Event Notification Report for August 11, 2022

EN Revision Imported Date: 8/11/2022

EN Revision Text: PARTIAL LOSS OF POWER TO RPS DURING MAINTENANCE

The following information was provided by the licensee via email:

"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing lncore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to an unplanned valid actuation of a system pursuant to 10 CFR 50.72(b)(3)(iv)(B)(2). Additionally, this is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"Emergency assessment capability was restored at 1008 PDT upon system restoration."

The NRC resident was notified by the licensee.

* * * UPDATE FROM SIMEON MORALES TO DONALD NORWOOD AT 1547 EDT ON 6/16/2022 * * *

The following information was received via email:

"This event is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) only for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"The containment isolation was not due to actual plant conditions or parameters meeting design criteria for containment isolation. Therefore, this is considered an invalid actuation.

"Updated ENS Text:
"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing Incore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.

"This is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"Emergency assessment capability was restored at 1008 PDT upon system restoration.

"The plant is stable, and all effected systems have been restored.

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

"The NRC resident has been notified."

Notified R4DO (Azua).

* * * UPDATE FROM TRACY HOWARD TO ERNEST WEST AT 1853 EDT ON 8/10/2022 * * *

The following information was received via email:

"At 0923 [PDT] on June 13, 2022, a partial loss of power to the Reactor Protection System (RPS) 'B' occurred due to the inadvertent opening of circuit breaker RPS-CB-7B during thermography of RPS-PP-C72/P001. The partial loss of RPS 'B' resulted in closure of primary containment isolation valves (PCIVs) in multiple systems. No plant parameters existed which would cause the opening of RPS-CB-7B or actuation of the primary containment isolation; therefore, this is considered to be an invalid actuation of a system listed in 10 CFR 50.73(a)(iv)(B).

"The closure of PCIVs were expected responses to the partial loss of RPS 'B'.

"Circuit breaker RPS-CB-7B was closed lo restore energy lo RPS 'B' at 1008 [PDT], containment isolation valves were opened, and the affected systems were returned to normal operating conditions for the current configuration per plant procedures.

"As indicated in 10 CFR 50.73(a)(1), in the case of an invalid actuation reported under 10 CFR 50.73(a)(2)(iv)(A), the licensee may, at its option, provide a telephonic notification lo the NRC Operations Center within 60 days of discovery of the event instead of submitting a written Licensee Event Report. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73 (a)(2)(iv)(A). This actuation was invalid since it was caused by maintenance activities and not the result of actual plant conditions warranting containment isolation.

"The following additional information is provided as specified in NUREG-1022:

"The following inboard containment isolation valves were actuated when personnel inadvertently bumped into RPS-CB-7B during the removal of a panel
 RWCU-V-1 Reactor Water Cleanup Suction Inboard Isolation Valve
 EDR-V-19 Drywell Equipment Drain Inboard Isolation Valve
 FDR-V-3 Drywell Floor Drain Inboard Isolation Valve
 RRC-V-19 Reactor Water Sample Inboard Isolation Valve
 TIP-V-15 Traversing In-Core Probe Purge Isolation Valve

"All actuations occurred as designed upon the partial loss of RPS power.

"There were no actual safety consequences associated with this event since all affected equipment responded as designed.

"The NRG Residents have been notified."

Notified R4DO (O'Keefe).

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 SIR-SPHERES

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"On 8/3/2022 at 1444 EDT, the licensee reported [to the agency (MA Department of Public Health Radiation Control Program)] a medical event for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a two-site Y-90 16.2 mCi microsphere therapy treatment delivered to the patient liver on 8/2/22 remained in the delivery system causing delivery of 12.7 mCi Y-90 of the prescribed 16.2 mCi. The error was discovered the next morning during final post-treatment calculations. The administered dose to the treatment area differed from the prescribed dose by 21.6 percent. The licensee stated that the cause, including possible equipment malfunction, has not yet been determined. The prescribing physician and referring physician have been notified. The physician is to notify the patient (not yet confirmed). The licensee stated no negative health effects to the patient due to the situation. No additional Y-90 therapy treatment is expected due to this situation. The licensee stated that all Y-90 was accounted for. The licensee is to submit a written report within 15 days of discovery date. This is a next day reportable medical event per regulation.

"Investigation is ongoing. The agency considers this event docket to still be open."

MA Event Number: TBD

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: 8/8/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING CATEGORY 2 RADIOACTIVE MATERIAL SHIPMENT

The following information was received from the Massachusetts Radiation Control Program via email:

"QSA Global reported via telephone at 1400 EDT on 8/4/2022 [to the agency (MA Department of Public Health Radiation Control Program)] that a 6/30/2022 shipment from Australia, containing thirty-two Ir-192 sealed sources totaling 134 Ci and two Se-75 sealed sources totaling 8.38 Ci, was missing in transit. The shipment departed from Sydney, Australia (SYD) via Qatar Airways on or about 7/1/2022 and arrived at Chicago O'Hare International Airport (ORD). QSA Global stated last known (scanned) location was at ORD on 7/20/2022. QSA Global was informed that shipment was missing at 1345 EDT on 8/4/2022. This shipment included three 34x34x40 cm, RQ UN2916, Yellow-II, Type B packages containing Ir-192 with a Transport Index of 0.3 DIM, two 49x49x53 cm, RQ UN2916, Yellow-II, Type B packages containing Ir-192 with a Transport Index of 0.2 DIM, and one 25x21x43 cm, RQ UN2916, Yellow-II, Type B package containing Se-75 with a Transport Index of 0.1 DIM, at time of shipment. QSA updated last known location by later stating that the shipment was picked up in Chicago by Forward Air Corporation trucking company on 7/21/22 and arrived in Boston on 7/25/22 (current last known location is Forward Air facility in Boston).

"This situation is an immediately reportable event per regulation.

"Search for the missing shipment by Forward Air Corporation is ongoing.

"The agency currently considers this docket to still be open."

MA Event Docket Number: TBD

Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk.

* * * UPDATE ON 8/5/2022 AT 1532 EDT FROM TONY CARPENITO TO MIKE STAFFORD * * *

The following was received from the Massachusetts Radiation Control Program via email:

"Shipment discovered on loading dock at carrier (Forward Air Corporation) facility in Boston 8/4/22. Receiver licensee (QSA Global Inc.) reported receipt of shipment on 8/5/22 and confirmed all six individual package seals were observed to be intact."

Notified internal: R1RDO (Henrion), IR MOC (Crouch), and ILTAB (MacDonald), and via email: NMSS (Williams), INES (Smith), NMSS Events Notification, and ILTAB.

Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk.

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - ATTEMPT TO OBTAIN MATERIAL WITHOUT LICENSE

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On August 4, 2022, this Agency received information that a former licensee was trying to obtain 500 microCi of Am-241 without a license. The material would reportedly be used for calibration. The issue was reported to the appropriate Agency in California because that is where the seller is located. An informal report was made to the NRC in Arlington, Texas. It was decided that this needed to be reported to the FBI which was accomplished on this same day. The seller has reported that they will not provide a quote to the former licensee and hence will not be supplying the material. It is not clear if this is a misunderstanding or an attempt to gain material while bypassing regulations. This Agency will not investigate this matter immediately but will give the FBI some time to investigate. No further information is expected in the near future, but information will be provided when obtained per SA-300."

Texas Incident Number: I-9944

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

NON-AGREEMENT STATE - SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE

The following is a synopsis of information provided by the licensee via phone call:

On April 12, 2022, the licensee received a package containing I-131 sources. Initial receipt wipe inspection yielded a count of 7132 DPM which equates to 713.2 DPM per 100 sq. cm. A second wipe test revealed 903 DPM per 100 sq. cm. The RSO was informed, who contacted the supplier. The package was put in storage, and allowed to decay until levels were acceptable to dispose of the package.