Event Notification Report for November 09, 2020

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The following information was received via E-mail from the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB):

"Big River Electric Corporation reported a shutter failure.
KY RHB was notified via email on October 28, 2020at 1511 EDT) by a
representative from a specifically licensed facility, Big Rivers Electric Corporation, indicating that one fixed gauging device (Kay Ray Model 7062P, Serial Number 8555), containing a 10 mCi Cs-137 source located in the Reid/Green/HMP&L Station II had a shutter malfunction. The source was found to have a broken shutter arm. The gauge has been left in place and a contractor will be scheduled to service the gauge. The Radiation Safety Officer (RSO) has notified the production manager and production leaders to ensure they are aware of the issue. Reporting criteria in 10 CFR 30.50(b)(2)."

Kentucky Event Report ID Number: KY200005

AGREEMENT STATE REPORT - SHUTTER STUCK CLOSED ON NUCLEAR GAUGE

The following is a synopsis of a notification from the Oklahoma Department of Environmental Quality (OK DEQ) via telephone:

OK DEQ was notified on 10/30/2020 by Western Farmers Electric Cooperative that they had discovered a fixed gauge (Texas Nuclear 57157C), with a stuck closed shutter. Licensee plans to secure the shutter in the closed position and decommission the device.


* * * UPDATE ON 10/30/2020 AT 1716 EDT FROM KEVIN SAMPSON TO THOMAS KENDZIA * * *

The following update was received from OK DEQ via email:

"This incident was originally reported to OK DEQ in September. The gauge in question is mounted approximately 15 feet above grade and the shutter is operated by cables. In September the licensee informed [OK DEQ] that the cable system was not working but the shutter was functional. At the time, [OK DEQ] concluded that this was not reportable. On October 1, a technician was on site to repair the cable system but discovered that the shutter was now stuck in the closed position. The licensee did not report this to [OK DEQ] until today."

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

AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERS BY GREATER THAN 20 PERCENT

The following was received from Georgia Radioactive Materials Program (GA RMP) via email:

"On Oct 30, 2020, [GA RMP] received an email, from the Assistant RSO [Radiation Safety Officer, Emory University], informing [GA RMP] that a second Y-90 TheraSpheres event occurred on Oct 29, 2020.

"A patient was administered with 16.2 mCi of Y-90 TheraSpheres using a high flow microcatheter and a larger syringe. The product representative from Boston Scientific was there to consult with the authorized users and technologist prior to treatment. Once it appeared that the micro catheter and Y-90 line and vial were in proper positioning, the Y-90 was administered. Subsequently, the line was flushed three times using approximately 50-60 ml of saline.

"After the procedure, all items were surveyed and calculated that only 7.3 mCi of Y-90 was administered. Since all waste was surveyed as a whole and not independently from each item, the Assistant RSO did not have the information to discern whether residual Y-90 remained in each product (micro-catheter, line, and vial).

"Until they can determine the causes of the misadministration, Emory has halted TheraSpheres administration at Emory at Midtown, and substituted Y-90 Sirspheres where they can. Emory University Hospital also uses TheraSpheres, but has not reported any problems. Emory investigation is ongoing. [GA RMP] will provide follow-up information as it is obtained."

Georgia Incident No: 32

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.

This material event contains a "Less than Cat 3" level of radioactive material.

AGREEMENT STATE REPORT - LOST DENSITY GAUGE

The following was received from the Arizona Department of Health Services (Department) via email:

"The Department received notification from the licensee that a portable gauge was lost. A technician left the portable gauge on the tailgate of his truck while completing paperwork and then drove off. When he realized that the gauge was missing, he retraced his steps but was unable to locate it. The gauge is a Troxler 3430, Serial Number 32909, containing approximately 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241:Beryllium. The Department has requested additional information and continues to investigate the event."

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

AUTOMATIC REACTOR SCRAM DUE TO TURBINE/GENERATOR TRIP

"On November 6, 2020, at 0239 CST, Grand Gulf Nuclear Station (GGNS) experienced an Automatic Reactor Scram from 84 percent Reactor Power after a Main Turbine and Generator Trip.

"All control rods fully inserted and there were no complications. All systems responded as designed.

"Reactor pressure is being maintained with Main Turbine Bypass Valves. Reactor water level is being maintained in normal band with the condensate system.

"No radiological releases have occurred due to this event from the unit.

"The NRC Resident has been notified."

EN Revision Imported Date: 11/9/2020

EN Revision Text: UNUSUAL EVENT DUE TO EARTHQUAKE FELT ONSITE

Millstone Units 2 & 3 declared an Unusual Event at 0921 EST after an earthquake was felt onsite. The earthquake monitoring instrumentation did not actuate, and there were no station system actuations. No damage has been detected at this time.

Millstone has initiated their Abnormal Operating Procedure for an earthquake and performing station walkdowns.

The State of Massachusetts has been notified. The Waterford Police and U.S. Coast Guard have contacted the station. The NRC resident has been notified.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 11/09/2020 AT 0715 EST FROM JASON HARRIS TO THOMAS KENDZIA * * *

At 1510 EST on November 8, 2020, Millstone Units 2 & 3 exited the Unusual Event due to the earthquake following plant walkdowns that revealed no damage to plant structures, systems, or components. Station and System walkdowns identified no issues due to the earthquake. Millstone notified the State and local authorities, and the NRC Resident Inspector.

Notified R1DO (DeFrancisco), IRD (Grant), NRR (Nieh), R1RA (Lew), NRR EO (Miller), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).