Event Notification Report for July 05, 2022

EN Revision Imported Date: 6/27/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING LICENSED MATERIAL

The following was received from the state of South Carolina via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone on 11/18/2019 that two Ba-133 sources (Isotope Product Laboratories Model PHI-133 GFS series, serial numbers XX-621 and XX-622) contained in a Marconi Medical Systems BEACON non-uniform attenuation correction device (Model N211xxx series source housing) attached to a Marconi Axis camera were lost and could not be found. According to the licensee's report, on 04/18/2017 the camera was de-installed by a vendor and shipped to a scrap metal dealer in North Carolina. The estimated activity at deinstallation on 04/18/17 was 2.4 mCi total. Details of the event were provided to the North Carolina Agreement State Program on 12/18/2019.

"This event was entered into NMED in 2019, the NMED reference number 200018."



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: 6/27/2022

EN Revision Text: AGREEMENT STATE REPORT - TREATMENT SEEDS RELEASED TO PUBLIC SEWER

The following was received from the State of South Carolina via email:

"On March 10, 2021, the inspector received a telephone message recorded at 7:30 a.m. [EST] from McLeod Regional Medical Center (Lic No. 139) to report an incident that occurred at their facility. The chief medical physicist at the hospital, called to report that at approximately 1:30 p.m., a member of the Day Hospital nursing staff flushed three implant seeds down the toilet into the sanitary sewer. The inspector called to get additional information about the incident.

"On March 9, 2021, at approximately noon, a patient had prostate seed implantation to act as a boost to the external beam treatment. Following the implantation, the patient passed three Theragenics Model 200 Pd-103 seeds with activity of 1.3 milli-Curie each (3.9 milli-Curie total).

"On March 12, 2021, the inspector travelled to McLeod Regional Medical Center to talk to the Chief Medical Physicist, Radiation Safety Officer, and other staff to find out additional information about the incident. During the review, the inspector was informed that a nurse did as she was instructed about straining the patient's urine but did not know the next steps once the implant seeds were filtered out. The nurse stated that she was told by another unnamed nurse that they could be flushed. This goes against the procedures that state that a member of health physics is to be informed, and will pick up the seeds once strained. Nursing is supposed to use the available seed recovery kits when a situation like this occurs. Because the toilets flow directly into the public sewer system, the seeds were irretrievable. Additionally, the licensee has procedures in place that state that a urologist will be present to perform a cystoscopy upon the conclusion of the implantation to ensure that there are no seeds in the bladder. This was not performed on the patient before his release to the Day Hospital staff.

"Both health physics and nursing explained that there has been a high turnover in nursing and that the training should be performed more frequently to ensure compliance from the staff. They are changing the policy to increase the training from annual to at least quarterly to address communication, training, and turnover issues. Day Surgery management stated that they plan to retrain monthly."

NMED #210164


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: 6/27/2022

EN Revision Text: AGREEMENT STATE REPORT - OCCUPATIONAL OVEREXPOSURE

The following was received from Illinois Emergency Management Agency (the Agency) via email:

"The Agency was notified on 6/24/2022, that an employee at Decatur Memorial Hospital handled a vial of F-18 and may have received an extremity dose in excess of 2.5 Gy (250 rad). The exposure reportedly occurred on Monday, June 20, and was not reported timely. Agency staff will perform a reactionary inspection at 0600 CDT, Monday, June 27, when licensee staff are back on site.

"Agency inspectors were contacted via email by the RSO [(Radiation Safety Officer)] designee for Decatur Memorial Hospital (RML, IL-02444-01) on 6/22/2022, to advise an operator grabbed a reaction vessel vial containing 10 mCi of F-18 FDG [(fluorodeoxyglucose)] for roughly 20 seconds in order to save a production run. NOTE: The reported activity was updated on 6/24/2022, to 10 Ci. Reportedly, the employee was training a new operator and noticed during synthesis, the reaction vessel wasn't placed in the heating apparatus and synthesis would fail. He opened up the mini cells and placed the vessel into the correct spot with his gloved hand. At that time, both Agency and licensee staff estimated the exposure to the hand to be in the range of several hundred millirem to possibly over the 50 rem occupational limit. The licensee was instructed to expedite processing of the employee's extremity and whole-body badges and conduct a time-motion study to determine if occupational limits had been exceeded. During a phone discussion with the licensee on 6/24/2022, the license corrected previously provided information and stated the production vial contained 10 Ci of F-18. Agency staff immediately made a second call to the licensee's on-duty pharmacist to confirm. At 10 Ci, Agency staff estimate the operator's actions may have caused or threatens to cause a shallow dose equivalent to the extremities of 2.5 Gy (250 rad) or more. This is based on a 20 second contact time with a vial containing 10 Ci of F-18 and using a 1cm distance. Clarification will be obtained on 6/27/2022, during a reactionary inspection to perform a time motion study. The Agency is awaiting the dosimetry results."

Illinois Item Number: IL220022

AGREEMENT STATE REPORT - IRRADIATOR POOL WATER EXCEEDED CONDUCTIVITY LIMIT

The following is a synopsis of information received from the state of Nebraska via phone:

This report is being made in accordance with the corresponding 10 CFR 36.83(a)(10) requirement if "Pool water conductivity exceeding 100 microsiemens per centimeter" occurs.

On 6/22/22, the licensee began having problems with the irradiator pool heat exchanger and condenser. On 6/23/22, the licensee noticed that the pool water was cloudy and conductivity began to increase. Conductivity exceeded 20 microsiemens per centimeter and the licensee began investigating to determine the cause. On 6/26/22, the licensee identified that conductivity had exceeded 100 microsiemens per centimeter and found a pinhole sized leak in the heat exchanger that was leaking Freon and oil into the pool. The highest conductivity noted was 160 microsiemens per centimeter.

The licensee is currently filtering the pool water. They are also working to have the heat exchanger replaced.

There was no excess external radiation received by any workers.

AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG LOCATION

The following information was received from the state of Colorado via facsimile:

"On June 24, 2022, a patient was prescribed 1.45 GBq (39.2 mCi) of Y-90 microspheres (TheraSphere) to the right lobe of the liver, lobe estimated size of 474 grams, for a target dose of 148 Gy. However, imaging after the administration indicates that the dose was incorrectly delivered to the left lobe of the liver, lobe estimated size of 283 grams, for an estimated delivered dose of 240 Gy. The preliminary cause is based on the patient's anatomy with the left hepatic branch close to the intended treatment site. The physician's office is reaching out to the patient to notify them but has not been able to at the time of this initial notification."

Colorado Event Report ID No.: CO220019

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 - LOST AND FOUND SOURCE

The following is a summary of a report received from Florida Bureau of Radiation Control (the Bureau) via email:

On February 24, 2022, at 0920 EST, the Vice-President of Imaging Physics at Landauer Medical Physics at the Cleveland Clinic Martin South Hospital called the Bureau to report a missing source. A 15 mCi Co-57 Med 3709 (s/n 2281-093, reference date February 1, 2022) source was ordered from Primestar to be delivered to the Nuclear Medicine (NM) Department. The order shipped January 12, 2022, at 1104 EST, and delivery was signed for, but the individual who signed for delivery did not remember seeing a radioactive box. The source was never received in NM. The South Hospital facility and all other NM departments checked for the source the week of the February 14 but were unable to locate it. The source was considered missing/lost by February 21, 2022.

The Bureau received an update on February 25, 2022, at 1647 EST. The Department Heads met to see how something could be received and not accounted for. The theory was that the person that signed for the package did not have the best handwriting, and the intraoffice label may have been misunderstood, sending it to nutrition instead of nuclear. A search of the nutrition storage shed at the South Hospital revealed the source. The shed is a secure, unoccupied space away from any staff, with limited access. This incident is considered closed.

Florida Incident Number: FL22-027

INVALID SPECIFIED SYSTEM ACTUATION

The following information was provided by the licensee via phone and email:

"This non-emergency notification is being made pursuant to the provisions of 10 CFR 50.73(a)(1) to report the occurrence of an invalid automatic actuation satisfying the reporting criterion of 10 CFR 50.73(a)(2)(iv)(A), specifically for the actuation of one train of the Essential Service Water (ESW) system that occurred on May 1, 2022.

"On May 1, 2022, with the plant shut down and the core offloaded, control room personnel were performing a fast power transfer from Engineered Safety Feature (ESF) transformer XNB02 to ESF transformer XNB01. In anticipation of this activity, the `B' load shedder and emergency load sequencer (LSELS) had been removed from service. Also, at the time, a portion of the `A' ESW train was isolated to support performance of a local leak rate test (LLRT) of a containment isolation valve in the affected portion of `A' ESW train piping. Service Water was supplying cooling water flow to `A' train loads (in lieu of ESW cooling water). When the power transfer was performed, an unexpected automatic start of the `A' ESW pump, along with some associated, automatic valve repositioning, occurred.

"The actuation occurred due to inadvertent satisfaction of automatic start logic for the ESW pump. The logic is intended to detect loss of ESW flow when the opposite train LSELS isolates Service Water during an undervoltage condition on a safety bus. The flow transmitter involved in the actuation is situated in a portion of the ESW piping that was isolated for the LLRT. The low-flow signal from the transmitter was consequently not reflective of low cooling water flow to plant loads in light of the fact that cooling water flow was being supplied to plant loads and the transmitter was locally isolated. In regard to the ESW train actuation, therefore, although the undervoltage signal was considered a valid signal due to the voltage drop caused by the fast transfer activity, the low-flow signal from the noted transmitter was considered to be invalid.

"For this invalid actuation, it was concluded that the actuation was not part of a pre-planned sequence, that the affected system was not properly removed from service during the occurrence, and that the safety function had not already been performed relative to the occurrence.

"[The] NRC Resident Inspector has been notified and an email of this report has been sent to hoo.hoc@nrc.gov."

EN Revision Imported Date: 7/1/2022

EN Revision Text: MANUAL SCRAM DUE TO LOSS OF TRANSFORMER

The following information was provided by the licensee via phone and email:

"At 1445 [CDT] on June 30, 2022, with Grand Gulf Nuclear Station in Mode 1 and at 100 percent power, the reactor was manually scrammed due to the loss of balance of plant (BOP) transformer 23. All control rods fully inserted into the core and all systems responded appropriately.

"Reactor level is being maintained with condensate and feedwater. Reactor pressure is being maintained with turbine bypass valves. The cause of the loss of BOP transformer 23 is under investigation at this time.

"Standby Service Water 'A' and 'B' were manually initiated to supply cooling to Control Room A/C, ESF switchgear room coolers, and plant auxiliary loads.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B) as an event or condition that resulted in actuation of the Reactor Protection System and 10 CFR 50.72(b)(3)(iv)(A) due to the actuation of Standby Service Water.

"The NRC Senior Resident Inspector was notified."

PART 21 REPORT- FAILURE OF FLOWSERVE SOLENOID COIL

The following is a synopsis of information received via facsimile:

A Model 38878-8 solenoid valve failed a routine coil resistance test at Catawba Nuclear Station while installed on a feed water isolation valve actuator. The solenoid valve was returned to Flowserve where the low resistance was confirmed. The solenoid coil was then sent to the Original Equipment Manufacturer (OEM) for further evaluation.
The OEM (Ohmega) completed their analysis and found the reason for failure to be associated with the magnet wire, but the exact point of failure could not be located due to the construction of the coil.
Additionally, Flowserve compiled shipment data for the subject coil and found there to be at least 273 instances where the part was shipped to customers. Of those 273+, this case is the only known instance of a failure associated with the coil.

Sites that Flowserve shipped the Model 38878-8 Solenoid Valve to: Comanche Peak, Catawba, Braidwood, Byron, Beaver Valley, Seabrook

Due to the rigorous functional testing and the historical reliability of the coil in the field, Flowserve does not believe this incident is indicative of an issue with the manufacturing or testing of the coil and concludes that this issue does not affect other coils currently in service.
Ohmega suggests a possible manufacturing improvement of winding the coil with a varnish to provide extra insulation of the magnet wire.
Flowserve suggests that plant operators using these solenoid coils measure the resistance of the coil periodically, especially after the coil has been energized for testing or service.

REACTOR MANUAL SCRAM DUE TO LOWERING REACTOR WATER LEVEL

The following information was received from the licensee via facsimile:

"On July 4, 2022 at 0104 CDT, with Unit 2 in Mode 1 at 100 percent power, a manual scram was inserted on U2 due to lowering reactor water level, which occurred following an unexpected closure of the 2A Feedwater Regulating Valve. Following the reactor scram, reactor water level decreased to approximately minus 16 inches, which resulted in an automatic Group II and Group III isolation (expected response). Following the scram, reactor water level rose to plus 75 inches resulting in a trip of all three Reactor Feedwater Pumps. At 0114 CDT, Reactor Water Level lowered to less than the Feedwater Pump High Level Trip setpoint and the 2C Reactor Feedwater Pump was restarted. Reactor Water Level control has been established in a normal band. The cause and details of the event are under investigation.

"The Unit 2 scram was not complicated. Operations responded using the Emergency Operating Procedure and stabilized the plant in mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"Unit 1 was unaffected by the event and remains at 100 percent power.

"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).

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

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

The licensee will notify the Illinois Emergency Management Agency.

BOTH TRAINS OF STANDBY GAS TREATMENT INOPERABLE

The following information was received from the licensee via email:

"At 0130 CDT on July 4 2022, it was discovered both trains of Standby Gas Treatment System were simultaneously inoperable due to failure to reach required flow rates. Both trains were capable of starting but failed to reach the required flow of 4000 SCFM. Secondary Containment differential pressure was not able to be maintained at greater than or equal to 0.25 inches of vacuum water gauge, causing Secondary Containment to also be inoperable. Due to this inoperability, the system was in a condition that could have prevented the 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)(C) and 10 CFR 50.72(b)(3)(v)(D).

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