Event Notification Report for December 11, 2020

AGREEMENT STATE REPORT- UNDER DOSAGE

The following was received from the state of Arizona via email:

"The Department (Arizona Department of Health Services) received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed a dose of 120 Gy but was delivered 47.6 Gy, a percent dose delivered of 32.5%. The Department has requested additional information and continues to investigate the event.

"The Licensee is: Arizona License Number- 10-044, Banner University Medical Center - Tucson, 1625 N. Campbell Ave, Tucson, Arizona 85719

"Additional information will be provided as it is received in accordance with SA-300.

Arizona Incident: 20-025

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 REACTOR SCRAM DUE TO MAIN TURBINE / GENERATOR TRIP

"On December 11, 2020 at 1204 CST, Grand Gulf Nuclear Station (GGNS) experienced an Automatic Reactor Scram from 100 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 Branch Chief has been notified."

DAMAGE NUCLEAR MOISTURE DENSITY GAUGE - RUNOVER

The following is a synopsis of a report received via telephone:

On December 11, 2020, the licensee reported that a CPN moisture density gauge (model MC-1DR-P) had been run-over and damaged. The gauge contained two sources (Americium-241 and Cesium-137). The activity of the Americium-241 is 1.85 GBq. The activity of Cesium-137 is 370 MBq. The shielding around sources is intact. Both sources are outside the gauge, but placed in lead containers. The manufacturer has been notified and the sources will be leak tested before returning to the manufacturer.

60-DAY OPTION TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION

"On October 13, 2020, at approximately 02:25 [MST], an automatic start of the Unit 1 'A' Train EDG and SP systems occurred following the restoration of power to the 'A' Train 4160 Volt Class Bus. The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the EDG and the Engineered Safety Features Actuation Systems to simulated design basis events. During the test, technicians installed a jumper across incorrect relay points that caused the running Unit 1 'A' Train EDG to trip, resulting in a loss of power to the 'A' Train 4160 Volt Class Bus.

"Following restoration of normal offsite power to the 'A' Train 4160 Volt Class Bus, the Loss of Power Actuation signal was reset, however, EDG start relay logic was not reset at the EDG Local Panel. This resulted in the Unit 1 'A' Train EDG and SP system actuations with the EDG running unloaded. The system actuations did not occur as a result of valid plant conditions or parameters and are therefore invalid.

"The Unit 1 'A' Train EDG and SP system actuations were complete and the systems started and functioned successfully.

"The event was attributed to a human performance error and entered into the corrective action program. There was no adverse impact to public health and safety nor to plant employees.

"The NRC Resident Inspectors have been informed."

AGREEMENT STATE REPORT - UNRETRACTABLE SOURCE

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

"On December 12, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that on December 11, 2020, they were unable to retract a source string composed of 16 strontium - 90 sources with a total activity of 36 milliCuries to the fully shielded position. The RSO stated they had completed the treatment of a patient using a Best Vascular model A1000 brachytherapy device and Novoste Beta-Cath Delivery System and when they attempted to retract the source to the shielded position, the source stuck just outside the device. The source did retract outside the patient. The source and associated equipment were placed in a shield box and have been placed in storage. The RSO stated neither the patient or individuals operating the device received any additional exposure from the event. The RSO stated the patient received the prescribed dose from the treatment. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9816

EN Revision Imported Date: 5/12/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITUM EXIT SIGNS

The following synopsis was received from the Colorado Department of Public Health and Environment via email:

During an inventory, a hotel manager discovered two exit signs were lost, each containing 7.62 Ci of tritium.

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