Event Notification Report for May 20, 2021

EN Revision Imported Date: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the Alabama Department of Public Health Office of Radiation Control via email:

"On April 20, 2021 about 1130 [EDT], Alabama licensee Building and Earth Sciences, Inc. (license number 1266) called to report that a moisture density gauge had been run over by a compactor while at a temporary job site. The licensee's representative stated that the gauge was in several pieces, and the source rod/probe could not be retracted into the safe shielded position. The licensee collected a leak test once the gauge was safely stored; exposure measurements from the leak test envelope were less than or equal to background. The gauge is a Troxler 3430 s/n 32716, with 9 milliCuries Cs-137 and 44 milliCuries Am-241:Be. The Agency is waiting on the licensee's report of this matter. More information to follow."

Alabama Report No.: 21-12

* * * UPDATE ON 5/19/21 AT 1109 EDT FROM MYRON K. RILEY TO LLOYD DESOTELL * * *

The following is a summary of information that was received from the Alabama Department of Public Health Office of Radiation Control (the Department) via E-mail:

The Department has reviewed the licensee's actions to mitigate the consequences of this event as well as their proposed corrective actions. The licensee's corrective actions include stressing radiation safety to their technicians during regularly scheduled meetings. The Department indicates that these actions appear appropriate. The dosimeter results for the gauge operator have not been received at this time.

The Department considers this matter closed.

Notified R1DO (Greives) and NMSS Events Notification via email.

EN Revision Imported Date: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - DEVICE NOT LOCATED DURING INSPECTION

The following was received from the Alabama Office of Radiation Control (the Agency) via email:

"An Agency inspector performed an inspection of Wallace State Community College, registrant 554 GL [Generic License], in Hanceville, AL on 4/27/2021. The registrant's GL device was not located during the inspection. The registrant stated the device was moved/disposed in 2019. The registrant was unable to provide documentation of disposal. The inspector followed up with Perkin Elmer (manufacturer); the Perkin Elmer representative stated that no documentation of receipt/disposal of this device was/is present. No further information is available at this time.

"Device description: Perkin Elmer model N610-0063 s/n 3345, source model N610-0063, s/n 3345, with 15 milliCuries of nickel-63 as of 9/1/2000."

Alabama Incident 21-16

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: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - EQUIPMENT FAILED IN SHIELDED POSITION

The following report was received from the Illinois Emergency Management Agency (the Agency) via email:

"On May 12, 2021, the [Division of Nuclear Safety - Radioactive Material] DNS-RAM section was verbally notified that a reportable equipment failure had occurred on the Agency's JL Shepherd Model 81-12T irradiator the previous day. The equipment failed in the shielded position and no public/staff exposures were reported as a result of the failure. The unit has been taken out of service pending repair by the manufacturer. All security systems required under 32 [Illinois Admin] Code 337 remain unaffected.

"This equipment and associated calibration activities are operated under a self-issued materials license, IL-01030-01. Additional details on the equipment failure are forthcoming. Initial notification was made within the 24 hour reporting requirement. A written report containing the information in 32 [Illinois Admin] Code 340.1230 is required within 30 days. This report will be updated as information becomes available."

Illinois Item Number: IL210016

EN Revision Imported Date: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The following is a synopsis of an email received from the Colorado Department of Health:

The licensee could not find an exit sign (H-3; 6.22 Ci) during a routine inventory inspection on 6/24/20.

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: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The following is a synopsis of an email received from the Colorado Department of Health:

The licensee could not find an exit sign (H-3; 11.47 Ci) during a routine inventory inspection on 6/9/20.

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: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On May 12, 2021, the Agency was notified by the licensee that a medical event had occurred on May 10, 2021. The event involved a prostate seed treatment using cesium - 131 seeds. The licensee reported that after the implant procedure they discovered that a large portion of the seeds had been implanted in the wrong location. The licensee stated the seeds that were misplaced ended up in mostly fatty tissue and they do not believe any adverse effects will be experienced by the patient. The licensee could not provide specific information on what percent of the prescribe dose had been received by the targeted tissue. The event and its cause is currently under investigation by the licensee. The prescribing physician has been made aware of the event and is notifying the patient. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9848

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.

EN Revision Imported Date: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE AND WRONG TREATMENT SITE

The following was received from the California Department of Public Health via email:

"On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event."

California Item Number: 051221

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.

EN Revision Imported Date: 5/20/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOGRAPHY SOURCE

The following was received from the Florida Department of Health (Bureau of Radiation Control) via email:

"At around 2020 [EDT] this evening, [the licensee] reported a lost radiography source from the Nuc-Med department.

"It was confirmed as missing from the lead pig this morning by a PET-CT tech after performing a [quality control] QC check on the camera. The PET-CT tech believes that they put it in their pocket yesterday afternoon after they were finished using it, instead of putting it back in the pig. [The] licensee reports to have used four detectors in the work area, and in the PET-CT's car and residence, but the source is still missing."

Source: Na-22
Activity: 100 uCi on 01 June 2018, 45uCi today
Manufacturer: Eckert & Ziegler
Serial Number: Q5-225

Florida Event Number: FL21-063

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: 5/20/2021

EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID DIESEL GENERATOR INITIATION

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid specific system actuation. On March 23, 2021, during the performance of the Division 1 ECCS [(Emergency Core Cooling System)] Integrated Test, the Division 1 Diesel Generator (DG) unexpectedly started. While performing the local lockout testing, per the procedure, a step was performed that initiated the unexpected DG start. The following step was to verify the diesel did NOT start. It was later determined that this was a procedural deficiency. The DG started and ran as designed. The DG did not tie to the safety bus as no undervoltage condition was detected.

"This event is considered an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A). The actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. Therefore, this notification is provided via a 60-day optional phone call in accordance with 10 CFR 50.73(a)(1) instead of submitting a written Licensee Event Report.

"All affected systems functioned as expected in response to the actuation. The DG was shut down in accordance with plant procedures and the testing procedure corrected. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

AUTOMATIC REACTOR TRIP DUE TO HIGH PRESSURIZER PRESSURE

"At 0315 MST on May 19, 2021, Unit 2 reactor automatically tripped during testing of the Plant Protection System. The Reactor Protection System actuated to trip the reactor on High Pressurizer Pressure, although no plant protection setpoints were exceeded. Main Steam Isolation Signal (MSIS), Safety Injection Actuation Signal (SIAS), and Containment Isolation Actuation Signal (CIAS) were received. No injection of water into the Reactor Coolant System occurred. Auxiliary Feedwater Actuation Signals (AFAS) 1 and 2 actuated on low Steam Generator water level post trip as designed. This event is being reported as a reactor protection system and a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"Following the reactor trip, all [Control Element Assemblies] CEAs inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. Unit 2 is stable and in Mode 3. Steam Generator heat removal is via the class 1 E powered motor driven auxiliary feedwater pump and Atmospheric Dump Valves.

"The NRC Senior Resident Inspector has been informed."

* * * UPDATE ON 5/19/21 AT 1351 EDT FROM JASON HILL TO BRIAN P. SMITH * * *

"The Unit 2 reactor tripped because of actual High Pressurizer Pressure that occurred as a result of a Main Steam Isolation Signal actuation.

"At 0337 MST, both trains of Low Pressure and High Pressure Safety Injection (LPSI and HPSI) were made inoperable when the injection valves were overridden and closed in accordance with station procedures. At 0346 MST, in accordance with station procedures, both trains of Containment Spray, LPSI, and HPSI pumps were overridden and stopped, rendering Containment Spray inoperable as well. This represents a condition that would have prevented the fulfillment of a safety function required to mitigate the consequences of an accident per 10 CFR 50.72(b)(3)(v)(D). Additionally, at the time of the Safety Injection Actuation Signal (0315 MST), both trains of Emergency Diesel Generators actuated as required and both 4160 VAC busses remained energized from off-site power.

"The NRC Senior Resident Inspector has been informed."

Notified R4DO (Young)