Event Notification Report for August 03, 2020

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the Texas Department of State Health Services (the Agency) via email:

"On August 4, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that an event occurred during the administration of Y-90 TheraSpheres on August 3, 2020. The RSO stated the written directive prescribed dosage was 22.3 mCi. During the administration of the TheraSpheres, the pressure observed by the Authorized User (AU) became significantly less than expected, and activity leaving the dose administration vial into the catheter decreased significantly before the entire dose could be delivered. The RSO stated a TheraSpheres (Boston Scientific) representative was present during the procedure and assisted the authorized user through troubleshooting, and remote consultation with TheraSpheres medical specialists. However, flow from the dose administration vial could not be re-initiated. The AU chose to end the procedure.

"Following survey of the dose administration vial in the hot lab, it was determined that approximately 7.1 mCi (31.8 percent) was delivered to the patient. The RSO stated that their initial assessment is that this was the result of a device malfunction. There were no adverse effects to the patient. It is likely that a second procedure will be scheduled to complete the procedure. The RSO stated that the patient and referring physician were notified.

"This is the first event involving TheraSpheres reported to the Agency by this licensee.

"The RSO stated additional information on the event will be provided within the next 10 days. Additional information will be provided as it is received by the Agency in accordance with SA-300."

Texas Incident Number: 9782

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 - MISSING SHUTTER ON FIXED GAUGE

"On August 3, 2020, during a routine inspection, the Department [Arizona Department of Health Services] discovered that the licensee had a shutter go missing from a fixed gauge in November of 2016. The radiation safety officer was attempting to perform a lock-out procedure when he realized that the entire shutter mechanism was missing from the unit. The gauge was a Texas Nuclear Corporation Model 5192, SN: B4192, containing 100 milliCuries of Cs-137.

"The Department has requested additional information and continues to investigate the event."

Arizona Incident: 20-013.

UNUSUAL EVENT DECLARED DUE TO A LOSS OF OFFSITE POWER

At 2312 EDT, on August 4, 2020, Brunswick Unit 1 declared an Unusual Event due to a loss of offsite power. The unit was at approximately 20 percent power and was not synced to the grid when the unit automatically scrammed. All control rods fully inserted. Emergency Diesel Generators started and began powering the safety buses. Safety systems actuated as expected.

The Unit also experienced a loss of Fuel Pool Cooling and Cleanup System, but one pump was returned to service.

Unit 2 remains at 100 percent power and is unaffected.

The licensee notified State and local governments, as well as the NRC Resident Inspector.

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


* * * UPDATE FROM MARK TURKAL TO DONALD NORWOOD AT 0120 EDT ON 8/4/2020 * * *

"At approximately 2302 EDT, a loss of offsite power occurred on Unit 1. This resulted in a Reactor Protection System (RPS) actuation. Per design, emergency diesel generators 1 and 2 properly started and loaded to their respective emergency buses. The Reactor Core Isolation Cooling (RCIC) system was manually started and is being used to control reactor water level. The High Pressure Coolant Injection (HPCI) system was manually started and is being used for pressure control. As previously reported, an Unusual Event was declared at 2312 EDT due to the loss of offsite power. At the time of the event, Unit 1 was in the process of shutting down for maintenance associated with a ground on the main generator.

"Due to the RPS actuation while critical, this event is being reported as a four-hour, nonemergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"As a result of the reactor trip, reactor water level reached low level 1 (LL1). The LL1 signal causes a Group 2 (i.e., floor and equipment drain isolation valves), Group 6 (i.e., monitoring and sample 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. Per design, the loss of offsite power also caused a Group 1 (i.e., main steam isolation valve) isolations.

"Due to the Emergency Diesel Generator and Primary Containment Isolation System (PCIS) actuations, this event is also being reported as an eight-hour, nonemergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"Unit 2 was not affected. There was no impact to the health and safety of the public or plant personnel. The safety significance of the event is minimal. All safety related systems operated as designed.

"Investigation of the cause of the loss of offsite power is in progress."

The licensee notified the NRC Resident Inspector. Notified R2DO (Inverso).

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following is a summary of information received from the Alabama Department of Public Health via telephone:

On August 3, 2020 at approximately 1700 CDT, the licensee was working at an asphalt plant in Mulga, AL, when one of its radiography cameras was damaged. The source of the radiography camera was being exposed when a magnetic stand, which was attached to the source, fell and crushed part of the guide tube. Multiple efforts to retrieve the source were unsuccessful. The licensee's radiation safety officer (RSO) responded to the scene. The RSO was able to retract the source after cutting part of the guide tube.

No un-badged personnel received any dose as part of the event and applicable dosimetry badges have been sent for emergency processing. The camera is being sent to the manufacturer for investigation.

Alabama Incident Report No.: 20-16

PART 21 REPORT - DEFECT OF MASONEILAN 8012N-3C ELECTROPNEUMATIC POSITIONER

The following was received from the licensee:

"On August 3, 2020, Entergy Operations, Inc. (Entergy) completed an evaluation of a deviation at Waterford 3 which concluded the condition constitutes a defect pursuant to 10 CFR 21. The Waterford 3 Site Vice President was notified of the result of this evaluation on August 10, 2020.

"The Masoneilan 8012N-3C electropneumatic positioner installed on Emergency Feedwater Valve EFW-223A locked during as-found diagnostic testing. Failure analysis concluded that the condition was due to an internal failure of the magnet-coil assembly due to the magnet base had poor solder joints. This has been attributed to a manufacturing defect. Entergy concluded that this condition could affect the ability to properly respond to an Emergency Feedwater Actuation Signal / Main Steam Isolation Signal if present on any of the four air operated Emergency Feedwater to Steam Generator flow control valves; therefore, it could have created a substantial safety hazard."

Licensees affected: Waterford.

The licensee notified the NRC Resident Inspector.

Notified R4DO and the Part 21 group via email.