Event Notification Report for June 03, 2021

EN Revision Imported Date: 6/3/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS ON TWO GAUGES

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

"On May 26,2021, the Agency was notified by the licensee service provider that the shutters on two nuclear gauges were found stuck in the open position. Open is the normal operating position. The gauges are Vega model SH-F1 each containing a 20 milliCurie cesium-137 sources. The licensee stated there is no increased risk of exposure to members of the general public or workers at the facility due to the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 9850

EN Revision Imported Date: 6/3/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received from the North Carolina Division of Health Service Regulation via email:

"The facility had two I-125 prostate implant procedures scheduled for 5/26/2021, one from approximately 0800-1030 EDT and another one following that. During the preparation of the second patient, the [authorized medical physicist/ radiation safety officer] (AMP/RSO) realized he may have made a mistake inputting the source strength into the treatment planning computer. The treatment planning computer has two options for source strength (millicuries and air-kerma). He went back to verify and realized he had input the millicurie source strength (0.357 mCi) into the air-kerma strength (0.453 U) spot and not air-kerma. This resulted in the treatment planning computer to believe the activity of the sources were lower than they actually were and generated a plan off of this strength. This caused the delivered dosage to be 27 percent greater than the prescribed dosage (~1400 Gy not 1100 Gy). The referring physician was present for the procedure and was notified upon the realization of the error. The patient was still in recovery from the procedure and was informed by the authorized user as soon as he was recovered and able to receive the news, before leaving the facility. The AMP/RSO stated that no negative outcome was expected for the patient, as this was the first part of a two part treatment plan, with the second part being linear accelerator treatment on the prostate. The second part of the treatment can be adjusted to accommodate for the increased dose given during the permanent implant, with no expected harm to the patient."

NC Tracking Number: NC210008


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: 6/3/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE

The following was received from the Massachusetts Radiation Control Program via email:

"At 1551 EDT on May 27, 2021, the Massachusetts Radiation Control Program received a phone call from the Radiation Safety Officer (RSO) of Thermo Scientific Portable Analytical Instruments, License Number 55-0238. The RSO stated that a source was removed from the licensee's manufactured device that was sent to them for servicing. During this receipt procedure, a wipe sample taken on the device resulted in positive contamination. The Nickel-63 source was found to be leaking and the wipe test indicated a removable contamination level of 0.0728 microcurie. The limit for reporting the activity is 0.005 microcurie.

"Further information will be forthcoming as the event is under investigation."

* * * UPDATE ON MAY 28, 2021 AT 1603 EDT FROM ANTHONY CARPENITO TO BRIAN P. SMITH * * *

The following update was received from the Massachusetts Radiation Control Program [MRCP] via email:

"The licensee notified the MRCP at 1202 [EDT] on May 28, 2021 to correct and update its earlier report. The sealed source isotope of interest is Iron-55 (Fe-55), not Nickel-63 as reported earlier, and the source activity is 20 millicuries. [The] Source was contained within an X-ray fluorescence device Model XLi 969, SN 5249. The customer had shipped the device to the licensee for decommissioning rather than service/repair. The accompanying leak test result prior to shipment was negative for contamination. Wipe survey results for areas within the licensee's facility where the device had been were negative for contamination. End of update."

Notified R1DO (Bower) and NMSS Events Notification

EN Revision Imported Date: 6/3/2021

EN Revision Text: 60-DAY TELEPHONIC NOTIFICATION OF INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM

"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 actuation of the 2A Reactor Protection System (RPS). On April 1, 2021, at 1302 (CDT), Browns Ferry Unit 2, 2A RPS [Motor Generator] MG set tripped causing a half scram. Unit 2 experienced an unexpected trip of the 2A RPS MG Set that resulted in automatic Primary Containment Isolation System (PCIS) Group 2, 3, 6, and 8 isolations and Trains A, B, and C Standby Gas Treatment (SGT) and Train A Control Room Emergency Ventilation (CREV) starts. At the time of the event, Unit 2 was in a refueling outage and the rods were already fully inserted. All systems responded as expected.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"Based on the troubleshooting conducted, the cause was determined to be a loose wiring connection in the motor circuit. The lugs were replaced with ring lugs. Operations reset the 2A RPS Half Scram and PCIS in accordance with 2-AOI-99-1 on April 1, 2021, at 1324 CDT thus correcting the condition and returning RPS to service.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Condition Report 1683358.

"The NRC Resident Inspector has been notified of this event."