomes available."

Notified R3DO (Hills), NMSS (Williams), NMSS Events (email), NMSS Regional Coordinator (Rivera-Capella) (email)

* * UPDATE ON 4/4/2024 AT 1322 EDT FROM GARY FORSEE TO TENISHA MEADOWS * * *

The following is a summary of information received from the Illinois Emergency Management Agency (the Agency) via email:

The Agency conducted additional site visits on 3/15, 3/21 and 3/29. The following updated assessment is available:

Contamination and Radioactive Material Accountability: Inspection findings indicate the licensee has used grinders/wire wheels on licensed sources to remove solidified steel both in response to this incident and others. In at least two instances, the grinding has penetrated the stainless-steel capsule and impacted the internal Co-60 wire. This led to contamination in the area referred to as the "mold repair room". Activities giving rise to this contamination and occupational exposures have been identified and ceased. Both can be traced back to inadequate training and a failure to follow operating/emergency procedures. Additional surveys, wipes and air sampling activities performed by the Agency indicate the Co-60 contamination is isolated to the "mold repair room" and is not being re-suspended, distributed throughout the facility or rendered available for inhalation/ingestion. Personnel and vehicle surveys have indicated no contamination. Surveys of locker rooms, bathrooms, elevators, adjacent areas, water circulation and sedimentation systems have all indicated no contamination. The licensee is working with a licensed service provider to perform characterization surveys and mobilize for proper remediation of the area. In the interim, the licensee has implemented appropriate access controls, personal protective equipment (PPE), surveys and additional contamination control measures. Working with the manufacturer, the Agency estimates a combined 328 microCi of Co-60 remains unaccounted for from the two damaged sources. At this point, licensee and Agency surveys limit the likelihood the fragments remain on site on the casting deck, spray down chamber or the resulting collection systems. On 3/29/24, the pathways in which the source fragments could be re-introduced into cast billets was investigated. However, the Agency surveys performed on 3/29/24 of billets representative from heats conducted after the incident date as well as the resulting roll-formed products; all yielded radiation readings consistent with background.

Occupational Exposures and Contamination: Agency inspectors confirmed estimates of exposure which led to an employee exceeding the annual occupational limit for an extremity (114 rem to the hands). The employee has ceased work with radioactive materials for the year. Inadequate training and failure to follow operating procedures are causative for improper handling and damaging sources. In addition, the improper handling of sources is due, in part, to an unauthorized modification of the sealed source, dated shielding assemblies and repeated physical damage/fouling of the threads atop the sealed source.

Based on all information available to the Agency, this is the most likely disposition of the 328 microCi of Co-60. While the sheer volume of the pile, size of the casting remnants and shielding afforded to the 328 microCi of Co-60 is unlikely to yield productive surveys; Agency staff will evaluate on 4/8/24. The Agency will continue to assess contamination control measures and evaluate the licensee's contracted characterization surveys and remediation activities. The Agency will review proposed remediation goals, evaluate the resulting remediation plan, and perform verification surveys once the final status survey is received. Appropriate enforcement action and updating of the license is pending.

Notified R3DO (Edwards), NMSS (Williams), NMSS Events (email), NMSS Regional Coordinator (Rivera-Capella) (email)

* * UPDATE ON 4/16/24 AT 1700 EDT FROM GARY FORSEE TO KERBY SCALES * * *

The following is a summary of information received from the Illinois Emergency Management Agency (the Agency) via email:

The Agency conducted additional site visits on 4/5/24 and 4/8/24. Agency inspectors confirmed estimates of exposure which led to an employee exceeding the annual occupational limit for an extremity of 95 rem to the hands, not 114 rem as previously reported. The Agency will continue to assess contamination control measures and evaluate the licensee's contracted characterization surveys and remediation activities. The Agency will review proposed remediation goals, evaluate the resulting remediation plan, and perform verification surveys once the final status survey is received.

Pending no further developments and proper remediation of the impacted room; this incident report is considered closed.

Notified R3DO (Betancourt-Roldan), NMSS (Williams), NMSS Events (email), NMSS Regional Coordinator (Rivera-Capella) (email).

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

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MERCYONE DES MOINES MEDICAL CENTER

Iowa Department of Public Health - Des Moines IA

Report Date 03/19/2024 17:53:00

Event Date 03/18/2024 0:00:00

EN Revision Imported Date: 4/5/2024

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO UNPLANNED SITE

The following was received from the Iowa Health and Human Services (HHS) via email:

"On 3/19/2024, MercyOne Des Moines Medical Center reported an equipment failure involving a Best Vascular Inc. A1000 series intravascular brachytherapy device, and a 2.16 Gbq (58.4 mCi) strontium-90 source that occurred on 3/18/2024.

"The initial attempt to send the source train failed to reach the dwell position and stopped short of the treatment area by about 30 millimeters. After the authorized user's (AU) attempts to try and increase pressure to send the sources further to the treatment area failed, the licensee decided to return the source to the device. There was a small delay in the source returning, because there was a slight bend in the catheter, and it seemed that was impeding the water pressure to push the source back. The licensee straightened the catheter a little bit, and when they did the source train returned to the device. At that point, the licensee disconnected and reconnected the catheter to try again and the source train again stopped in the same exact place. The licensee returned the source immediately.

"In total the source was in the incorrect position for approximately 30 seconds. The source was at the same position about 30 millimeters proximal to the treatment area.

"The AU picked up the radiopaque marker set to put back in and see if they could see how far it would go in on fluoroscopic imaging. When the AU picked up the radiopaque marker set, he noticed that there was a very strong kink (almost 90-degree bend) in the radiopaque marker set. Instead of putting the source radiopaque marker set back in, the licensee decided to pull the entire catheter and place a new beta-cath catheter in the patient. While testing the new radiopaque marker set (pulled them out, push them back in) the AU realized that when he did it on the other radiopaque marker set, he had felt a click at some point.

"The licensee's hypothesis is that, when the AU felt the click, the radiopaque marker set bent and there is a potential that when it bent, there was damage to the catheter itself, and it would not allow the source train to go past that position where the kink happened. With the new catheter in place, the AU connected the device and sent the source train out to the treatment position without issue. The licensee continued to treat for the prescribed treatment time.

"Preliminary information: It is estimated that the source train sat for approximately 30 seconds in the wrong location. The dose delivered to that area about 30 millimeter proximal to the treatment site is 0.0632 Gy/s times 30 s equals 1.896 Gy, which is greater than the limits described in 10 CFR 35.3045(a)(1)(iii) reports and notification of a medical event.

"Iowa HHS will do a reactive inspection on 3/20/2024 and will update this event as more details are confirmed."

* * RETRACTION ON 4/4/24 AT 1301 EDT FROM STUART JORDAN TO TENISHA MEADOWS * * *

The following was received from the Iowa Health and Human Services (HHS) via email:

"Iowa HHS performed a reactive inspection on 3/20/2024 to confirm the facts and dose information. During this inspection, it was determined that the source train stopped in the aorta (30 mm vessel) in which the licensee's initial dose calculations was to a 2 mm vessel. Due to the characteristics of the strontium-90 beta emitter, there is a significant drop off in dose to the tissue with increased distance (3.75 mm goes below the 50 rem threshold). The catheter was not resting against the aorta wall when it had stopped for 20-30 seconds and the actual dose to the tissue was determined to be 5.25 rads [0.0525 Gy], which is approximately 10 percent of the reportable medical event threshold as described in 10 CFR 35.3045. Additionally, the reporting requirements described in 10 CFR 30.50(b)(2) also were not met. Specifically, the day of the incident the licensee used a new catheter and successfully treated without incident so there was redundant equipment available and operable to perform the required safety function.

"The licensee has sent the partially failed catheter to the vendor for an evaluation."

Notified R3DO (Edwards) 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.

--------------------

Ameren Ue

Callaway - Fulton MO

Report Date 03/22/2024 1:46:00

Event Date 03/21/2024 20:56:00

EN Revision Imported Date: 4/26/2024

EN Revision Text: AUTOMATIC TURBINE DRIVEN AUXILIARY FEEDWATER PUMP ACTUATION

The following information was provided by the licensee via email:

"At 2056 on 3/21/24, Callaway Plant was in Mode 1 at approximately 100 percent power when an automatic start of the turbine driven auxiliary feedwater pump occurred. The event occurred while restoring inverter NN12 from maintenance. NN12 is the normal in-service inverter for the group 2 120-VAC instrument bus (NN02). The actuation occurred while swapping from the swing inverter (NN18) to the normal in-service inverter (NN12).

"All safety systems responded as expected. At 2334, the turbine driven auxiliary feedwater pump was secured.

"The plant is being maintained in a stable condition, in mode 1.

"The NRC Resident Inspector was notified"

The licensee is investigating the cause of the automatic start.

* * * RETRACTION ON 4/25/2024 AT 1432 EDT FROM GREG CIZIN TO ERNEST WEST * * *

"Event Notification (EN) 57043, made on 03/21/2024 pursuant to 10 CFR 50.72(b)(3)(iv)(A), is being retracted based upon further investigation into the cause of the turbine driven auxiliary feedwater pump (TDAFP) actuation. The TDAFP received an invalid manual initiation signal caused by a voltage transient that was generated on the NK02 125-VDC bus upon closure of downstream breaker NK0211 (while restoring inverter NN12 from maintenance). This actuation signal was due to degradation of a 48-VDC power supply (PS1) within engineered safety features actuation system (ESFAS) logic cabinet SA036C. This degradation likely prevented the power supply from sufficiently filtering the transient that occurred on the 125-VDC bus associated with the NN12 inverter."

Notified R4DO (Warnick)

--------------------

Detroit Edison Co.

Fermi - Newport MI

Report Date 03/23/2024 3:47:00

Event Date 03/23/2024 0:04:00

EN Revision Imported Date: 4/23/2024

EN Revision Text: AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 0004 EDT on March 23, 2024, with the unit in Mode 1 at 23 percent power, the reactor automatically scrammed due to high reactor pressure vessel pressure when the turbine bypass valves unexpectedly closed while attempting to lower generator MW to 55 MWe to support shutdown for a refueling outage. The scram was not complex, with systems responding normally post-scram, with the exception of the pressure control system. The transient occurred while lowering on turbine speed/load demand which caused a rise in pressure and power until the reactor protection system setpoint for reactor pressure high was exceeded and resulted in an automatic reactor scram. The plant was preparing to shut down for a refueling outage when the trip occurred.

"Operations responded and stabilized the plant. Reactor water level is being maintained at normal level. Decay heat is being removed by the main steam system to the main condenser using manual operation of the turbine bypass valves. All control rods inserted into the core.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CPR 50.72(b)(2)(iv)(B). Additionally, received expected [primary containment] isolations for Level 3: Group 13 drywell sumps, Group 15 [traverse in-core probe] TlPs (which was already isolated) and Group 4 [residual heat removal - shutdown cooling] RHR-SDC (which was already isolated). The primary containment isolation event is being reported under 10 CFR 50.72(b)(3)(iv)(A). Also, due to the main turbine bypass valves unexpectedly closing, this is also being reported under 10 CFR 50.72(b)(3)(v)(D).

"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

* * UPDATE ON 4/22/24 AT 1448 EDT FROM WHITNEY HEMINGWAY TO ADAM KOZIOL * * *

"The purpose of this notification is to retract the 10 CFR 50.72(b)(3)(v)(D) reporting criteria of event notification 57046 reported on March 23,2024. Based on further evaluation, Fermi 2 has concluded that there was no event or condition that could have prevented fulfillment of a safety function that was needed to mitigate the consequence of an accident. Although discussed in Chapter 15 of the UFSAR, the turbine bypass valves do not provide a safety related function and are not credited safety related components for accident mitigation. Therefore, Fermi 2 is retracting the 10 CFR 50.72(b)(3)(v)(D) reporting criteria that was included on the March 23, 2024 event notification."

Notified R3DO (Betancourt-Roldan)

--------------------

Central AR Rad Therapy Institute

Arkansas Department of Health - Little Rock AR

Report Date 03/25/2024 14:04:00

Event Date 02/07/2024 0:00:00

EN Revision Imported Date: 4/26/2024

EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MISADMINISTRATION

The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:

"The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected.

"The discovery was made during a quarterly review of their written directive on March 20, 2024.

"The Agency is awaiting further information from the licensee."

* * UPDATE ON 4/25/24 AT 1045 EDT FROM SUSAN ELLIOTT TO BILL GOTT * * *

The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:

"The discovery was made during a quarterly review of their written directive on March 12, 2024 (Corrected date).

"The authorized user prescribed an activity of 2.6 GBq (70 mCi) on February 7, 2024. The technologist drew up 3.17 GBq (85.8 mCi) which was 122 percent of the prescribed activity and delivered the syringe to the authorized user. The authorized user performed the administration within 30 minutes of the dose being drawn. The administered activity was estimated to be 84.5 mCi, 120 percent of the prescribed activity.

"The authorized user contacted the patient's referring physician and both were satisfied with the activity delivered as the goal was to ablate the entire segment of diseased liver. The absorbed doses to all other tissues were below the targets for treatment with Y90.

"Personnel interviews were conducted by the department on April 2, 2024, aimed at gaining insight into the incident and engaging in discussions regarding the procedures involved.

"The event is considered closed."

Notified R4DO (Warnick) and NMSS Events Notification (email)

Arkansas Event #: AR-2024-2

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.

--------------------

University of California San Francisco Medical Center

California Radiation Control Prgm - San Francisco CA

Report Date 03/25/2024 15:48:00

Event Date 03/24/2024 0:00:00

AGREEMENT STATE REPORT - Y-90 THERAPY MISADMINISTRATION

The following information was received from the California Department of Public Health, Radiological Health Branch (RHB) via email:

"On 3/24/24, the alternate radiation safety officer phoned the RHB to report a medical event associated with a yttrium-90 (Y-90) therapy. A patient receiving Y-90 therapy was underdosed by more than 20 percent from the planned dose.

"RHB will investigate."

California Report Number: 032424

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.

--------------------

Radius Recycling

WA Office of Radiation Protection - Burbank WA

Report Date 03/25/2024 18:54:00

Event Date 04/04/2022 0:00:00

AGREEMENT STATE REPORT - FOUND SOURCE

The following information was received from the Washington State Department of Health, Office of Radiation Protection (the Department) via email:

"Action Towing LLC transported a car to the Schnitzer Steel Industries scrap metal facility, and it triggered the scrap yard's radiation detectors. The scrap yard staff measured about 35 micro roentgen/hour on the outside of the car. Officials at Schnitzer Steel Industries contacted the Department which resulted in an evaluation of the concern and issuance of a DOT special permit so that the radioactive car could be returned to Action Towing LLC for proper handling.

"The Action Towing office manager was informed that the staff had seen some sort of radiation equipment in the car, so the Department requested pictures of the equipment. The pictures showed an old military Geiger-Mueller (GM) survey meter and other items. The Department went to Action Towing to investigate the radioactivity. In addition to the old military GM survey meter, which was not radioactive, the Department found two glass tubes containing radioactive material, which measured about 2 milliroentgen/hour on contact. One of the tubes was labeled as radium-226. The Department took the radioactive tubes for disposal, then surveyed the car and found no elevated radioactivity remaining in the car, and therefore released the car for unrestricted use."

WA State Item Number: WA240001

--------------------

Nondestructive & Visual Inspection LLC.

Texas Dept of State Health Services - Carthage TX

Report Date 03/26/2024 14:15:00

Event Date 03/26/2024 0:00:00

AGREEMENT STATE REPORT - DETACHED SOURCE

The following was received from the Texas Department of State Health Services (the Department) via phone and email:

"On March 26, 2024, the Department was notified by the licensee's radiation safety office (RSO) that earlier this day a radiography crew had a source disconnect while using a SPEC 150 exposure device. The device contained a 23 curie, iridium-192 source.

"The disconnect occurred on the first shot of the day. The RSO reported that the radiographers had completed set up for the first shot but had failed to properly connect the guide tube to the camera. When the radiographers cranked the source out and it hit the collimator, the guide tube popped loose from the camera. The radiographer immediately attempted to crank the source back into the camera but when the source reached the end of the guide tube the source pigtail disconnected from the drive cable.

"The radiographers set up new boundaries and contacted the RSO. An RSO from a nearby office responded to the location. The RSO was wearing a self-reading dosimeter (SRD), alarming rate meter, and TLD [thermoluminescent dosimeter] exposure badge. The RSO placed the camera on the source for shielding, attached the source back to the drive cable, and retracted the source into the camera. The responding RSO's SRD was reading off scale after retracting the source. The badge has been sent to the licensee's dosimetry processor for emergency processing.

"The licensee does not believe any individual exceeded any limit due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # 10095

--------------------

Northern Colorado University

Colorado Dept of Health - Greeley CO

Report Date 03/26/2024 17:51:00

Event Date 03/25/2024 0:00:00

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Three SRB Technologies exit signs, model SLXTU1GB10, containing 7.09 curies each of tritium (21.27 curies total) were determined to be lost.

Colorado event number CO240008

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

--------------------

First Bank - Vail

Colorado Dept of Health - Vail CO

Report Date 03/26/2024 18:00:00

Event Date 03/22/2024 0:00:00

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Seven Isolite Corporation exit signs, model 2040, containing 11.5 curies each, of tritium (80.5 curies total) were determined to be lost.

Colorado event number CO240007

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

--------------------

Clean Earth of Connecticut

Clean Earth of Connecticut - Plainville CT

Report Date 03/27/2024 14:10:00

Event Date 03/18/2024 0:00:00

LOST NICKEL-63 SOURCES

The following is a summary of information received from the licensee via phone:

Licensee discovered three electron capture detectors (ECD) were missing on 03/18/2024. Each ECD contained 15 millicuries of nickel-63 (45 millicuries total). The last known accountability of these ECDs occurred at a leak test performed in 08/25/2020. The licensee suspects the ECDs may have been disposed of improperly.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

--------------------

Olinger Hampden Funeral Home & Ceme

Colorado Dept of Health - Denver CO

Report Date 03/27/2024 19:00:00

Event Date 03/25/2024 0:00:00

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Two Best Lighting Products, Inc. exit signs, model SLXTU1GB10, containing 14.18 curies each, of tritium (26.36 curies total) were determined to be lost.

Colorado event number CO240009

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

--------------------

Dow Chemical

Dow Chemical - Midland MI

Report Date 03/28/2024 12:55:00

Event Date 03/27/2024 11:01:00

EN Revision Imported Date: 4/29/2024

EN Revision Text: UNPLANNED CONTAMINATION

The following information was provided by the licensee via telephone:

On March 27, 2024, at 1101 EDT, a sample containing 20.3 mCi of carbon-14 (C-14) in 1,3-Dichloropropene liquid form (348 microliters) was dropped when being removed from a storage container. The authorized user immediately called for assistance and restricted access to the laboratory where the spill occurred. Decontamination efforts began immediately after the incident, and it was confirmed that the contamination was contained to the laboratory where the spill occurred. It was determined on March 28, 2024, at 1025 EDT that restrictions would remain in place greater than 24 hours, and that this incident was reportable under 10 CFR 30.50(b)(1).

Following the spill, a nasal swab was taken of the worker with no detectable activity, however, a urine bioassay taken the following day indicated a potential internal dose of 213 mrem. No other staff were exposed, and there was no risk to public safety or the environment.

The applicable 10 CFR 20 Appendix B annual limit for intake for C-14 is 2000 microcuries.

Decontamination efforts will continue until detectable surface contamination is less than 1000 dpm/100 square centimeters.

* * UPDATE ON 4/26/24 AT 1609 EDT FROM KELLY WEGENER-GAVE TO ADAM KOZIOL * * *

The licensee submitted a 30-day written report for this event.

Notified R3DO (Betancourt-Roldan) and NMSS Events (email).

--------------------

Cardinal Health, Boise, ID

Cardinal Health - Boise ID

Report Date 03/29/2024 10:24:00

Event Date 03/24/2024 0:00:00

ELUATE EXCEEDING PERMISSIBLE CONCENTRATION

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

On March 24, 2024, a generator experienced a breakthrough event. The elution from a Curium technetium-99m (Tc-99m) generator did not meet the concentration requirements of 0.15 microcuries molybdenum-99 (Mo-99)/millicurie Tc-99m per 10 CFR 35.204. The generator is from lot number 914024034. The elution contained 1251.3 millicuries of Tc-99m and 203.1 microcuries of Mo-99, resulting in a ratio of 0.16 microcurie Mo-99/millicurie Tc-99m.

The elution was not used to prepare a radiopharmaceutical kit or for dispensing of patient doses. The elution was set aside immediately for decay and disposal. The generator was eluted multiple times following the breakthrough and none of those elutions exceeded the regulatory limit. Curium, the manufacturer, was notified on 3/29/2024. The generator is being quarantined pending disposal.

--------------------

Louisiana Energy Services, Llc

Louisiana Energy Services - Eunice NM

Report Date 04/02/2024 2:36:00

Event Date 04/01/2024 23:45:00

EN Revision Imported Date: 4/19/2024

EN Revision Text: ITEM RELIED ON FOR SAFETY (IROFS) INOPERABLE

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

"At approximately 2345 MDT, on 4/1/2024, it was observed that the physical boundary of IROFS10 had been opened while this boundary was being relied upon to perform its safety function. This initial report is being made as a 1-hour notification under Appendix A to 10 CFR70 (a)(4). The boundary (an isolation valve) was partially opened inadvertently by contact with adjacent equipment while performing operation of 1003 liquid sampling autoclave. The partially opened valve has been shut, restoring the IROFS10 boundary, and the autoclave has been placed in cooling mode. Out of conservatism, until an extent of condition can be performed, the 1004 autoclave which has a similar design has been taken out of service and placed in cooling mode as well.

"There has been no indication of leakage from any operating liquid sampling autoclave to the environment. The system and plant are in a stable condition."

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

The isolation valve was open less than 30 seconds and there was no exposures to personnel. The licensee will notify the NRC Region.

* * * RETRACTION ON 4/18/2024 AT 1029 EDT FROM JIM RICKMAN TO BILL GOTT * * *

"The potential leakage through the open boundary has been determined. The valve, if fully open, would not result in exceeding the 10 CFR 70.61 performance requirements. Thus, the 10 CFR 70 (a)(4) reporting requirement was not met, and this event notification is retracted."

Notified R2DO (Miller) and NMSS Events Notification (email).

--------------------

Piedmont Cartersville Medical Ctr.

Georgia Radioactive Material Pgm - Cartersville GA

Report Date 04/03/2024 9:03:00

Event Date 04/01/2024 0:00:00

AGREEMENT STATE REPORT - RECEIVED DOSE LESS THAN PRESCRIBED

The following information was received from the Georgia Department of Natural Resources (GADNR), Georgia Radioactive Materials Program, via email:

"On Monday April 1, 2024, GADNR received notification from our licensee, [license number] GA 796-1, of a brachytherapy seed migration post implant of Iodine-125 seeds. The reporting official is the hospital's Manager of Radiation Physics [MRP]. [The MRP] was contacted via cell phone today, April 2, 2024, for further information. [They] stated that each seed was approximately 0.635 mCi, totaling 18.62 mCi. The patient was seen some time last week and their computed tomography (CT) results were analyzed yesterday during their post implant CT exam. The prescription was 145 Gy to the prostate using 18.62 mCi of I-125. The D90 to the target was 46.2 percent instead of the expected 80-120 percent on the post implant dosimetry. [The MRP] will be sending a full report of this incident within the next 15 days. [GANDR] will follow up with more information at a later date."

* * RETRACTION ON 4/9/24 AT 0807 EDT FROM ANASTASIA BENNETT TO BILL GOTT * * *

The following information was received from the Georgia Department of Natural Resources (GANDR), Georgia Radioactive Materials Program, via email:

"GADNR is requesting closure of the incident case as it does not meet the reporting criteria outlined in 10 CFR 35.3045(a)(2)(i)(2) for permanent implant brachytherapy. Specifically, the incident does not involve the administration of byproduct material or radiation from byproduct material resulting in a total source strength administered differing by 20 percent or more from that documented in the post-implantation portion of the written directive, excluding instances where sources migrate outside the treatment site."

Notified R1DO (DeFrancisco) and NMSS Events Notification via email.

Georgia Incident number: 83

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.

--------------------

G.E. Healthcare

Illinois Emergency Mgmt. Agency - Arlington Heights IL

Report Date 04/04/2024 12:24:00

Event Date 02/29/2024 0:00:00

AGREEMENT STATE - LOST PACKAGE

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

"On March 4, 2024, the Agency received a notification from G.E. Healthcare in Arlington Heights, IL to advise of one missing radiopharmaceutical package at the Memphis, TN [common carrier] hub. The package contained one vial of I-123 with 14.268 mCi at the time of shipment.

"G.E. Healthcare was notified on March 4, 2024 by [common carrier] in Memphis, TN that a radiopharmaceutical package was missing with no indication of the contents being separated from the package. The package was originally shipped out of G.E. Arlington Heights, IL facility on February 29, 2024. The lead shielded package contained 14.268 mCi of I-123 in one 10 mL vial at the time of shipment. The destination was Spokane, WA. The last measured activity was 0.094 mCi. The last scan was at the [common carrier] hub in Memphis on February 29, 2024 and [common carrier] confirmed the package could not be found on March 4, 2024. This matter will continue to be tracked until an update is available or the package has decayed to background levels.

"As of April 3, 2024, the licensee indicates there are no changes to the status of the package or contents of the package. The package content has decayed to background levels. This does not pose a threat to the health and safety of the public. Provided there are no changes, this matter is considered closed."

Item number: IL240007

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

--------------------

Innovative Probing Solutions

Illinois Emergency Mgmt. Agency - Mount Vernon IL

Report Date 04/04/2024 14:36:00

Event Date 02/29/2024 0:00:00

AGREEMENT STATE REPORT - LOST SOURCE

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

"Annual self-inspection request was sent to all generally licensed entities on February 15, 2024. This registrant e-mailed back on February 21, 2024, indicating that he was no longer associated with the company, the company was no longer in business in Illinois, and the radioactive material was lost. The company was sold and the radioactive material was sold with the other assets. However, the sources were in place as recently as January 3, 2020, when they submitted their last self-inspection.

"The registration had three 10 mCi nickel-63 (Ni-63) sealed sources on their inventory. After continued research, the Agency was unable to track down the sources. The Agency contacted the manufacturer, Shimadzu, who did not have any records of any service work on the 3 sources or disposal paperwork. The new company could not be found. These sources do not pose a health or safety risk to the public. Pending any new information, this matter is considered closed."

Illinois Item Number: IL240005

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Genesis Alkali

Genesis Alkali - WY

Report Date 04/04/2024 18:10:00

Event Date 04/04/2024 10:00:00

STUCK SHUTTER

The following information was provided by the licensee via phone:

The radiation safety officer (RSO) was showing a new employee the nuclear gauges when they noticed that a gauge was missing a handle. The handle opens and closes the shutter. The RSO believes the shutter may be stuck in the open position. The gauge was manufactured by Burthold in 1995 with model number 7440 and serial number 2964 containing 50 millicuries of Cs-137. There is no additional exposure to plant personnel or the public due to the position of the shutter. Burthold has been contacted for maintenance.

--------------------

Arizona Nuclear Power Project

Palo Verde - Wintersburg AZ

Report Date 04/04/2024 19:35:00

Event Date 04/04/2024 16:18:00

NOTIFICATION OF UNUSUAL EVENT DUE TO FIRE ALARM IN THE VITAL AREA

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

On 4/4/2024 at 1618 MST, a Notification of Unusual Event, HU4.2 was declared based on an unverified fire alarm in the containment building greater than 15 minutes. Palo Verde, Unit 3 was operating in Mode 1 at 91 percent power due to end of cycle coast down to a refueling outage. There is no known plant damage at this time. Offsite assistance cannot enter the containment building, therefore, offsite assistance was not requested. The plant is stable in Mode 1.

The licensee notified State and local authorities and the NRC Senior Resident Inspector.

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

* * * UPDATE ON 04/04/24 AT 2313 EDT FROM YOLANDA GOOD TO IAN HOWARD * * *

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

At 2013 MST, Palo Verde Unit 3 terminated the notification of unusual event. The basis for termination was that a containment entry was performed. All levels were inspected, and no fires were found. The NRC Resident Inspector has been notified.

Notified R4DO (Deese), IR-MOC (Crouch), NRR-EO (Felts), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).

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Roke Technologies USA, Inc.

Louisiana Radiation Protection Div - Opelousas Field LA

Report Date 04/04/2024 19:25:00

Event Date 04/04/2024 14:00:00

AGREEMENT STATE REPORT - STUCK WELL LOGGING SOURCE

The following information was provided by the Louisiana Radiation Protection Division (the Division) via email:

"On April 4, 2024 at approximately 1619 CDT, the president and radiation safety officer (RSO) of Roke Technologies USA, Inc. [was] working under Louisiana reciprocity when they reported to the Division that at approximately 1400 CDT, two QSA Global 3.0 Ci well logging sources of Americium-241:Be (Model AMN.CY3) contained in the licensee's custom made proprietary logging tool became stuck in tubing at a depth of approximately 1,965 feet. The well, Ronald Richard et ux No. 1, is in Opelousas Field, St. Landry Parish, Louisiana. The E-line holding the logging tool, rated at 3,150 lbs., pulled out of the rope socket on the logging head after the subcontractor logging crew, Verde Services, LLC (Verde) of Laurel, MS, attempted to pull out the tool. The licensee's plan is to meet Verde's braided line truck that is arriving on site at 0800 CDT on April 5, 2024. The braided line is much stronger than the E-line and this truck has a greater pulling strength than the E-line truck. The licensee has high confidence that they will be able to recover the tool as they are also equipped with a fishing neck for the 1-11/16-inch tool which faces upward inside the 2-3/8-inch tubing. The RSO is remaining on site until the tool and sources are recovered. The RSO will follow up with a status report tomorrow morning."

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Transco Products Inc. - Streator IL

Report Date 04/09/2024 16:26:00

Event Date 11/16/2023 0:00:00

PART 21 - INTERIM REPORT FOR UNVERIFIED CRITICAL CHARACTERISTICS OF DARMATT KM-1 FLAT BOARD

The following is a summary of the information provided by Transco Products Inc. via email:

10 CFR Part 21 Initial Notification: TPI-LTR-2024-01-01-0

On November 16, 2023, during an audit review, it was determined that the dedication plan was inadequate. The dedication plan lists chemical properties as one of the critical characteristics with the acceptance criteria. The extent of condition is limited to Darmatt KM-1 flat board supplied to Energy Northwest (Columbia Generating Station). The issue has been entered into Transco Products Inc.'s corrective action program. Testing to verify the chemical properties of the supplied flat board is in process. Energy Northwest was the only impacted licensee and they have been notified.

Notified R4DO (Azua) and Part 21 Group via email.

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Vartanian Medical, PLLC

Vartanian Medical, PLLC - Farmington Hills MI

Report Date 04/09/2024 16:12:00

Event Date 04/09/2024 12:40:00

MEDICAL EVENT - UNDERDOSE

The following information is an event summary via phone call from Vartanian Medical, PLLC:

On April 9, 2024, at 1240 EDT, a patient received only 73 percent of the intended dose of Y-90 TheraSpheres during a radioembolization. The prescribed dose was 3000 Gy and the dose received was approximately 2200 Gy. The physician described the cause of the event to be due to a smaller catheter needle used for treatment, which impeded the requisite flow.

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.

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Tennessee Valley Authority

Browns Ferry - Decatur AL

Report Date 04/10/2024 11:23:00

Event Date 04/09/2024 14:09:00

FITNESS FOR DUTY

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

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

"The NRC Senior Resident Inspector has been notified."

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Alabama River Cellulose, LLC

Alabama Radiation Control - Perdue Hill AL

Report Date 04/12/2024 12:05:00

Event Date 04/11/2024 15:00:00

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following is a summary of information received from the Alabama Office of Radiation Control via email:

On April 11, 2024, at 1500 CST, a device (Ohmart/Vega, SH-F1, Model A-2102, Source SN 9254GK, 100 mCi Cs-137) was discovered to have a stuck open shutter during routine shutter checks. The device is in place and operational. The area around the vessel on which the device is mounted has been barricaded and marked for no entry. The licensee's plan is to replace the source holder with a new one. The licensee is getting a quote for replacement and installation with an estimated repair date of May 10, 2024.

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Fitzpatrick NPS

Engine Systems, Inc - Oswego NY

Report Date 04/12/2024 11:49:00

Event Date 02/22/2024 0:00:00

EN Revision Imported Date: 4/15/2024

EN Revision Text: PART 21 - LEAKING CYLINDER LINER IN EMERGENCY DIESEL GENERATOR

The following is a summary of the information provided by Engine Systems Inc. (ESI) via facsimile:

An EMD (Brand Name: Electro-Motive Diesel) cylinder liner developed a jacket water leak following installation on an emergency diesel generator set at the James A. Fitzpatrick Nuclear Power Plant. The leak occurred at a brazed joint and was detected after post-installation engine testing. Had the leak gone undetected, jacket water may have accumulated in the combustion chamber, airbox, and/or lubricating oil which could have eventually led to failure of the emergency diesel generator set.

ESI was the supplier of the EMD cylinder liner (part number: 9318833, serial number: 20D6294). The EMD cylinder was a component of a Blade Power Pack Assembly, part number: 40124898, serial number: 20L0603

Corrective Actions: ESI will revise the dedication package to include additional verifications to prevent reoccurrence. The revision will be implemented within 30 days. Fitzpatrick returned the power assembly to ESI for replacement and no further action is required from Fitzpatrick.

Affected Plants: Fitzpatrick. No other sites known to be affected.

The name and address of the individuals reporting this information is:

John Kriesel Engineering Manager Engine Systems, Inc.; 175 Freight Rd. Rocky Mount, NC 27804

Dan Roberts Quality Manager Engine Systems, Inc.; 175 Freight Rd. Rocky Mount, NC 27804

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Medical University of South Carolina

SC Dept of Health & Env Control - Charleston SC

Report Date 04/12/2024 13:53:00

Event Date 04/12/2024 11:30:00

AGREEMENT STATE - MEDICAL UNDERDOSE

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

"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

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.

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Brighton United Methodist Church

Colorado Dept of Health - Brighton CO

Report Date 04/12/2024 16:43:00

Event Date 04/12/2024 0:00:00

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Two SRB Technologies exit signs, model number: BX10GY, containing 10 curies each, of tritium (20 curies total) were determined to be lost by the licensee.

Colorado event number CO240010

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Firstenergy Nuclear Operating Company

Beaver Valley - Shippingport PA

Report Date 04/13/2024 3:55:00

Event Date 04/13/2024 0:35:00

EN Revision Imported Date: 4/15/2024

EN Revision Text: AUTOMATIC REACTOR TRIP

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

"At 0035 EDT on April 13, 2024, with Unit 1 at 97 percent power, the reactor automatically tripped due to 1 of 3 reactor coolant pump (RCP) low flow reactor trip [signal] associated with a loss of the 'A' and 'B' 4160 volt normal buses. Auxiliary feedwater and the 1-1 emergency diesel generator (EDG) automatically started on valid actuation signals. The 1-1 EDG sequenced on to supply all required loads per plant design. All control rods fully inserted and the trip was not complex with all systems responding normally post-trip. Operators have responded and stabilized the unit in Mode 3 [Hot Standby]. Decay heat is being removed by discharging steam to the main condenser via the condenser steam dump system with steam generators being supplied by the main feedwater system.

"Unit 2 is not affected by the event.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Due to the valid actuations of auxiliary feedwater and the 1-1 EDG, this event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact to the health and safety of the public or plant personnel. The NRC senior resident inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: Power for the A-E Bus is on the 1-1 EDG. The D-F Bus is on offsite power. One electrical train of offsite power is down.

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Nondestructive & Visual Inspection

Colorado Dept of Health - Northglenn CO

Report Date 04/15/2024 12:28:00

Event Date 03/24/2024 0:00:00

AGREEMENT STATE REPORT - BROKEN LOCK ON RADIOGRAPHY CAMERA

The following information was received from the Colorado Department of Public Health and Environment via email:

"This letter is serving as notification of an equipment failure under [Colorado Regulation] Section 4.52.2.3 and 5.38.1.3. A QSA Global 880 Delta camera was received from Source Production and Equipment Company, Inc. (SPEC), after being resourced. During the check-in procedure and mechanism check, it was discovered that the lock that controls access to the pigtail attachment was broken in the locked position. The camera was tagged out until it could be sent to Industrial Nuclear Company (INC), for repairs on 04/04/2024. The lock was repaired at INC, and the camera was returned to the licensee on 04/10/2024 with no issues."

Colorado Event Report ID: CO240011

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Tennessee Valley Authority

Watts Bar - Spring City TN

Report Date 04/15/2024 14:38:00

Event Date 02/15/2024 22:24:00

INVALID ACTUATION OF EMERGENCY DIESEL GENERATORS

The following information was provided by the licensee via email:

"At 2224 EST on February 15, 2024, with both units 1 and 2 in Mode 1 at 100 percent power, an invalid start of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The 1A-A, 1B-B, and 2B-B EDGs started and functioned successfully.

"The start signal for the 1A-A, 1B-B, and 2B-B EDGs was generated from the common emergency start of the 2A-A EDG. The signal was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design [basis] safety function.

"The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system.

"This event was originally reported under EN 56970 on February 16, 2024, at 0205 EST in accordance with 10 CFR 50.72(b)(3) (iv)(A) as an event that results in a valid actuation of the emergency diesel generator system. This EN was retracted on February 21, 2024, at 1549 EST.

"This event is being reported in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the emergency diesel generator system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

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Testing Engineers, Inc.

California Radiation Control Prgm - Concord CA

Report Date 04/16/2024 15:57:00

Event Date 04/13/2024 0:00:00

AGREEMENT STATE - STOLEN GAUGE

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

"On 4/15/2024, the California Office of Emergency Services (OES) forwarded a report from Testing Engineers, Inc. The radiation safety officer (RSO) notified OES that one of their nuclear gauges (CPN MC-1, serial number MD71108870 containing 10 mCi of Cs-137 and 50 mCi of Am-241) was stolen from a storage unit that is located within a public storage facility in Concord, CA. The gauge was stolen from the storage unit at an unknown time between 04/13/2024 and 04/14/2024, but was discovered missing at 1541 [PDT] on 04/15/2024. A car was used to ram the door of the storage unit, and a pry bar was used to remove the gauge from a locked cabinet. Local law enforcement was notified, and a reward was posted on Craigslist, Facebook, and Nextdoor for the safe return of the gauge.

"RHB will investigate the incident."

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

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Paragon Energy Solutions - Fort Worth TX

Report Date 04/16/2024 23:29:00

Event Date 02/15/2024 0:00:00

EN Revision Imported Date: 5/3/2024

EN Revision Text: INITIAL PART 21 REPORT - POTENTIAL DEFECT WITH CIRCUIT BREAKER

The following information was provided by the licensee via email:

"Pursuant to 10CFR 21.21 (a)(2), Paragon Energy Solutions, LLC is providing this interim notification of ongoing analysis for Part 21 reportability of a potential defect with a Schneider Electric Medium Voltage VR Type Circuit Breaker Part Number V5D4133Y000.

"On February 15, 2024, Paragon completed initial documentation of a potential defect with the subject circuit breaker in which Duke-Oconee had identified failure to close on demand or delayed operation to close with extended application of the remote closing signal. Since the primary safety function of the circuit breaker is to close and maintain continuity of power to downstream loads, failure to close could potentially contribute to a substantial safety hazard.

"This is the first reported instance of this failure mode, and Paragon suspects the issue to be related to aging of the circuit breaker's lubrication. Paragon requires more time to complete testing and analysis to confirm the failure mode and determine reportability.

"Date when evaluation is expected to be complete: 5/03/2024."

Affected licensee: Oconee. Paragon is currently evaluating the extent of condition as it pertains to other plants and equipment that may utilize the same or similar circuit breakers.

* * UPDATE ON 05/02/24 FROM R. KNOTT TO T. HERRITY VIA EMAIL AND PHONE CALL * * *

Due to inconclusive results, the completion date of the testing is revised to 05/31/2024.

Notified R2DO (Miller) and Part 21/50.55 Reactors (email).

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The Dow Chemical Company

Texas Dept of State Health Services - Lake Jackson TX

Report Date 04/17/2024 10:34:00

Event Date 04/16/2024 0:00:00

AGREEMENT STATE REPORT - DAMAGED GAUGE SHUTTER

The following was received from the Texas Department of State Health Services (the Department) via email:

"On April 16, 2024, the Department was notified by the licensee that they had removed a Natco model B-20-06 nuclear gauge containing a 175 millicurie (original activity) Cs-137 source from a vessel to allow work on the vessel. The gauge shutter was in the closed position and was functioning normally. Dose rates taken at the gauge before removal were normal at 0.65 millirem per hour.

"After the gauge was removed from the vessel, it was placed on a pallet with other gauges that had been removed from the vessel. At this time, the licensee performed additional radiation surveys, and the dose rate taken within a foot at the top of the gauge shutter was now reading 8.65 millirem per hour. The gauges were all moved to a locked storage location.

"The licensee has contacted a service company to inspect the gauge and determine the cause for the increased dose rates. The licensee's radiation safety officer (RSO) stated the shutter may have been damaged as the gauge was being moved to the pallet. The RSO stated no overexposures had occurred.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10099

Texas NMED No.: TX240012

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University of Pennsylvania

PA Bureau of Radiation Protection - Philadelphia PA

Report Date 04/18/2024 16:32:00

Event Date 04/17/2024 0:00:00

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email:

"On April 18, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 17, 2024, a patient was receiving an iodine-131 [sodium iodine solution] treatment. The patient was prescribed 100 mCi of I-131. However, the patient received only 5 mCi of I-131. At this time no other information is available. The Department will update this event as soon as more information is provided.

"The Department will perform a reactive inspection. More information will be provided upon receipt."

PA Event Number: PA240006

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.

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Valero Refining Company

Texas Dept of State Health Services - Texas City TX

Report Date 04/18/2024 18:18:00

Event Date 04/18/2024 0:00:00

AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received from the Texas Department of State Health Services (the Department) via email:

"On April 18, 2024, the Department was notified by the licensee that the shutter on a Vega model SH-F1 nuclear gauge failed to close. The gauge contains a 20 millicurie (original activity) cesium - 137 source. Open is the normal position for the gauge shutter. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this failure. The manufacturer has been contacted to repair the gauge shutter. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10100

Texas NMED Number: TX240013

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Exelon Nuclear Co.

LaSalle - Marseilles IL

Report Date 04/20/2024 13:51:00

Event Date 04/20/2024 7:04:00

AUTOMATIC ACTUATION OF EMERGENCY DIESEL GENERATORS

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

"At 0704 CDT on 4/20/24 with Unit 1 in Mode 1 at 100 percent power, an actuation of the emergency AC power system, specifically the Division 1 and Division 3 emergency diesel generators (EDGs) occurred during an unexpected loss of the Unit 1 system auxiliary transformer (SAT). The cause of the emergency AC power system auto-start was an unexpected loss of the Unit 1 SAT during switchyard maintenance. Bus 141Y did not fast transfer as designed resulting in the actuation of the Division 1 EDG. Division 3 EDG actuation is expected for this condition. The Division 1 and Division 3 EDGs automatically started as designed when the emergency AC power system valid actuation signal was received.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the emergency AC power system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

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

Division 1 and Division 3 EDGs will remain in operation and loaded until the Unit 1 SAT is restored. This event resulted in the plant entering an unplanned 72 hour limiting condition for operation (LCO) in accordance with technical specification 3.8.1. The licensee is investigating the cause of the unexpected loss of the Unit 1 SAT and the failure of the bus 141Y fast transfer.

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University of Pennsylvania

PA Bureau of Radiation Protection - Philadelphia PA

Report Date 04/22/2024 13:44:00

Event Date 12/28/2022 0:00:00

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from December 28, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."

* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.

PA Event Number: PA240008

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.

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University of Pennsylvania

PA Bureau of Radiation Protection - Philadelphia PA

Report Date 04/22/2024 13:44:00

Event Date 12/29/2022 0:00:00

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."

* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.

PA Event Number: PA240009

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.

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University of Pennsylvania

PA Bureau of Radiation Protection - Philadelphia PA

Report Date 04/22/2024 13:44:00

Event Date 01/31/2023 0:00:00

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.

"On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.

"At this time, no other information is available. The Department will update this event as soon as more information is provided."

* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:

"The Department wishes to retract this event as it does not meet the qualifications for reporting."

Notified R1DO (Werkheiser) and NMSS Events Notification via email.

PA Event Number: PA240010

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.

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Arconic Davenport, LLC

Iowa Department of Public Health - Bettendorf IA

Report Date 04/22/2024 15:46:00

Event Date 04/22/2024 0:00:00

AGREEMENT STATE REPORT - SHUTTER STUCK PARTIALLY OPEN

The following was received from the Iowa Department of Public Health - Bureau of Radiological Health (Iowa HHS) via email:

"Arconic Davenport possesses an IMS Measuring System (model 5221-02 profile thickness gauge) for measuring thickness of aluminum on the production line. The C-frame gauge contains five independent source housings, with each housing containing a 5 curie, americium-241, sealed source. The C-frame gauge is constructed from steel and is suspended from a monorail which allows the device to be moved offline to a restricted access calibration area. The shutter [on each source] is opened and closed by a pneumatic cylinder that is controlled from a remote location.

"On the morning of April 22, 2024, it was determined that shutter number 1 of the C-frame gauge B had failed to fully close. This was determined [during] an automated attempt to close all 5 shutters on the gauge, and the computer indicated that shutter number 1 was not fully closed. Per the licensee's procedures, the C-frame gauge was removed from the line using the monorail to the secured calibration house. Radiation surveys of the outside wall adjacent to the shutter 1 position were above background with a maximum dose rate of 0.1 mR/hr.

"The licensee has contacted their service provider to perform repair work (identify and fix the equipment problem) which is tentatively scheduled for same day or April 23, 2024. No reported overexposures have occurred because of this incident, no release or contamination of radioactive material occurred because of this incident (most recent negative leak test was November 2, 2023), and Iowa HHS will update this report once additional information is provided (cause, corrective actions, etc.)."

IA Event Number: IA240002

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GE-Hitachi Nuclear Energy Americas, LLC

Global Nuclear Fuel - Wilmington NC

Report Date 04/22/2024 14:33:00

Event Date 04/22/2024 0:00:00

EN Revision Imported Date: 4/30/2024

EN Revision Text: PART 21 - FUEL ASSEMBLY SPACER RELOCATION

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

Global Nuclear Fuel discovered instances of GNF3 fuel assembly spacers relocating within the fuel bundle. A safety communication was issued in 2022 following the discovery of a raised water rod (WR) at Grand Gulf Nuclear Station. Shutdown inspections in February 2024 at Lasalle identified five spacers out of position. Shutdown inspections at Limerick in April 2024 identified four spacers out of position. Those discoveries prompted this Part 21 report. An evaluation concluded that the relocated spacers could result in a degraded critical power margin, but the evaluation of this condition indicates it will not compromise or greatly reduce protection to public health and safety.

Plants with suspect bundles installed: Grand Gulf Nuclear Station (Raised WR but no defective spacers) Lasalle (1 bundle with 5 relocated spacers found) Limerick (1 bundle with 4 relocated spacers found) Nine Mile Point (No defects found) Fermi (No defects found) Peach Bottom (Shutdown scheduled in Fall 2024) Fitzpatrick (Shutdown scheduled in Fall 2024)

* * UPDATE ON 4/26/24 AT 1220 EDT FROM LISA SCHICHLEIN TO ADAM KOZIOL * * *

Updated to correct administrative errors in the summary of defects. Corrections were made above.

Notified R1DO (Werkheiser), R3DO (Betancourt-Roldan), R4DO (Warnick), Part 21/Reactor Group (email)

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Mistras Group

Mistras Group - Prudhoe Bay AK

Report Date 04/23/2024 8:48:00

Event Date 04/23/2024 0:30:00

RADIOGRAPHY CAMERA SOURCE RETRIEVAL

The following report is a summary of the event provided via phone from the licensee's radiation safety officer:

At 0030 AKDT on April 23, 2024, a radiography crew utilizing a QSA Global 880D exposure device with a 50.9 Ci Ir-192 sealed source experienced an issue where the slide lock of the device actuated prior to the source being in the fully shielded position. The licensee's radiation safety personnel were notified. The source was properly secured in the device at 0440 AKDT by trained personnel using a U tool to reengage the slide lock. There were no overexposures during this incident.

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Tennessee Valley Authority

Browns Ferry - Decatur AL

Report Date 04/25/2024 2:22:00

Event Date 04/24/2024 22:15:00

AUTOMATIC REACTOR SCRAM WITH ECCS ACTUATION

The following information was provided by the licensee via email:

"On 4/24/2024 at 2215 CDT, Browns Ferry Unit 1 experienced an automatic reactor scram. The cause of the scram is currently under investigation. The main steam isolation valves (MSIVs) remain open with the main turbine bypass valves controlling reactor pressure. The reactor feedwater pumps are in service to control reactor water level.

"Primary containment isolation systems (PCIS) Groups 2, 3, 6, and 8 isolation signals were received. Upon receipt of these signals, all components actuated as required. Following the reactor scram, due to reactor water level reaching minus 45 inches, both high pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) initiation signals were received, and both initiated as designed. All safety systems operated as expected.

"This event requires a 4-hour report per 10 CFR 50.72(b)(2)(iv)(A), `Any event that results or should have resulted in emergency core cooling system (ECCS) discharge into the reactor coolant system as a result of a valid signal except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'

"This event requires a 4-hour report per 10 CFR 50.72(b)(2)(iv)(B), `Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'

"This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A), `Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B): 1) Reactor protection system (RPS) including: reactor scram or reactor trip. 2) General containment isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs). 4) ECCS for boiling water reactors (BWRs) - high-pressure coolant injection (HPCI). 5) BWR reactor core isolation cooling system (RCIC).'

"All safety systems operated as expected. At no time was public health and safety at risk. The NRC resident inspector has been notified."

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

Units 2 and 3 were not affected.

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Ameren Ue

Callaway - Fulton MO

Report Date 04/25/2024 13:38:00

Event Date 03/24/2024 20:56:00

INVALID ACTUATION OF AUTOMATIC TURBINE DRIVEN AUXILIARY FEEDWATER PUMP

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

"This report is being made in accordance with 10 CFR 50.73(a)(2)(iv)(A), under the provision of 10 CFR 50.73(a)(1), detailing the event in which an unplanned actuation of the turbine driven auxiliary feedwater pump (TDAFP) at the Callaway plant occurred in response to an invalid actuation signal.

"The actuation occurred at 2056 [CDT] on 3/21/2024 during restoration from maintenance on the NN12 inverter. The actuation signal was received while closing breaker NK0211 (for connecting the inverter to its associated 125-VDC bus). In response to the TDAFP actuation, operators closed the flow control valves and reduced turbine load by approximately 10 MW electrical. Initial investigation showed that a spurious manual actuation signal had been received and cleared 5 seconds later.

"The direct cause of the event was due to a voltage transient generated on the NK02 125-VDC bus during closure of the NK0211 breaker. The actuation occurred due to degradation of a 48-VDC power supply (PS1) within engineered safety features actuation system (ESFAS) logic cabinet SA036C. The power supply exhibited elevated ripple during testing as part of troubleshooting efforts, which was indicative of degradation of the regulation circuitry within the supply. This degradation prevented the power supply from sufficiently filtering the transient that occurred on the 125-VDC bus associated with the NN12 inverter. The power supply was replaced."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee originally submitted this event under 10 CFR 50.72(b)(3)(iv)(A) in EN 57043. The licensee has retracted EN 57043.

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Firstenergy Nuclear Operating Company

Perry - Perry OH

Report Date 04/25/2024 20:24:00

Event Date 04/25/2024 17:55:00

CONFIGURATION OF 'B' AND 'C' RESIDUAL HEAT REMOVAL LOOPS IN AN UNANALYZED CONDITION

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

"On April 25, 2024, it was determined that between March 25, 2024, 2015 [EDT] and March 30, 2024, 2024 [EDT], the condensate transfer and storage system was employed as a method of alternate keepfill in place of the installed residual heat removal (RHR) system's waterleg pump for RHR system loops `B' and `C'. This condition is not bounded by existing design and licensing documents.

"Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

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