Event Notification Report for January 03, 2022

EN Revision Imported Date: 1/3/2022

EN Revision Text: AGREEMENT STATE REPORT - WORKER EXTREMITY OVEREXPOSURE

The following was received from the state of Ohio by email:

"On December 16, 2021, the Ohio Department of Health was notified by Cardinal Health 414 LLC PET Manufacturing Services that one of their employees exceeded their extremity dose limits.

"On November 26, 2021 at 0440 EST, an employee of Cardinal Health was synthesizing Fluorine-18 FDG in a mini-cell. The employee heard a sound indicating the conical reservoir cap blew-off during synthesis and opened the door to the mini-cell. He contaminated his gloves, lab coat and pants, which he removed and replaced. He did not contaminate his skin, and the licensee stated surveys were conducted showing the floor was not contaminated as a result of this event.

"The Columbus PET Manufacturing RSO (MRSO) sent the employee's finger rings and TLD to Landauer for processing. The dosimetry is sent in biweekly. For the period of November 15 to November 28, the employee received 208 mRem total DDE to the chest, 58,330 mRem to the left hand, and 6,442 mRem to the right hand.

"On December 9, 2021 the MRSO notified the Corporate RSO of the event and removed the employee from radiation related work."

Ohio Item Number: OH210011

EN Revision Imported Date: 1/3/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was provided by the Nebraska Department of Health and Human Services via email:

"During annual inventory inspection, two devices were found missing and new non-radioactive exit lights had been installed. Further investigation found that on October 11, 2021, Slater Electric of Grand Island, NE was hired to install the devices. Removal of the tritium [23 curies] devices was not part of the scope of work, but Slater took it upon themselves to remove the old devices and disposed of them in the garbage at their shop in Grand Island, NE which has since went to the landfill. To avoid future instances, Aurora Cooperative discussed with Slater Electric the importance of proper disposal of the signs containing radioactive material and steps to take if hired to do such work again. No further follow up is needed.

"Item Number: NE210004"

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

EN Revision Imported Date: 1/3/2022

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following was received from the Tennessee Division of Radiological Health via email:

"A dozer ran over a density gauge at a construction site in Oneida, TN. Source was in the shielded position. Licensee was able to fit gauge back into the case and return to their facility.

"Corrective actions will be updated with a report within 30 days."

The gauge contains a 40 mCi Am:Be-241 and an 8 mCi Cs-137 source.

State Event Report ID Number: TN-21-120

EN Revision Imported Date: 1/3/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE

The following information from the New York State Department of Health was received via email:

"The New York State Department of Health (NYSDOH) conducted a routine inspection of an x-ray registrant on October 15, 2021, where the inspector was made aware that the registrant, M & M Environmental Corporation rented an XRF Lead-in- Paint Analyzer containing 5 mCi of Cobalt-57 (Viken Pb200i; S/N 1173) without possessing a New York State Department of Health Radioactive Materials License, thereby violating the requirements in 10 NYCRR 16.100.

"Geotech Environmental Equipment, Inc. provided M & M Environmental Corporation with the rental XRF in question. M & M Environmental did apply for a New York State Radioactive Materials License in August 2021, but the license was not yet approved due to failure to respond to NYSDOH's request for additional information and still not issued to date under Licensing Action No. 2021-0557.

"The Radiation Safety Officer for M & M Environmental Corporation also mentioned on September 25, 2021, the rental XRF was reported as stolen/lost in the 42nd Street Station of New York City. This was reported to NYCPD [(New York City Police Department)]. The XRF device is still missing to date. A formal written report to NYSDOH is also pending to date in accordance with 10 NYCRR 16.15(a)(2).

"NYSDOH will continue to monitor this incident under NYSDOH Incident No. 1367. The applicant will be providing additional information on the event, corrective actions, and steps to prevent recurrence in the future. Subsequently, NYSDOH is working with Washington State Department of Health regarding the involvement of Geotech Environmental Equipment, Inc. in this incident and to identify other potential recipients in New York State that received an XRF device without a specific license in violation of 10 NYCRR 16.100."

New York Incident No.: NY-21-03


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

EN Revision Imported Date: 1/3/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the state of Nebraska via email:

"During annual inventory, it was noticed by Siouxland Ethanol that one device was missing. The device was not scheduled to be removed or replaced. Part of the mounting hardware and a small portion of the sign casing remained, but the rest of the sign was no longer intact or accounted for. [An employee] checked with maintenance who reported that they had not removed the sign and offered that by the look of what was left it looked like it may have been hit by an implement and the remainder cleaned up by staff not knowing it contained radioactive material. The sign is presumed to have been thrown away in the trash and taken to the landfill. It will be replaced with an LED. No further follow-up is needed. We spoke to them about the need for these signs to be properly disposed of as quite a few in their inventory are nearing the end of their useful life and directed them to where they could find disposal instructions."

Nebraska Item Number: NE210005


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

EN Revision Imported Date: 1/3/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSING OF PATIENT WITH YTTRIUM-90 MICROSPHERES

The following was received from the state of Washington via email.

"The patient was scheduled to receive three doses of yttrium-90 microspheres [to the liver], but only the first two doses were successfully administered. However, it appears that only five percent of the final dose was administered, and the rest was caught up in the tubing from the vial. The exact radiation dose administered is not known at this time. The licensee will investigate this event further and provide a written report."

Washington State Incident Number: WA-21-027

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

EN Revision Imported Date: 1/3/2022

EN Revision Text: MANUAL REACTOR TRIP and AUTOMATIC ACTUATION OF CONTAINMENT ISOLATION VALVES

This following information was conveyed by the licensee via phone and email:

"At 1552 EST on 12/29/21, with Unit 1 in Mode 1 at 90 percent power, the reactor was manually tripped due to reactor pressure perturbations. The cause of the reactor pressure perturbations is under investigation. Additionally, closure of [containment isolation valves] CIVs in multiple systems occurred during the trip as a result of reaching the actuation setpoint on reactor water level. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Reactor water level is being maintained via condensate / feedwater. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 2 is not affected.

"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). It is also reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of CIVs.

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

EN Revision Imported Date: 1/3/2022

EN Revision Text: HIGH PRESSURE CORE SPRAY SYSTEM DECLARED INOPERABLE
The Licensee provided the following information via fax:
"During performance of a surveillance of the High Pressure Core Spray (HPCS) service water system on January 1, 2022, the HPCS system was declared inoperable for performance of the surveillance. During the surveillance, pump discharge pressure and flow were above the action range curve specified in the surveillance. For the given flow rate, pump discharge pressure was too high. This condition prevents declaring the HPCS service water system and HPCS system operable. The HPCS service water and HPCS systems remain inoperable.

"The station entered Technical Specification (TS) 3.7.2.A and TS 3.5.1.B at 0910 [PST] on January 1, 2022. In accordance with TS 3.5.1.B, the Reactor Core Isolation Cooling (RCIC) system was verified to be operable. TS 3.5.1 Action B provides a 14-day completion time to restore HPCS to an operable status.

"All other Emergency Core Cooling systems (ECCS) are operable. This event is being reported as an event or condition that could have prevented the fulfillment of a safety function credited for mitigating the consequences of an accident per 10 CFR 50.72(b)(3)(v)(D). The HPCS system is a single train system at Columbia.

"The NRC resident has been notified."

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

The licensee is investigating the cause of the high pump discharge pressure and verifying instrumentation accuracy.