Event Notification Report for February 25, 2022

EN Revision Imported Date: 2/25/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following information was provided by the the state of Illinois via email:

"During a 2/16/22 inspection, inspectors discovered an unreported medical event at The Carle Foundation (IL-01156-01) that occurred on December 30, 2021. No adverse patient impact reported. This was reported to the Headquarters Operations Officers on 2/17/2022.

"DETAILS: Agency inspectors performed a routine inspection on 2/16/2022, of The Carle Foundation d/b/a The Carle Foundation Hospital. During a review of Y-90 Theraspheres procedures on the afternoon of 2/16/2022, inspectors noted an unreported medical event which occurred on December 30, 2021. Inspectors noted that on 12/30/2021, a written directive to deliver 0.30 GBq Y-90 Theraspheres to the left hepatic artery was prepared; however, only 0.11 GBq (37 percent) was delivered. The licensee reported using a smaller microcatheter than usual.

"No further treatment to the patient is planned. The authorized user advised that the dose delivered was medically satisfactory for this case.

"The event remains under investigation."

Item Number: IL220005

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: 2/25/2022

EN Revision Text: AGREEMENT STATE REPORT- STUCK SHUTTERS ON TWO FIXED GAUGES

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

"The South Carolina Department of Health and Environmental Control was notified via phone at 1626 [EST] on 02/16/2022, that shutters were stuck in the open position on two different fixed gauges. The licensee is reporting that one of the fixed gauges is a Cs-137 Berthold Model LB 7440D gauging device, serial number 1678-6-88, with an activity of 150 mCi. The licensee is reporting that the second fixed gauge is a Cs-137 Berthold Model LB 7440D gauging device, serial number 1003-4-96, with an activity of 50 mCi. The licensee is reporting that the locking mechanisms for both shutters is disabled and won't allow for the shutters to close. The licensee is reporting that the gauging devices are still mounted to vessels. A Department inspector was dispatched to the facility on 02/17/22, and found the gauging devices as the licensee described. Dose rate readings using a NDS ND-2000A (calibrated 9/14/21) indicated readings as high as 1.8 mR/hr on the surface of the Cs-137 Berthold Model LB 7440D gauging device, serial number 1003-4-96, with an activity of 50 mCi. Dose rate readings using a NDS ND-2000A (calibrated 9/14/21) indicated readings as high as 2.2 mR/hr on the surface of the Cs-137 Berthold Model LB 7440D gauging device, serial number 1678-6-88, with an activity of 150 mCi. The gauges are located in a controlled area within the licensee's facility. A licensed consultant was scheduled to arrive at the licensee's facility on 02/17/22, to remove the gauges, attach a replacement shutter, and place the gauging devices in storage at the licensee's facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

EN Revision Imported Date: 2/25/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER FIXED GAUGE

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

"The South Carolina Department of Health and Environmental Control was notified via email at 1250 [EST] on 02/17/22, that during routine shutter checks a shutter was identified as stuck in the open position on a fixed gauging device. The licensee is reporting that the fixed gauge is a Cs-137 Ohmart Model SH-F1 gauging device, serial number 67581, with an activity of 100 mCi. The licensee is reporting that the gauging device is currently mounted to a vessel, in a low-traffic, and controlled area. The licensee is reporting that they will not be issuing any entry permits into the vessel until they have remediated the shutter. The licensee is reporting that the manufacturer of the gauging device has been contacted for repair. Department inspectors will be dispatched to the facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES
The following information was provided by the licensee via email:

"This 60-day optional telephone notification is being made in lieu of an LER [Licensee Event Report] submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 1316 Eastern Standard Time [EST] on January 4, 2022, during performance of isolation logic periodic testing associated with Primary Containment Isolation System Groups 2 and 6, an invalid actuation of Group 6 Primary Containment Isolation Valves (PCIVs) (i.e., Containment Atmospheric Control/Monitoring (CAC/CAM) and Post Accident Sampling (PASS) isolation valves) occurred. This resulted in a Division I CAC isolation signal, a full CAM isolation, and a full PASS isolation. Reactor Building Ventilation isolated and Standby Gas Treatment started per design. No manipulations associated with the isolation or reset logic were ongoing at the time.

"Troubleshooting determined that the Group 6 isolation signal resulted from a high resistance contact on a relay associated with the main stack radiation high-high isolation logic. This condition interrupted electrical continuity and prevented the Group 6 logic from resetting. Following cleaning of the relay contacts, the isolation logic remained in the reset state.

"The main stack radiation monitor is a shared component that sends isolation signals to Unit 1 and Unit 2. It was verified that the radiation monitor was not in trip electrically and there were no Unit 2 actuations. Therefore, the actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. As a result, this event has been determined to be an invalid actuation.

"This event did not result in any adverse impact to the health and safety of the public."

The NRC Resident Inspector was notified.