Event Notification Report for August 26, 2020

EN Revision Imported Date: 10/22/2021

EN Revision Text: DESIGN CHANGE ALTERED BASIS FOR ITAAC

"In accordance with 10 CFR 52.99(c)(2), as described in NEI 08-01, 'Industry Guideline for the ITAAC Closure Process Under 10 CFR Part 52,' Vogtle Units 3 and 4 Construction is making this notification to the NRC for determining that Inspections, Tests, Analyses and Acceptance Criteria (ITAAC) 2.5.02.07a (Index No. 534) and ITAAC 2.5.02.07e (Index No. 538) for both units require additional actions to restore their completed status. The ITAAC Closure Notifications for ITAAC 534 were submitted on March 31, 2017 (Unit 3 ML17093A286, Unit 4 ML17093A535). The ITAAC Closure Notifications for ITAAC 538 were submitted on November 30, 2016 (Unit 3 ML16351A350, Unit 4 ML16351A334).

"On August 26, 2020, it was determined that a design change, issued for several Protection and Safety Monitoring System (PMS) isolation barrier assemblies (ISBs), materially altered the basis for determining that the ITAAC 534 and ITAAC 538 Acceptance Criteria were met. The modified ISBs will require testing per IEEE 384-1981, Standard Criteria for Independence of Class 1E Equipment and Circuits, to demonstrate that the Acceptance Criteria is met. System function is not required while the plant is under construction.

"ITAAC Post Closure Notifications in accordance with 10 CFR 52.99(c)(2) will be submitted following completion of corrective actions.

"The 10 CFR 52.99(c)(4) All ITAAC Complete Notification has not been submitted for VEGP [(Vogtle Electric Generating Plant)] 3 and 4.

"The NRC Resident Inspector has been notified."

* * * UPDATE ON 9/22/21 AT 1534 EDT FROM NICK KELLENBERGER TO HOWIE CROUCH * * *

"Upon successful completion of the work to correct the identified impact to ITAAC 534, it has been determined there was no material impact to ITAAC 538. Confirmation was made that the credible fault only affected PMS to PLS analog ISBs and not PMS to PLS relay isolation ISBs. It was also confirmed that the relay isolation ISB testing and qualification summary information was unaffected by the modifications made to the analog ISBs to correct the credible fault scenario condition. Resolution of the credible fault scenario did not result in modifications to the relay isolation ISBs which are the subject of ITAAC 538. Therefore, the ITAAC Closure Notifications submitted for ITAAC 538 on November 30, 2016 (Unit 3 ML16351A350, Unit 4 ML16351A334) continue to be valid and ITAAC Post Closure Notifications are not required."

The licensee has notified NRC Region 2. Notified R2DO (Miller) and NRR Vogtle Project Office (via email).

AUTOMATIC REACTOR TRIP DUE TO FLUX RATE

"At 1319 CDT, on August 26, 2020, with Unit 1 in Mode 1 at 95.2 percent power in coast down for the 1R32 refueling outage, the reactor automatically tripped due to flux rate. All systems responded normally to these conditions with auxiliary feedwater initiating as expected. Operations stabilized the plant without complication. Decay heat is being removed via a main feedwater pump to the steam generators. Unit 2 is not affected and remains at 100 percent power. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour report per 10 CFR 50.72(b)(3)(iv)(A), specified system actuation. The cause of the scram is under investigation.

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

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following information was received from the State of Colorado via email:

"A Troxler 3400 Series moisture/density gauge, containing 9 mCi Cs-137 and 44 mCi Am-241:Be or 66 microCi of Cf-252 sealed sources, fell out of the back of a pickup truck during transport by the licensee and was recovered by a member of the public, who turned the gauge into the fire department and the fire department returned the gauge to the licensee."

Colorado Event Report ID No.: CO200058

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

EN Revision Imported Date : 9/2/2020

EN Revision Text: AGREEMENT STATE REPORT - UNABLE TO DETERMINE IF SOURCE IN SHIELDED POSITION ON LEVEL INDICATOR

The following information was received via E-mail:

"On August 26, 2020, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that while making preparations for the coming hurricane, the position of the source rod on a Tracerco, Model T-218-160032 [used for level indication] could not be confirmed. The source rod contains 10 cesium-137 sources of 10 milliCuries each (original activity.) The RSO stated when they return the sources to the shielded position, the control system does indicate the sources are shielded as indicated by a light change on the system console. When the licensee attempted to shield the sources on this day, the light did not change to indicate the sources were shielded. The gauge source rod is operated manually. They tried it a couple of times, but the light still did not change. A survey was performed on the outside of the vessel. The RSO stated there wasn't enough change in dose rate readings with shutter in the open and closed positions to determine whether the sources were shielded based on survey. The RSO stated it may be that the sources are not moving, or it may be that there is an issue within the control system causing the light not to change. They cannot determine at this time which problem is occurring. The RSO is contacting the manufacturer to send someone out after the hurricane. There is no risk of exposure. The RSO stated they will update the Agency once the manufacturer determines the problem. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9787

* * * RETRACTION ON 9/01/2020 AT 1406 EDT FROM ART TUCKER TO THOMAS HERRITY * * *

The following information was received via e-mail:

"On September 1, 2020, the licensee notified the Agency (Texas DSHS) that on August 31, 2020, a service company came onsite to investigate the shutter problem they had reported, and identified that there was no mechanical issue with the shutter. The problem they had was a failure of the output signal to indicate source position. The source rod was functioning normally. Based on this information, the Agency is retracting this event."

Notified R4DO (Deese) and NMSS Events (email).

PART 21 REPORT - FAILURE OF AIR CONDITIONER COMPRESSOR HEAD GASKET

The following is a synopsis of the information received from the supplier.

On August 26, 2020, H. B. Robinson Generating Station, Unit 2 experienced a failure during post maintenance testing of a newly installed air conditioning compressor, which serves one of the Control Room HVAC units. Robinson plant contacted QualTech (the supplier) on September 22, 2020, detailing the findings of their investigation which indicated an incorrect head gasket had been installed, allowing high pressure gas to discharge to the low pressure side.

QualTech NP reviewed the investigation and agrees, the incorrect gasket was installed. The root cause was determined to be an improper dedication plan of the gaskets, not recognizing the delta between the 'left' and 'right' head gaskets. QualTech has taken action to revise the dedication plan. This is the only compressor unit of this model sold. No other similar failures have been reported. QualTech believes this to be an isolated case.

For further information contact:
Tim Franchuk
Quality Assurance Director
QualTech NP, Curtiss-Wright Nuclear Division
(513) 528-7900 x176

EN Revision Imported Date: 9/17/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE-125 SEED

The following information was obtained from the State of North Carolina via email:

"On 25 August 2020, an iodine-125 (I-125) seed was implanted into a perirectal mass in a patient for the purpose of localization and excisional biopsy. Following implantation, the Imaging team surveyed the needle and patient with a Geiger-Mueller detector per standard procedure to confirm proper placement of the seed within the mass. In addition, a post-implantation CT scan confirmed the presence of the seed within the mass. The seed and patient data were entered into the on-line 'Seed Tracker' software by the Imaging team per standard procedure. Excision of the tumor containing the seed was planned for the next day, and the patient was discharged home.

"At the time of surgery on 26 August 2020, the operative team was unable to detect the seed within the mass. Although the absence of the seed was documented in the operative note, the surgical team did not report that unusual occurrence to the Imaging team or the Radiation Safety Division. The specimen, which contained no seed and was not labeled as containing a seed, was sent to Surgical Pathology as a routine specimen and was processed as such. However, the Surgical Pathology team failed to notice that an entry for that patient and seed had been made in the 'Seed Tracker'. The error was not detected until an audit of the information in the 'Seed Tracker' was performed by staff of the Imaging teams and the Radiopharmacy in July 2021. The discrepancy between the 'Seed Tracker' data and the labeling and processing of the specimen as 'non-radioactive' was resolved when the surgical team's operative note was consulted. Because locating the seed would have been unlikely and impractical after 10 months (activity estimated to be 4 microcuries), our efforts were focused on investigating the root causes and identifying corrective actions.

"Probable disposition of lost material: Based upon the confirmation of seed placement in the perirectal mass by survey and CT scan, and its absence upon excision the following day, the seed most likely migrated out the implantation track and was discharged into the sanitary sewer during a bowel movement. Migration of seeds is uncommon but does occur. In this case, it would not have been noticed by the patient."

North Carolina Item Number: NC210013

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