Event Notification Report for April 28, 2022

EN Revision Imported Date: 4/28/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was obtained from the state of Iowa via e-mail:

"When conducting routine shutter checks on an Ohmart/Vega SHLG-2 fixed gauge, the operator was not able to extend the plunger to move the source into a shielded position (use of hands and basic tools). The device is in a facility that is restricted access and unmanned due to chemical production. Unless manually operated for shutter checks or vessel maintenance, the standard position of this device is open. No increase of radiation levels compared to standard operating conditions. Radiation Safety Officer (RSO) has contacted Vega for corrective action guidance and direct support. Initial guidance is the application of a coil lubricant and rotating the handle. Any action above this will be performed by a Vega service technician. The Licensee has a scheduled shutdown of the production line next week when they will schedule the Vega tech for support."

"Source/Radioactive Material: SEALED SOURCE GAUGE
Manufacturer: OHMART CORP.
Model Number: A-2102 IAEA Category: 3
Serial Number: 9849CN
Radionuclide: Cs-137
Activity: 4 Ci (148 GBq)
Iowa Event Number: IA220002"

* * * UPDATE ON 04/27/2022 AT 1331 EDT FROM STUART JORDAN TO BRIAN PARKS * * *
The following information was received from the state of Iowa via email:

"Update to Iowa Event No. IA220002 involving a stuck fixed nuclear gauge shutter operating on a low pressure separator on top of a vessel within the low-density production unit. On March 30, 2022, the RSO, under the direction of the manufacturer, removed a small amount of debris, applied Kroil lubricant to the shutter plunger, and was able to successfully close the Vega SHLG-2 gauge shutter. After an additional application of the Kroil lubricant, the gauge shutter operation was back to normal without resistance and no additional actions were necessary. The manufacturer instructed the RSO to apply the Kroil lubricant annually as a preventative measure which the licensee is planning on doing and there are no generic concerns. The 30-day written report was provided to the Iowa Department of Public Health (IDPH) on April 26, 2022. There was no exposure to any individuals to radiation from this event and IDPH considers this to be closed."

Notified R3DO (Ziolkowski)

EN Revision Imported Date: 4/26/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING SOURCE

The following is a synopsis of an email received from the state of Georgia:

On April 14, 2022, the state of Georgia received the following complaint from the licensee's Assistant Radiation Safety Officer (ARSO): the licensee had a shipment of Y-90 seeds that was supposed to be delivered from Sirtex on the morning of April 11, 2022 for a procedure. The package did not arrive. The ARSO was notified on April 12, 2022 and reported the information to the state of Georgia on April 13, 2022. The package contained 81 milliCi of Y-90 spheres. The ARSO was unable to obtain any information about the location of the shipment from the common carrier.

Georgia Incident Number: 53

* * * UPDATE ON 04/25/2022 AT 0945 EDT FROM LESLINES LEVEQUE TO THOMAS HERRITY * * *

The following is update was received from the state of Georgia via email:

On April 25, 2022, Georgia received notice that the package had been located and is being returned to Sirtex. Georgia has closed the incident.

Notified R1DO (Young) and ILTAB and NMSS Events Notification via 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

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the Pennsylvania Bureau of Radiation Protection by e-mail:

"On April 18, 2022, a patient underwent a Y-90 SIR-Sphere treatment. The prescribed dosage was 7.07 milliCuries, however only 5.27 milliCuries was able to be delivered, or 74.5 percent. The apparent cause is that the blood vessel the catheter was placed in had a complicated vasculature which inhibited the flow of the spheres. No harm is expected to the patient. The referring physician and the patient have been informed."

Event Report ID Number: PA220014

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.

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the Ohio Bureau of Radiation Protection by e-mail:

"On 4/18/22, a patient was scheduled to receive 120 Gy to the right hepatic lobe of the liver [involving Y-90 TheraSpheres], however only 94.2 Gy was delivered, resulting in an underdose of 21.5 percent. The [authorized user] notified the [Radiation Safety Officer] on 4/19/22. Stasis was not reached and at this time no cause was identified."

Item Number: OH220006

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.

INVALID ACTUATION 60-DAY TELEPHONE NOTIFICATION

The following information was provided by the licensee via fax or email:

"This 60-day telephone notification is being made in lieu of an LER submittal per 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 invalid actuations of systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 0040 Eastern Standard Time (EST) on March 7, 2022, Unit 1 received inadvertent High-Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) initiation signals. Subsequently, at approximately 0148 EST on March 7, 2022, Unit 1 received inadvertent Low-Pressure Coolant Injection (LPCI) and Core Spray initiation signals. In addition, all four Emergency Diesel Generators auto started, Group 10 (Instrument Air) Primary Containment Isolation System actuations occurred, and the Residual Heat Removal (RHR) Service Water Booster pumps tripped resulting in a brief interruption (approximately 9 minutes) to the Shutdown Cooling (SDC) heatsink. Jumpers, installed per planned refueling outage activities, prevented discharge of Emergency Core Cooling Systems into the reactor. HPCI, RCIC, and RHR Loop `A' were removed from service and under clearance. RHR SDC remained operable via RHR Loop `B' and forced circulation was maintained in the reactor.

"At the time of these events, Unit 1 was shutdown for refueling and the `A' and `C' reactor water level transmitters had been isolated in preparation for planned replacement. Leak-by of the instrument isolation valves occurred on both transmitters. Leak-by on the `C' instrument occurred at a faster rate with the `A' instrument providing the confirmatory signals resulting in Low Level 2 (LL2) and Low Level 3 (LL3) indication at approximately 0040 EST and 0148 EST, respectively. All actuations occurred as designed for LL2 and LL3 signals. During these events, reactor water level remained stable at the Reactor Vessel Head Flange and the `B' and `D' reactor water level transmitters remained off-scale-high, as expected under these conditions. Therefore, the actuations were 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 (i.e., there was no low reactor water level condition). Considering the above, these actuations were invalid."

"There was no impact on the health and safety of the public or plant personnel."

UNPLANNED CONTAMINATION EVENT

The following information was provided by the licensee via email:

"The plant is in a safe configuration. NRC Region II re-exited an inspection on April 26, 2022 from an inspection which was conducted March 21st through the 24th. During this exit, an event was reclassified as a Non-Cited Violation for failure to report an event. As a result, UUSA [Urenco-USA] is reporting this event as a 24-hour Report per the NRC's inspection.

"On February 28, 2022, water was discovered on the floor of the Liquid Effluent Collection and Transfer System (LECTS) room. The water was leaking from the slab tanks berm into the non-Radiological Controlled Area floor. The area was conservatively and promptly roped off and signage was posted. Radiological readings in the area were taken and found to be less than background and the the spill was cleaned up that day.

"Historical issues are being reviewed and will be added to this notification per the NRC's position shared with UUSA.

"This issue has been entered in UUSA's corrective action program as EV 149668 and 149975."