Event Notification Report for April 24, 2023

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was provided by the Maryland Department of the Environment (MDE) via email:

On 04/14/2023 at 0951 [EDT], the MDE discovered an unsigned, undated report from the University of Maryland Medical Center, Baltimore, MD, that a medical misadministration had occurred on 02/28/2023. [After] contacting a health physicist and the Radiation Safety Officer (RSO) [at the University of Maryland], they confirmed that the event had actually occurred. A dose of 104.73 mCi of Ludotadipep [Lu-177] was being administered to a patient as part of a phase 1 clinical trial to treat metastasis. During the procedure, catheter infiltration (catheter movement) occurred resulting in a significant portion of the dose remaining in the upper left arm. The study sponsor was informed. Subsequent gamma scans showed that within 24 to 48 hours the dose had migrated to the intended treatment site. MDE is following up with the RSO and medical staff to confirm that the actual dose delivered to the treatment site was within 20 percent of the dose prescribed in the written directive. The University of Maryland staff has determined that an unintended dose estimated at 157 Rem had been delivered to the upper arm tissue. As of 04/14/2023, no ill effects have been observed, and the patient has been scheduled to resume subsequent treatment. This event is being reported under 10CFR 35.3045 (a)(1)(ii) B `. a dose that exceeds 50 Rem to an organ or tissue from administration of a radioactive drug containing byproduct material by the wrong route of administration'."

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 - SHIPMENT DELAYED AND SOURCES HELD AT INTERIM LOCATION

The following information was provided by the California Radiation Control Program via email:

"Industrial Nuclear Company (INC) [located in California] shipped three nominal 103 Curie Ir-192 radiography sources to Miami for export to a customer in Venezuela on 9/27/22. The sources did not reach the Venezuelan customer. The sources were reported missing by INC on 4/10/23 [the sources were never 'lost' as their whereabouts were known to be in custody]. The sources have been recovered from a common carrier warehouse in the Miami area by the Florida Radiation Control Bureau and Florida law enforcement on 4/14/23.

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

A previous notification of this matter was made to the Headquarters Operations Officer (HOO) by the Florida Radiation Control Program on 4/10/23. On 4/10/2023 at 1300 EDT, the HOO also received a phone call from INC regarding a potentially abandoned radioactive source that was originally intended to be shipped to Venezuela but was in possession of the common carrier in Doral, FL. The state of Florida provided preliminary information on the incident and will provide additional information as it becomes available.

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

NON AGREEMENT STATE REPORT - STUCK SOURCE RETRIEVED

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

At approximately 2100 CDT on 04/16/23, the radiography crew began to setup a radiograph using a SPEC-150 camera on the East Cellar Mezzanine deck on an offshore oil rig near the state of Louisiana. The radiograph began at approximately 2120 CDT. After a 3 minute exposure, the crew attempted to retrieve the source back to its shielded position in the camera. During this time, the crew noticed that the camera's source lock/plunger was not engaging. After several attempts to expose and retract the source with hopes of a proper lock engagement, the crew determined that the source was unable to return to the shielded position. The crew expanded the 2 mR/hr boundaries on all affected areas and decks with a survey meter in hand. After unsuccessful attempts to retrieve the source, the technician was finally able to fully unscrew the crank hex out of the handle. Once the inside wire was exposed, the technician manually pulled the wire and was able to get the source back into its fully shielded and locked position. No crew members were injured, and there were no overexposures during this incident.

AUTOMATIC REACTOR TRIP DUE TO A TURBINE TRIP

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

"At 0148 Eastern Daylight Time (EDT) on April 20, 2023, with Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a turbine trip. Turbine Bypass valves did not open on the trip due to Turbine Protection system power supply failure; the Safety Relief Valves (SRVs) opened automatically to control reactor pressure. Reactor Pressure reached approximately 1095 psig on the trip; exceeding the 1060 psig RPS trip setpoint.

"Operations responded and stabilized the plant. Operations was able to transition from SRVs to main steam line drains to the condenser. Reactor water level is being maintained via the Condensate / Feedwater system. Decay heat is being removed by discharging steam to the main condenser using the main steam line drains. Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Reactor water level reached low level 1 (LL1) following the reactor trip. The LL1 signal causes Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sampling isolation valves), and Group 8 (i.e., shutdown cooling isolation valves) isolations. The LL1 isolations occurred as designed; the Group 8 valves were closed at the time of the event. Due to the valid Primary Containment Isolation System (PCIS) actuation and RPS actuation from the reactor pressure signal, this event is also being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"Unit 2 is not affected by this event. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

SAFE SHUTDOWN CAPABILITY AND ACCIDENT MITIGATION

The following information was provided by the licensee via email:

"Notification per 10 CFR 50.72 (b)(3)(v)(A) and (v)(D)

"At time 1630 CDT on 4/18/23, Comanche Peak Unit 1 entered TS (Technical Specification) 3.0.3 for 11 minutes due to declaring Train A component cooling water (CCW) inoperable in conjunction with a Train B centrifugal charging pump (CCP) inoperable for scheduled maintenance. This resulted in an event or condition that could have prevented fulfillment of a safety function, high head injection of the emergency core cooling system.

"CCP 1-02 and fan cooler were tagged out of service at 0400 CDT on 4/18/23 due to scheduled maintenance activities. Containment spray (CT) pump 1-03 seal oil cooler CCW leak was found by a watchstander at 0930 CDT on 4/18/23. Engineering determined that leakage was CCW from a pipe flange weld after insulation removal and could not [determine] operability and notified control room at 1630 CDT on 4/18/23. This placed unit 1 in a TS 3.0.3 condition from 1630 to 1641 CDT for approximately 11 minutes until CCP 1-02 was restored back to operable status. CCW was declared operable at 1912 after CT pump 1-03 seal oil cooler was isolated. CT pump 1-03 remained inoperable until weld repair completed. Train A CT pump 1-03 declared operable at 1211 CDT 4/19/23.

"ENS notification should have been made by 0030 CDT on 4/19/23. This report restores compliance."

The NRC Resident Inspector has been notified.

ITEM RELIED ON FOR SAFETY (IROFS) NOT ESTABLISHED

The following information was provided by the licensee via email:

"The plant is in a safe condition.

"On April 21, 2023, Urenco, USA (UUSA) was staging a construction crane to be used the following week and failed to maintain procedural compliance while implementing IROFS50f and IROFS50g. The crane was properly permitted and placed inside the Controlled Access Area but was not properly permitted for operation. At all times the required spotters for IROFS50f and IROFS50g were in place and the movement of the crane was sufficiently controlled to restrict its movement to not swing into an area where damage could occur. However, visual indicators (reference markers) were not established as required by procedure. Spotters were in place and exercised appropriate control.

"IROFS50f/g are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61.

"Work has been stopped and the crane has been demobilized. UUSA is conservatively reporting this event under 10 CFR 70 Appendix A (a)(4)."

The licensee will notify Region 2.

* * * UPDATE ON 04/22/2022 AT 1501 EDT FROM JIM RICKMAN TO BILL GOTT* * *

"This issue has been entered into the corrective actions program as EV 160170.

"Following a more detailed review, IROFS50g was determined to be operable and adequately implemented. As a result, the appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (b)(2)."

Notified R2DO (Miller) and NMSS Events Notification (email).

REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED

The following information was provided by the licensee via email:

"At 1942 EDT on April 22, 2023, during the Beaver Valley Power Station, Unit No. 2 refueling outage, while performing examinations of the 66 reactor vessel head penetrations, it was determined that one penetration could not be dispositioned as acceptable per ASME Code Section XI. The reactor vessel vent line penetration will require repair prior to returning the vessel head to service. The indication was not through-wall as there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

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