Event Notification Report for April 13, 2022

EN Revision Imported Date: 4/13/2022

EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE GAUGE DISCOVERED IN SCRAP METAL

The following information was received from the Ohio Department of Health Bureau (ODH) of Environmental Health and Radiation Protection via email:

"On 3/30/22, ODH received notification of a load that tripped radiation detectors at a scrap facility in Marion, Ohio. The load returned to point of origin in Columbus, Ohio under DOT SP OH-OH-22-014. The Originator contacted ODH on 4/4/22 to report that they had surveyed the load and isolated a device that was box shaped, perhaps 8x4x4 inches. The item reportedly pegged the facility's Ludlum 19 (5 mR/hr), and was secured in a quarantine area.

"ODH staff responded to site on 4/5/22 and identified a Ronan Engineering Model RLL-1 gauge containing a 0.27 mCi Cs-137 source with a reading of 750 microR/hr on the side of the gauge. No contamination was detected. The facility will keep the device secure while disposal options are arranged. ODH will contact the manufacturer (Ronan Engineering) to attempt to identify the owner based on mode; and serial number on the device."

Ohio item number: OH220005



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: 4/13/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE

The following was received from the State of Nevada via email:

"The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site.

"The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose.

"For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem.

"However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses.

"The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place."

Nevada Event Number: NV220002

EN Revision Imported Date: 4/13/2022

EN Revision Text: PART 21 - WESTINGHOUSE ACTUATOR FULL VOLTAGE REVERSING CONTACTORS DEFICENCY REPORT

The following information was provided by the licensee via email:

"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard.

"Name and address of the individual informing the Commission:
Camille T. Zozula
Westinghouse Electric Company
1000 Westinghouse Drive
Cranberry Township, Pennsylvania 16066
(412) 374-2577
zozulact@westinghouse.com

"Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018.

"The [FVRs] are designed and qualified to open and close on demand. The FVR contactors sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position.

"Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related FVR contactors that are potentially affected between 2014 and 2022.

"Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022.

"Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding.

"Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available.

"Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts.

"Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022.

"The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event.

"Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."