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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 Steels 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 licensees 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 manufacturers 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 Steels 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 licensees 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 licensees 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 licensees 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 licensees 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

The following information was provided by the licensee via email: At 1045 EST, on 2/19/2024, during a maintenance activity, a loss of all reactor building ventilation occurred on Unit 2. With no flow past the ventilation radiation monitors, the radiation monitors were inoperable to support their ability to perform primary and secondary containment isolation functions or start the standby gas treatment system. Reactor building ventilation was restored within 15 minutes. Due to this inoperability, the radiation monitor system was in a condition that could have prevented 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). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector will be notified.

• * * RETRACTION ON 3/15/24 AT 1315 EDT FROM BILL LINNELL TO ADAM KOZIOL * * *

Upon further investigation, it was verified that the reactor building and the refueling floor radiation monitors are not needed to control the release of radiation for events described in chapter 14 of the updated Final Safety Analysis Report. For the analyzed loss of coolant accident (LOCA), the primary and secondary signals for this purpose were available and unaffected by this event. The radiation monitors provide a tertiary redundant method that is not credited within the station analysis. For all other analyzed accidents, the signal provided by the radiation monitors is not needed, as the secondary containment isolation function and start of the standby gas treatment system are not credited. Additionally, the fuel handling accident was not credible during the time of the event because no activities were in progress on the refueling floor. Therefore, the threshold for reporting the issue as an event or condition that could have prevented the fulfillment of a safety function was not met. The NRC Resident Inspector has been notified. Notified R1DO (Jackson)

The following information was provided by the licensee via email: On 2/9/24 at 1322 EST, it was determined that the unit was in an unanalyzed condition. A review of DC feeder circuit protection schemes identified a circuit for the fuel pool cooling system is uncoordinated due to inadequate fuse sizing. This results in a concern that postulated fire damage in one area could cause a short circuit without adequate protection, leading to the unavailability of equipment credited for in 10 CFR 50 Appendix R, Fire Safe Shutdown. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). The postulated event affects the following fire zones: fire areas 6S and 6N (within the Unit 2 reactor building). Compensatory actions for affected fire areas have been implemented. An extent of condition review is being performed. 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: Fire watches have been established in the affected areas. These will be maintained until the protection scheme is revised.

• * * UPDATE ON 03/08/24 FROM PAUL BOKUS TO TOM HERRITY * * *

The following updated information was provided by the licensee via email and phone call: On 03/08/24 at 1418, extent of condition reviews identified circuit(s) in the Units 2 and 3 Reactor Protection Systems (RPS) which are also uncoordinated due to improper fuse sizing. These circuits are not bounded by existing design and licensing documents for 10 CFR 50 Appendix R Fire Safe Shutdown and, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel. The postulated event affects the following fire areas: 32, 33, 38 and 39 (Units 2 and 3 Switchgear Rooms). In accordance with procedural requirements, compensatory actions for the affected fire areas have been implemented and will remain until the condition is resolved. The NRC Senior Resident Inspector has been notified. Notified R1DO (Arner)

• * * UPDATE ON 3/13/2024 AT 1538 FROM TROY RALSTON TO SAM COLVARD * * *

On March 13, 2024, at 1350 EDT, extent of condition reviews identified a circuit in the Unit 2 reactor protection system (RPS) which is also uncoordinated due to improper fuse sizing. This circuit is not bounded by existing design and licensing documents for 10 CFR 50, Appendix R, Fire Safe Shutdown, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel. The postulated event affects fire area 57 (Switchgear Corridor, common to Units 2 and 3). In accordance with procedural requirements, compensatory actions for the affected fire areas have been implemented and will remain until the condition is resolved. Additionally, it was previously reported that fire area 6N contained a circuit which was not bounded by the Fire Safe Shutdown analysis; however, after further review it has been determined that compliance is maintained in this fire area and is therefore retracted from the scope of this report. The NRC Senior Resident Inspector has been notified. Notified R1DO (Jackson)

• * * UPDATE ON 3/21/2024 AT 1525 FROM PAUL BOKUS TO IAN HOWARD * * *

The following information was provided by the licensee via email: On 03/21/24 at 1211, extent of condition reviews identified an annunciator circuit for the Unit 3 emergency service water (ESW) and high pressure service water (HPSW) pump structure heating and ventilation panel that is also uncoordinated due to improper fuse sizing. This circuit is not bounded by existing design and licensing documents for 10 CFR 50 Appendix R Fire Safe Shutdown and, therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). This event poses no impact to the health and safety of the public or plant personnel. The postulated event affects fire area 47 (Unit 3 pump structure for `B' ESW and `3A'-`3D' HPSW pumps) and the yard fire area (Manhole 026D). In order to restore immediate compliance, the cable has been de-energized to eliminate the possibility of the event of concern. This circuit will remain de-energized or other measures will be implemented until the condition is permanently resolved. The NRC Senior Resident Inspector has been notified. Notified R1DO (Ford)

The following is a synopsis of information provided by the licensee via phone call: On December 15, 2023, at 0652 EST, JAN X-ray Services received notification from the laboratory performing regularly scheduled analysis of their employee's thermoluminescent dosimeters (TLDs) that one of the units is indicating an employee received a dose of 5.729 rem. The limit is 5.0 rem. The worker is not normally involved in radiography. The licensee is investigating how the employee received the indicated dose.

• * * RETRACTION ON 01/12/24 AT 0934 EST FROM JAMES MARAMBA TO KERBY SCALES * * *

The following retraction is a summary of information provided by the licensee via email: JAN X-Ray Services requested the event be retracted based on findings that indicated that the exposure was to whole-body monitoring badge and not the individual. Notified R3DO (Szwarc) and NMSS Event Notifications via email.

The following is a synopsis of information that was provided by AMETEK Solidstate Controls Inc. via email: This component (07-020139-10) is a 13 micro-Farad AC oil filled capacitor. During operation in an inverter, oil may be visible on, around, or dripping from the capacitor or its mounting bracket or tray. If allowed sufficient time, enough oil will leak from the capacitor that it will short internally and fail. Time required for the failure could be greater than the recommended 10-year preventative maintenance cycle for this part. AMETEK Solidstate Controls has not been able to determine a definitive cause of the failure, but is working to do so. These capacitors are generally part of a larger capacitor bank. The failure would result in a reduction of output voltage that is directly proportional to the number of capacitors in the bank that fail. Any single capacitor failure would be less than a 3 volt decrease in output voltage. Users of these capacitors should visually inspect any equipment containing the capacitor part number stated above for evidence of an oil leak. A review of the output voltage for the parent equipment for any consistent decrease in voltage of 0-3V may serve as an indication of capacitor failure. The user should notify AMETEK Solidstate Controls if any oil is observed during inspection. Corrective actions should be established by May 2024. Affected plants are not listed.

• * * UPDATE ON 05/17/24 AT 1305 EDT FROM ZACHARY RUMORA TO KAREN COTTON * * *

FINAL REPORT FOR OIL FILLED CAPACITORS AMETEK Solidstate Controls Inc, (SCI) has completed their evaluation of the deviation described in their interim report submitted on February 9, 2024, and concluded that there was no way of recreating the potential defect and no evidence of a broad defect with the general design, manufacture, or use of the capacitor. However, they identified hypothesized causes of the failure and corrective actions to mitigate failure risks. AMETEK SCI also identified the end users that may be potentially affected. The affected plants are Duke Energy; Oconee and Catawba, TVA; Browns Ferry and Watts Bar; Georgia Power, Vogtle 1 and 2; Dominion; Surry; and South Texas Nuclear Operating Company. Notified R2DO(Miller), R4DO(Josey) and Part 21/50.55 Reactors (email)

The following information was provided by the licensee via fax and phone call: An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility and felt inside the control room. A release of hazardous material has not occurred. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On 11/08/2023 at 0337 MST, Urenco USA declared an Alert (EAL 5.1A) due to a seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 0559 EST (0359 MST). No radioactive release has occurred. A 5.2 magnitude earthquake occurred in western Texas with an epicenter 36.7 km west-southwest of Mentone, Texas. Plant personnel are conducting walkdowns of the site. The State and local authorities have been notified. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)

• * * UPDATE ON 11/8/2023 AT 1153 EST FROM JIM RICKMAN TO SAMUEL COLVARD * * *

TERMINATION OF SEISMIC EVENT ALERT The following information was provided by the licensee via fax and phone call: The earthquake of 5.2 magnitude in western Texas was felt in the control room. No release of UF6 was detected. Building inspections have been completed with no damage identified. This event has been terminated at 0937 MST and has entered into the recovery process. The State and local authorities have been notified. Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Miller), NMSS (Brenneman), IRMOC (Grant), OPA (Burnell). The following additional information was obtained in accordance with Headquarters Operations Officers Report Guidance: US Geological Survey (USGS) updated the seismic event to 5.3 magnitude at 10:27 on 11/08/23.

The following was received from the Illinois Emergency Management Agency (the Agency) via email: On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported. The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available. Illinois Item Number: IL230027 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.

• * * UPDATE ON 10/13/23 AT 1638 EDT FROM GARY FORSEE TO KAREN COTTON * * *

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On September 29, 2023, the Agency was contacted by Rush University Medical Center (IL-01766-01) to advise of a Y-90 Therasphere under dose that occurred the day before. The prescribed dose was 200 Gy and the prescribed activity was 45.92 mCi. The administered dose was 153.1 Gy with an administered activity of 35.15 mCi. This is a 23.5 percent deviation (under dose). The administration was determined to be clinically effective with no adverse patient impact reported. The patient and the referring physician were notified within 24 hours. Agency inspectors performed a reactionary inspection on October 3, 2023. The infusion of the Y-90 TheraSpheres went as intended with no identifiable irregularities. Post-admin calculations were performed which calculated that the dose delivered was 35.15 mCi. At this time the (accredited medical practitioner) (AMP) determined the dose delivered was 23.5 percent less than the written directive resulting in a potential medical event. The RSO interviewed all staff involved in the procedure and performed PET/CT imaging of the waste container (with dose vial, administration tubing kit, connector, extension tubing, microcatheter, forceps, etc.). This image was processed, and 3D volume renderings were utilized to identify where hot spots were located within the waste materials. Images of the waste container showed the highest activity was located in the dose vial. No additional apparent issues were discovered by the RSO. During an interview with the AMP, they stated that they tilted the dose vial back and forth to 90 degrees and tapped the vial on a hard surface. After the inspectors reviewed the procedures and through further questioning, they realized that the AMP was not tapping the vial sharply enough against a hard surface. Agency investigation findings identified the root cause of this event as inadequate agitation of the dose vial. Inspectors determined that the tapping process was not performed firmly enough against a hard surface to release the microspheres from the septum of the dose vial. This likely resulted in an increased number of microspheres remaining on the septum of the dose vial, and not released into the solution for administration to the patient. The RSO stated that they had begun the process of revising the checklist utilized during Y-90 TheraSphere procedures to better describe the dose vial preparation which includes the agitation process. Pending no further developments, this matter is considered closed. Notified R3DO (Orth) and NMSS Events Notification (email).