Event Notification Report for June 11, 2021

EN Revision Imported Date: 6/11/2021

EN Revision Text: AGREEMENT STATE REPORT - MALFUNCTIONING GAUGE

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

"On April 21, 2021 a Licensee found that the count rate for one of their gauges was the same with shielding present and not present. The count rate was consistent with previous count rates with the shielding present. The Licensee shut down the device and called for service and repair who replaced two items resulting in the device working properly again. The Licensee then sent a letter dated May 2, 2021 to the Agency who received/stamped it on May 10, 2021. The letter was eventually passed to Randall Redd of the Investigations group on June 4, 2021. The letter provided a serial number for something. The Licensee was contacted on June 4, 2021 multiple times but I was unable to get any further information as multiple people are not in the office but on vacation. One person was able to give me the license number for the Licensee but when they looked at the serial number in the report it did not match any of the devices on their inventory. A meeting is set up for late Monday [June 7, 2021] to get this information. Additional information will be provided in accordance with SA-300."

Texas Event Report Number: 55289

EN Revision Imported Date: 6/11/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Radioactive Materials Inspection & Enforcement, of the Illinois Emergency Management Agency (the Agency) via email:

"Rush University Medical Center in Chicago, IL-01766-01, contacted the Agency the afternoon of June 4, 2021, to report a medical underdose of Y-90 that occurred on June 3, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.

"The Radiation Safety Officer for the licensee, contacted the Agency at 10:05 on June 4, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) received only 75 percent of the dose prescribed in the written directive. The Agency understands this to be one of two fractions delivered. Additional data is forthcoming.

"Reportedly, the underdose was due to a pinch clamp that was remaining on the infusion line during administration. It was noticed after the authorized user felt more pressure than normal when pushing the syringe, and stopped. The clamp was removed, and the authorized user completed the administration. No personnel or area contamination occurred.

"The system was flushed five times to ensure no microspheres were caught in the tubing of the kit. Images of the waste container were taken immediately after the event, showing the remaining microspheres were contained in the inlet and outlet lines. Following the manufacturer's procedures, the license determined the patient only received 21.62 mCi of the intended 28.86 mCi. The licensee believes that it was still a clinically effective dose.

"Agency staff are evaluating, and this report will be updated as information becomes available."

Illinois Item Number: IL210017

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: 6/11/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL SHIPMENT

The following report from the state of Wisconsin was received by email:

"On June 4, 2021 the licensee reported to the Department [of Health Services] that a package containing 25 Curies of Cs-137 had been shipped from Wisconsin on April 16, 2021 and did not arrive at its destination in California. The last known location of the package was in Chicago, Illinois on April 22, 2021. The licensee is following up with the common carrier, but to date the package has not been located."

WI Event Report ID No.: WI210004

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

EN Revision Imported Date: 6/11/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING FIXED GAUGING DEVICE

The following information from the state of Utah was received by email:

"The Utah Division of Waste Management and Radiation Control (DWMRC) was notified by the licensee that a fixed gauge was missing on 06/04/2021 at approximately 1430 MST.

"The licensee was reconfiguring a portion of their facility and had relocated a number of gauges from one location to another location in their operations for use at the new location. One of the fixed gauging devices, a Thermo Fisher, model 5202, serial number B3339, containing 500 milliCuries of cesium-137 (Cs-137) would not fit at the new location. The fixed gauge was supposed to be removed from the hopper where it was located and placed in storage for future use. For some reason, this removal did not occur. The fixed gauge was left in place and had not been moved to a secured storage location. The shutter on the gauge was locked in the closed position.

"Yesterday afternoon (06/03/2021), the Radiation Safety Officer (RSO) was notified that the structure that the gauge had been located on had been demolished and the whereabouts of the gauge was not known. All of the materials from the demolition of the structure are still located in the area and are on the licensee's property. The licensee's staff began looking for the device. At about 1000 to 1100 MST this morning (06/04/2021), the licensee indicated that they had verified which gauge was missing and that it could not be located. The RSO began notifying all of the company personnel he is to notify when this occurs. The RSO thought he had 24 hours to report the gauge as missing to the DWMRC instead of the immediate notification that was required and did not immediately notify the DWMRC.

"At this point, the licensee is continuing to search through the demolished parts of the structure for the gauge and will continue to do so. The materials from the demolition are not to be relocated or removed from the licensee's property until a through search of all of the materials can be made or the device is located. The DWMRC will conduct an on-site investigation of this issue."

UT Event Report ID No.: UT-21-0001

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: 6/11/2021

EN Revision Text: LOSS OF CAPABILITY TO ACTIVATE EMERGENCY SIRENS AND OFFSITE NOTIFICATION OF SAME

"At 1115 EDT on June 9, 2021, during a siren activation test, a loss of the capability to activate the sirens from both Surry local activation sites was identified. The Virginia EOC was participating in the activation test and is aware of the issue and notified the local government authorities in the Surry EPZ of the situation. The NRC Resident has been notified of this issue.

"The station telecommunications department has been contacted and is aware of the issue. In the event that a radiological emergency should occur at the Surry Power Station, Primary Route Alerting procedures will be put in use by the local jurisdictions.

"This report is being made in accordance with 10 CFR 50.72(b)(2)(xi) and 10 CFR 50.72(b)(3)(xiii) due to notification of other state and local government agencies of the failure of the Alert & Notification system for Surry."

PART 21 INITIAL REPORT - DEVIATION IDENTIFIED IN BOLTING UTILIZED TO MAINTAIN SEISMIC QUALIFICATION:

"Pursuant to 10 CFR 21.21 (d)(3)(i), Paragon Energy Solutions is providing initial notification of the identification of a deviation.
"Condition that requires evaluation:
"NLI 280-ton Custom Chillers, Serial Numbers XHX-0001A / XHX-0001B / XHX-0001C. The Chillers were originally supplied by Nuclear Logistics under PO: NU-02SR726683 in 2010.
"The original seismic qualification was questioned by plant personnel related to the size of the bolting utilized for the diagonal cross braces on the two lower chiller frames. Paragon performed a review and additional analysis of the original qualification report. It was confirmed that the bolting which was utilized to install the pinned diagonal braces on the condenser and compressor frame sections does not have a sufficient load bearing capacity to support the application loading during a seismic event.
"The upset and emergency loading for the diagonal brace is 5.59 kip and 8.59 kip, respectively. Compared to the load capacity of 2.32 kip and 3.09 kip for upset and emergency, respectively, for the 3/8" bolt in single-shear configuration with threads included in the shear plane.
"This condition does not affect normal operation of the chiller. However, this deviation has the potential to impact the ability to maintain structural integrity during a seismic event.
"Date of Discovery: 6/8/2021
"Formal notification will be submitted on or before 7/8/2021.
"Paragon contact: Tracy Bolt, Chief Nuclear Officer, Paragon Energy Solutions, 817-284-0077, tbolt@paragones.com."

This equipment was supplied to V.C. Summer Nuclear Station.