Event Notification Report for November 07, 2022

EN Revision Imported Date: 11/7/2022

EN Revision Text: AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL PACKAGE LOST IN TRANSIT

The following information was received via email:

"The Illinois Emergency Management Agency (the Agency) was contacted on 8/16/22 by GE Healthcare to advise that a radiopharmaceutical package containing one vial of Iodine-123 had not arrived at a Rochester, NY radiopharmacy as scheduled. The package contained one vial of Iodine-123 with an activity of 20 millicuries at the time of shipment (shipment date 8/11/2022). The last confirmed scan was 8/11/2022, at 1721 EDT, at the Greater Rochester International Airport. The package now contains approximately 0.0206 microcuries. The licensee is in continuous communication with the carrier, who is still actively looking for the package. This matter has a 30-day reporting requirement to the US NRC and is being phoned into the NRC HOO under event number IL220029. There is no indication of intentional theft or diversion, and the contents would not be useful for illicit intent."

Illinois Reference Number: IL220029

* * * UPDATE FROM GARY FORSEE TO LLOYD DESOTELL AT 1658 EDT ON 11/04/2022 * * *

The following information was provided by the Illinois Emergency Management Agency via email:

"The lost pharmaceutical package has been located and delivered."

Notified R3DO (Ruiz). Notified NMSS Events Notification and ILTAB 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

EN Revision Imported Date: 11/4/2022

EN Revision Text: POTENTIALLY CONTAMINATED INDIVIDUAL TRANSPORTED TO HOSPITAL

The following information was provided by the licensee via fax:

"On 10/7/2022 at 0050 CDT, a potentially contaminated individual was transported off-site via ambulance to a local hospital. Due to the nature of the medical condition, an initial on-site survey for radioactive contamination was not performed prior to transport. Prior to arrival at the hospital, it was confirmed the individual and [the individual's] clothing were not radiologically contaminated. Follow-up surveys performed by radiation technicians identified no radiological contamination of the ambulance and response personnel. This event is being reported per 50.72(b)(3)(xii) - 'Any event requiring the transport of a radioactively contaminated person to an offsite medical facility for treatment.' The NRC Resident Inspector has been notified."

EN Revision Imported Date: 11/7/2022

EN Revision Text: AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL PACKAGE LOST IN TRANSIT

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was notified after hours on 10/27/22, that a radiopharmaceutical package containing 4.089 mCi of In-111 was reported as lost while in the care of a common carrier. This does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. Details on the package and shipment are provided below. TN [Tennessee Department of Environment and Conservation] program have been notified along with the US NRC Operations Center.

"The package was shipped 10/13/22, from the licensee's facility in Arlington Heights, IL to Isologic Innovative in Burlington, Ontario Canada. The package made it to the [common carrier] hub in Memphis, TN under tracking number [REDACTED]. Thereafter, it could not be accounted for and was declared lost on 10/27/22. The package activity was 4.089 mCi at time of shipment, but has decayed to approximately 0.127 mCi at this time [10/28/22].

"Updates will be provided as they become available."

Illinois Event Number: IL220041

* * * UPDATE FROM GARY FORSEE TO LLOYD DESOTELL AT 1349 EDT ON 11/04/2022 * * *

The following information was provided by the Illinois Emergency Management Agency via email:

"The package has been located and delivered as intended. The Agency considers this matter closed."

Notified R3DO (Ruiz). Notified NMSS Events Notification and ILTAB 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

HIGH EXPOSURE READ ON TLD

The following information was provided by the the California Radiation Health Branch (RHB) via email:

"On 10/27/2022, the licensee was notified by their dosimetry provider that an employee's whole body thermoluminescent dosimeter (TLD) had a high dose for the reporting period ending in October 2022.

"Readings were as follows: Deep dose - 11,688 mrem, shallow dose - 11,942 mrem, and eye dose 11,964 mrem. The licensee started to investigate by speaking with the employee and informed him that he was not to use the nuclear gauge until the investigation was concluded.

"The alternate radiation safety officer (ARSO) then made a telephone report to RHB South on 10/28/2022."

California Event Number: Not yet assigned.

* * * RETRACTION ON 10/31/2022 AT 1308 EDT FROM ROBERT GREGER TO ERNEST WEST * * *

"[RHB] would like to retract the attached event notification that was submitted Friday, 10/28/2022.

"[RHB's] reason for retracting the notification is that it was reported prematurely since an investigation to [validate] the dose provided by the dosimetry vendor has not been completed, and the 30-day reportability period has only begun. If the investigation determines the dose to the individual exceeded 5 rem whole body, it will be reported accordingly."

Notified R4DO (Agrawal) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - STUCK SHUTTERS

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 10/31/22 that three fixed gauging device shutters were stuck in the closed position. All three fixed gauging devices are Thermo Fisher Scientific Model 5197 gauging devices, serial numbers B7842, B7847, and B7841. The activity of each gauging device is 100 mCi of Cs-137. The licensee is reporting that all three fixed gauging devices are mounted 12-15 feet above accessible areas. No elevated exposure rates are being reported. Department inspectors will be dispatched to the facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

South Carolina Event Number: To be assigned.

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the Washington State Department of Health via email:

"On 10/31/2022, a licensee, University of Washington - License Number: C001-1, reported that a 12.4 mCi Ni-63 source was leaking. The source was part of a Hewlett Packard electron capture detector (ECD) (Hewlett Packard, Model# G1223A, Source Serial # F5941). A pre-disposal wipe test of the ECD contained in a gas chromatograph (Hewlett Packard Model#5890) was performed on 10/25/22 after receiving the gas chromatograph from its owner for disposal. On 10/25/2022, the wipe test results indicated that the ECD had more than 0.005 microcuries of removable contamination. This device will be sent to NRD Static Control, LLC for recycling/disposal."

WA incident event number: WA-22-020

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ENGINEERED SAFETY FEATURE ACTUATION SIGNAL

The following information was provided by the licensee via email:

"This 60-day telephonic notification is being made in lieu of a licensee event report submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to an invalid engineered safety feature actuation signal.

"On September 6, 2022, at Waterford 3, while performing a plant protection system (PPS) power supply check, technicians observed an abnormally high voltage output. When the technicians opened the PPS bay cabinet door to adjust the voltage, they then observed low voltage indications. The direct cause of this issue is believed to be vibration induced relay chattering or an intermittent connection issue when opening the rear doors of PPS cabinets. This resulted in half the logic being met for the Engineered Safety Feature Actuation Signal (ESFAS) signals to fully actuate. The ESFAS signal opened the following valves: EFW-228A (EFW to SG 1 Primary Isolation), EFW-229A (EFW to SG 1 Backup Isolation), EFW-228B (EFW to SG 2 Primary Isolation) and EFW-229B (EFW to SG 2 Backup Isolation). This was a partial actuation of ESFAS. Affected plant systems functioned successfully.

"The inadvertent actuation was caused by a spurious signal and was not a valid signal resulting from actual parameter inputs. The 1992 Statements of Consideration define an invalid signal to include spurious signals including jarring of a cabinet door. In accordance with 10 CFR 50.73(a)(1) a telephone notification is being made in lieu of submitting a written licensee event report. The NRC Senior Resident Inspector has been notified. These events did not result in any adverse impact to the health and safety of the public."

BOTH TRAINS OF CONTROL ROOM AREA VENTILATION AIR CONDITIONING SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 0006 CDT on 11/04/2022, it was discovered that both trains of control room area ventilation air conditioning systems were simultaneously 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).

"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:

With both trains of control room area ventilation air conditioning systems inoperable, the plant entered a 72 hour limiting condition for operation (LCO). One train had been restored at the time of report which extends the LCO to 30 days.

CONCURRENT REPORT - ONSITE FATALITY

The following information was provided by the licensee via email:

"BWXT is making a concurrent report to the NRC for an OSHA reportable event under 29 CFR 1904.39 'Recording and Reporting Occupational Injuries and Illnesses.' BWXT reported this event to OSHA at 0930 EDT on November 4, 2022.

"On Friday November 4, 2022, at 0530 EDT an employee was found unconscious in his office area, by his co-workers. Co-workers began CPR and tried to resuscitate the employee, until the emergency team was able to respond. The emergency team responded and continued to perform medical treatment. The employee was transported to Lynchburg General Hospital. The medical providers were unable to resuscitate the employee. At this time, the cause of death is not considered work-related."

NRC Resident Inspector was notified.

PART 21 - PRIMARY/SECONDARY POWER SUPPLY FAILURES
The following is a summary of information provided by United Controls International (UCI) via email:

"On September 7, 2022, Dominion's Surry Power Station notified UCI that 3 Schneider Electric P/N: ASP840-000 Modicon Primary/Secondary Power Supply units failed to operate several days after installation at Dominion's Surry Power Station with hard failures that shutdown the associated [programmable logic controller]. The units were returned to UCI and initial observations indicated heavy shipping damage that was not present when initially supplied. Further evaluation of the damaged components requires manufacturer evaluation due to item complexity and proprietary design documentation. Investigation into the root cause(s) of the failures is ongoing. Evaluation of whether these failures represent deviations or failures to comply that would be associated with substantial safety hazards will be complete by January 3, 2023."

Contact Information: Anu Kulkarni, Quality Assurance Manager United Controls International (700- 496-1406)

MANUAL SCRAM DUE TO RISING WATER LEVEL
The following information was provided by the licensee via email:

"On November 4, 2022, at 1400 hours, with Unit 2 (U2) in Mode 1 at 100 percent power, a manual scram was inserted on U2 due to rising reactor water level, which occurred following an unexpected opening of the 2B Feedwater Regulating Valve. Following the reactor scram, reactor water level decreased to approximately 0 inches, which resulted in an automatic Group II and Group III isolation (expected response). 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 Procedures 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."

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following information was provided by North Carolina Department of Health and Human Services via email:

"Licensee reported a portable nuclear gauge [Troxler model 3400 containing Cs-137 and Am-241 sources] was damaged by a work truck at a construction site on 11/4/22. Inspector was dispatched to investigate immediately. The technician utilizing the gauge was able to cordon off the area to secure the gauge. Licensee was able to retrieve the gauge and verify the source rod was intact and retracted back into the gauge. Surveys confirmed the sources were intact and in the shielded position. The gauge sustained damage to its outer housing and is being transported to the manufacturer for repair.

"More information will be provided to close and complete this report."

NC Event No: TBD

NON-AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was provided by the licensee via phone:

On November 5, 2022 at 2230 HST, Engineering & Inspections, Hawaii was performing radiography operations at a refinery using a QSA 880 Series Delta camera (Industrial Nuclear Model 7 source containing 84 Ci of Ir-192) when the source became stuck. Attempts to retrieve the source resulted in breaking the drive cable. The source remains in the guide tube. The licensee placed lead shielding around the source and is continuously monitoring the area. No overexposures were reported.

The licensee is attempting to contact Industrial Nuclear Corporation and QSA Global for assistance in retrieving the source.