Event Notification Report for March 20, 2023

EN Revision Imported Date: 3/17/2023

EN Revision Text: CONTROL ROOM EMERGENCY VENTILATION SYSTEM INOPERABLE

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

"At 0800 on February 12, 2023, it was discovered that both trains of control room emergency ventilation system were simultaneously inoperable due to a safety injection relief valve discharging to a Unit 1 sump. This leakage in conjunction with design basis loss of coolant accident may result in radiological dose exceeding limits to the exclusion area boundary and to the control room, which is common to both Unit 1 and Unit 2. Therefore, this condition is being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(D) as an 'Unanalyzed Condition and a Condition that Could Have Prevented Fulfillment of a Safety Function.'

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

"The NRC Resident Inspector has been notified."

* * * RETRACTION FROM ROBERT TAYLOR TO DONALD NORWOOD AT 0530 EDT ON 3/17/2023 * * *

"Retraction of EN56350, Control Room Emergency Ventilation System Inoperable:

"Based on subsequent evaluation, it was determined that the control room emergency ventilation system remained operable due to the maximum measured leak rate being within the bounds of the analysis. The maximum measured leak rate of 32,594 cc/hr from the safety injection system did not challenge the calculated maximum engineered safety features leak rate of 45,600 cc/hr and remained within the current dose analysis limits. As such, this was not an unanalyzed condition and did not prevent the fulfillment of a safety function to mitigate the consequences of an accident.

"The NRC Resident Inspector has been notified."

Notified R1DO (Bickett).

MEDICAL EVENT - DOSAGE NOT IN ACCORDANCE WITH THE WRITTEN DIRECTIVE

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

On March 8, 2023 at 1230 CST, three of nine catheters of a Venezia applicator with 6.8 Ci of Ir-192 were incorrectly mapped to channels in the after loader. This resulted in a dose to the patient that was not in accordance with the written directive. This was discovered on March 9, 2023. The patient and ordering physician were notified.

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 - FOUND SOURCE

The following was received from the state of Wisconsin Department of Health Services (WI DHS) via phone and email:

"On 2/16/2023, WI DHS was notified that a citizen was in possession of a package labeled radioactive on their farm and that they had been in possession of the package for almost a year. The label on the package indicated that it contained 8.15 GBq (220 milliCuries) of Mo-99. The label on the box indicated that the intended destination was Medi-Ray. The shipper was unknown.

"On 03/01/2023, WI DHS took possession of the package and determined that it contained a Lantheus Mo-99/Tc-99m generator. The generator label indicated that it originally contained 277.5 GBq (7.5 Curies) Mo-99, with a calibration date of 04/03/2022. WI DHS confirmed that the package contents are no longer radioactive. WI DHS consulted with the NRC and determined that the event was not reportable based on the information known at the time, the lack of radioactive contents, an unidentified licensee, and an unknown common carrier.

"On 03/09/2023, WI DHS was contacted by a Lantheus representative who determined, based on the lot number, that the package was most likely originally distributed to the Medical College of Wisconsin (WI RAM license number: 079-1104-01). On 03/09/2023, WI DHS contacted the licensee to confirm if they had shipped the recovered package. On 03/09/2023, the licensee confirmed that they had possessed a generator from the identified lot number and that their records indicated a return shipment containing that generator should have been picked up for transfer to Medi-Ray by the common carrier on 04/17/2022. On 03/09/2023, Medical College of Wisconsin made an official telephone notification of a reportable event of the loss of 220 milliCuries of Mo-99.

"This investigation remains open and WI DHS is working with Medi-Ray to dispose of the generator."

Wisconsin Report ID: W1230003

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 - LOST FIXED GAUGES

The following information was received from the Arkansas Department of Health via email:

"The Arkansas Department of Health, Radiation Control Section (the Section), was notified on February 28, 2023, via a letter received from Anchor Packaging Company in Paragould, Arkansas, of two generally licensed fixed gauges that were determined to not be located on-site (GL-0010). The Section called the manufacturer on March 1, 2023, then received information on March 10, 2023, that they had no record of the gauges ever being returned to them. These gauges each contain 5.55 GBq (150 milliCuries) Am-241 -- NDC device model 102 (device SN 2844) and NDC device model 103X (device SN 13264, source SN 3576CW).

"Causes of the event are the following: the lack of effective procedures that stress the general licensee requirements, specifically those that aid accountability of sources; failure to ensure the appointing and support of the individual responsible for having knowledge of the regulations/requirements; and lack of training (though not required) needed to identify radioactive material/general license labeling and then to know what steps to take. The Section is currently working with the licensee regarding corrective actions due to a previous missing devices event, 55793."

Event Number: AR-2023-001

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 - MEDICAL EVENT

The following information was provided by the Tennessee Division of Radiological Health via email:

"The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and [the physician] connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows:

"1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy
"2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy

"Corrective actions will be sent with the follow-up NMED report."

State Event Report ID NO.: TN-23-013

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: 3/20/2023

EN Revision Text: LOSS OF RESPONSE CAPABILITIES

The following information was provided by the licensee via fax:

"On March 14, 2023, at 2000 EDT, in accordance with 10 CRFR 50.72(b)(3)(xiii). Yankee Nuclear Power Station Independent Spent Fuel Storage Installation (ISFSI) determined that the impacts of a severe winter storm have resulted in a major loss in off site response capability. Since approximately 0200, very heavy snow has fallen and greater than two feet has accumulated on site. All security related equipment has remained functional, and there have been no impacts to methods of offsite communications or emergency assessment capability. The concrete cask heat removal systems have remained operable in accordance with the NAC International multi-purpose container system (NAC-MPC) technical specifications. From approximately 0550 until 1840, offsite power was lost, and the site was powered by the security diesel generator. Periodically throughout the day, the Security Shift Supervisor was in contact with State and local police to ensure response capability. At the 2000 hours update, the law enforcement agencies reported that there were recent reports of trees and power lines being downed by the weight of the snowfall causing road closures and significantly impacting routes and response times to the site.

"The site remains fully staffed."

* * * UPDATE ON 3/17/2023 AT 1647 EDT FROM LLOYD BROOKS TO ERNEST WEST * * *

"On March 14, 2023, at 2000 EDT, in accordance with 10 CFR 50.72(b)(3)(xiii), Yankee Nuclear Power Station Independent Spent Fuel Storage Installation determined that the impacts of a severe winter storm resulted in a major loss in offsite response capability. Downed trees and power lines in conjunction with up to thirty-six (36) inches of snow prevented vehicle passage on normal response routes.

"On March 15, 2023, at approximately 1700 EDT, these roadways were passable, and employees and emergency vehicles regained normal access to the site. However, the Town of Rowe, Massachusetts police chief informed the site that the town remained in an emergency status and the roadways may need to be intermittently closed in order for utility workers to restore power lines and continue to clear tree limbs.

"On March 16, 2023, 1815 EDT, the Town of Rowe, Massachusetts police chief secured from the emergency. Therefore, this update is to inform the NRC that the Yankee Nuclear Power Station Independent Spent Fuel Storage Installation has similarly returned to baseline operations.

"NRC Region I management has been updated throughout the progression of the storm and recovery. A press release is not anticipated."

Notified R1DO (Bickett)

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 2157 EDT on 03/15/2023, with Unit 3 in Mode 1 at 18 percent power, the reactor automatically tripped due to the loss of two reactor coolant pumps when their electrical buses failed to transfer after a main generator excitation protective relay tripped.

"Operations responded and stabilized the plant. Decay heat is being removed by steam generator power operated relief valves. Units 1, 2, and 4 are not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, nonemergency 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."

EN Revision Imported Date: 3/17/2023

EN Revision Text: FAILED FITNESS-FOR-DUTY (FFD) TEST

The following information was provided by the licensee via email:

At 0845 EDT on March 16, 2023, it was determined that a contract employee supervisor failed a for-cause FFD test. The individual's authorization for site access has been terminated.

The NRC Resident Inspector has been notified.

FAILED FITNESS-FOR-DUTY TEST
The following information was provided by the licensee via email:

"On March 16, 2023, at 2226 EDT, a site supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's authorization for access to the plant has been terminated.

The Resident Inspector has been notified."

PART 21 - INCONSISTENT CRIMPING OF MOTOR LEADS

The following is a synopsis of information provided by Trillium Valves USA via fax and email:

Trillium Valves USA has identified defects in butterfly valves with Limitorque SMB motor actuators supplied to Westinghouse Electric Company from 2010 to 2016. The defect identified is inconsistent crimping of motor leads which caused lack of continuity and either intermittent function or nonfunction of the actuator motor preventing the butterfly valve to close on demand. The defect was identified on July 1, 2022. Westinghouse was notified of the affected orders on March 6, 2023. Trillium Valves USA recommends the inspection of these actuators for lack of continuity at the motor leads which may be impacted by inconsistent crimping of the lead wire to the ring tongue terminal.

Trillium Valve USA's Approved Suppliers List has been updated to add a restriction that any repairs or service of safety related equipment must be completed at Limitorque's facility. No service or repair of safety related Limitorque equipment should be performed at Trillium sites. This action was completed on March 2, 2023.

The failure to comply with initial notification and written notification has been initiated under Trillium Valves USA corrective action program. Corrective actions will include additional training on the implementation and reporting requirements under 10 CFR 21. This action will be completed by March 31, 2023.

U.S. plants affected:
Vogtle Unit 3
Vogtle Unit 4
Summer Unit 2
Summer Unit 3

Additional overseas plants affected:
Sanmen Unit 1
Haiyang Unit 1

DEFECT IN REACTOR PENETRATION WELD

The following information was provided by the licensee via email:

"On 3/18/2023 at 1410 EDT, with Nine Mile Point Nuclear Station Unit 1 in a planned refueling outage, the main control room was notified of the results of an automated examination of a dissimilar metal weld on reactor penetration N2E. The results indicate a defect present which cannot be found acceptable under ASME Section XI, IWB-3600.

"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(ii)(A) which states, `The licensee shall notify the NRC ... of the occurrence of ... any event or condition that results in: (A) The condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.'

"The NRC Senior Resident was informed. A repair plan is being developed."