Event Notification Report for June 27, 2019

AGREEMENT STATE - TWO DEVICES CONTAINING SEALED RADIOACTIVE SOURCES FOUND

The following was received from the Commonwealth of Massachusetts via email:

"This shipment containing scrap metal with radioactive material was first discovered at Sims Metal Management in North Haven, CT on June 27, 2019. As a result, SP 10656 Number CT-MA-19-01 was issued by members of the Connecticut Department of Energy and Environmental Protection and the shipment was sent back to Joseph Freedman Company in Springfield, MA. The material was received at the licensee and the radioactive items were removed, isolated, and stored in a locked 55 gallon drum on site in a secure area for further analysis.

"The site hired a contract health physics service to aid in the identification of the material and to perform radiation surveys. That occurred on 7/8/19. Two devices were discovered. The contractor provided survey information and attempted isotope identification for the two devices. One source was identified as Ra-226 and the other could not be clearly identified. Since the identification of one of the two sources was in question, the Massachusetts Radiation Control Program Director visited the site on 7/9/19 carrying multiple survey instruments for additional measurements and for visual inspection of the two units.

"One of the devices was identified as a Pyralarm Demonstrator Unit manufactured by Pyrotronics, Inc. The isotope was identified as Ra-226 with an approximate activity of 56 microCuries. The other device appeared to be an industrial nuclear gauge, but there were no legible markings on it other than a Radioactive Material sticker. The isotope identified was Am-241 with an approximate activity of 15 milliCuries as determined on 7/9/19. The spectra for this source contained peak energy channels in addition to the Am-241 peak that could not be readily identified given the proposed use of the device. It is possible other isotopes are there and we will continue to evaluate with the contractor until appropriate disposal by a licensed waste broker.

"Dose rates provided for the Pyralarm smoke detector containing Ra-226 were 37 mR/hr at one centimeter, 0.275 mR/hr at 30 centimeters and 0.42 mR/hr at one meter inclusive of approximately 0.5 cm of lead shielding. Dose rates for the unidentified gauge containing Am-241 were measured as 85 mR/hr at 2.5 centimeters and 2.8 mR/hr at 30 centimeters. The highest dose rate on contact with the storage drum containing the two devices was 0.550 mR/hr. Wipe surveys were taken on all surfaces by the contractor and there was no radioactive contamination found.

"These devices were discarded by unknown persons and are pending disposal by a licensed waste broker."

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

LOSS OF POWER RESULTED IN A VALID ISOLATION SIGNAL

"At 0937 EDT on 6/27/19, Susquehanna Unit 2 had a control power fuse fail that caused a loss of power to one of two power distribution systems of the Reactor Protection System. This loss of power resulted in a valid isolation signal and actuation of the Primary Containment Isolation System that affected multiple systems, and is reportable per 10 CFR 50.72(b)(3)(iv)(A)."

The situation has been resolved and the plant is currently using an alternate power source. Offsite power and the Emergency Diesel Generators are still available.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - UNDERDOSE TO THE LIVER

The following information is summarized from an email received from the state of Ohio:

A patient was undergoing Y-90 Therasphere treatment of both lobes of the liver. The calculations and dose were ordered for the volume of the left lobe which was 230cc. Due to a communication error, that dose was delivered to the right lobe which had a volume of 1600cc. This represents an underdose to the right lobe. The intended dose to the right lobe was 120 Gy. The delivered dose was 17.6 Gy. The licensee is evaluating additional treatment.

The patient and prescribing physician were notified.

The State will be performing an investigation.

Ohio report no.: OH190013

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.

AUTOMATIC TRANSFER OF 4-kV VITAL BUS FROM AUXILIARY TO STARTUP POWER

"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) regarding an invalid Engineered Safety Feature actuation signal.

"On June 27, 2019, at 0130 hours Pacific Daylight Time (PDT), with Unit 2 operating at 100 percent power, the U2 4-kV Vital Bus F was automatically transferred from its auxiliary power to its startup power due to an invalid loss of bus voltage signal. The cause of the invalid signal was due to a test jumper that was inadvertently left in place during surveillance testing. As a result, one auxiliary saltwater pump started and two containment fan cooler units started in slow speed.

"At 1245 PDT, Vital Bus F was transferred back from startup power to auxiliary power which is the normal plant operating configuration.

"This event was entered into the Diablo Canyon Power Plant corrective action program for resolution. This event did not result in any adverse impact on the health and safety of the public. The plant responded as expected.

"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 licensee has notified the NRC Senior Resident Inspector."