Event Notification Report for July 12, 2021

EN Revision Imported Date: 7/12/2021

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO RADIOGRAPHER

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

"On May 30, 2021, at approximately [1500] CDT one of the licensee's radiographers reported to the radiation safety officer that on May 28, 2021, he had handled a collimator while the source was in it. The radiographer was using a SPEC 150 camera with a 22 curie Iridium-192 source. The radiographer had taken a shot on top of a 2-inch pipe on a pipe stand. He then set up for the next shot by taking hold of the collimator (back, shielded side) and slid it down to the side of the pipe (90 degree). The beam was always facing the pipe. When he walked back to the camera to crank out the source, he found he had not cranked it back in after the first shot. The radiographer was not wearing an alarming rate meter, a pocket dosimeter, or a dosimetry badge, and he was not carrying/using a survey meter at the time of the incident. The licensee's initial, rough calculations indicate the dose will be lower than the reporting criteria used for this report, but until they can get more information, this report is being made as an immediate report. The radiographer was seen by a physician today and the licensee reported white blood cell counts were normal. The licensee is investigating the event and also why the radiographer did not report the incident when it occurred. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident number not assigned as of the time of the report.


* * * RETRACTION ON 7/9/21 AT 0809 EDT FROM ART TUCKER TO KERBY SCALES * * *

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

"On May 30, 2021, the Agency was informed by the licensee that on May 30, 2021, at approximately [1500] CDT one of the licensee's radiographers reported to the radiation safety officer that on May 28, 2021, he had handled a collimator while the source was in it. The radiographer was using a SPEC 150 camera with a 22 Curie Iridium-192 source. The radiographer had taken a shot on top of a 2-inch pipe on a pipe stand. He then set up for the next shot by taking hold of the collimator (back, shielded side) and slid it down to side of the pipe (90 degree). The beam was always facing the pipe. When he walked back to the camera to crank out the source, he found he had not cranked it back in after the first shot. The radiographer was not wearing an alarming rate meter, a pocket dosimeter, or a dosimetry badge, and he was not carrying/using a survey meter at the time of the incident. The licensee conducted a reenactment of the radiographer's actions on June 1, 2021. The Agency conducted an on-line meeting with the licensee on June 16, 2021 and reviewed the video. Using the reenactment and the National Council on Radiation Protection (NCRP) 41 table 6, it was determined that the exposure to the radiographer's fingers was 31.28 Rem (exposed for 2 seconds) and to the remainder of his hand was 7.629 Rem (exposed for 6 seconds collimator 4.25 half-layer values (HLVS)). The whole-body dose was 124.68 milliRem. No exposure limits were exceeded."

Texas Incident Number: 9853

Notified R4DO (Warnick), NMSS Events and DIR MSST (Williams) via email.

EN Revision Imported Date: 7/12/2021

EN Revision Text: REPORT OF LOST MATERIAL

The following is a summary of a phone call with the licensee:

During a recent NRC inspection, the Radiation Safety Officer (RSO) and the NRC inspector determined that 2 Exit Signs (H-3; 0.352 Bq each) were missing and could not be located. The RSO has been searching since the inspection and has yet to locate the signs. The RSO noted that the exit signs were ordered in 2009 but was unable to find any removal work orders and is unaware of any effort to dispose of the signs. The RSO is unsure how long the signs have been missing. The licensee notified the NRC Region III Office.

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: 7/12/2021

EN Revision Text: SAMPLE DISCOVERED MISSING

The following was received from the licensee via email:

"A metallurgy laboratory (Met Lab) sample was determined to be missing from its prescribed location in the Physical Test Lab on June 30, 2021 at approximately 1330 EDT. A search for the item was immediately initiated per requirements. As of 1300 EDT on July 2, 2021, the item has not been located and as a result, formal notification of a missing item is being made to the NRC per Chapter 3 of BWXT NOG-L's Fundamental Nuclear Material Control Plan (FNMCP). 10 CFR 74.51 requirements do not apply since the item does not contain Strategic Special Nuclear Material (SSNM). The search for the item has been concluded and an investigation into the disposition has been initiated. The missing item was categorized as low enriched uranium and contained 0.03 grams of U-235.

"The Resident Inspector will be notified."

EN Revision Imported Date: 7/12/2021

EN Revision Text:
AGREEMENT STATE REPORT - PATIENT UNDER DOSE

The following was received via an email from the state of Pennsylvania:

"The Department [PA Bureau of Radiation Protection] received notification from a licensee on July 2, 2021 of a medical event involving a Y-90 TheraSphere. The licensee noted 71 percent of the prescribed dose of 30.8 millicuries was administered to the patient. A mechanical blockage occurred in the delivery system preventing spheres from exiting the administration vial. All material was contained in the delivery system, lines, and patient. Area monitoring confirmed that no leak occurred and no contamination of the work area. Nuclear Medicine imaging of the waste confirmed activity concentrated within the vial. The physician and patient have been notified. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA210006

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: 7/12/2021

EN Revision Text: INVALID ACTUATION OF CONTAINMENT ISOLATION SIGNAL

"This 60-Day telephone notification is being made per the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation of containment isolation signal affecting more than one system. On May 13, 2021, during the restoration of the Unit 2 Refuel Floor High Radiation Isolation Logic an invalid isolation signal was received. The condition requiring an isolation signal was verified not to be present prior to restoring the logic; however, it was not recognized that a previous isolation signal was latched in and had not been reset. When the isolation logic was restored, the Primary Containment Isolation System (PCIS) isolated on the invalid signal. The systems successfully completed the isolation per the plant design and plant configuration.

"The following systems actuated due to the Unit 2 PCIS Group 6C Isolation:
- Isolation of Containment Hydrogen and Oxygen Sampling Valves,
- Start of the 2A Reactor Enclosure Recirculation System,
- Trip of the Units 1 and 2 Refuel Floor HVAC,
- Start of the A and B Trains of Standby Gas Treatment Systems."

The NRC Resident Inspector was notified.

EN Revision Imported Date: 7/12/2021

EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO MAIN TURBINE TRIP

"At 2154 EDT on 7/8/2021, with the Unit in Mode 1 at 100% power, the reactor automatically tripped due to trip of the main turbine, caused by failure of a non-safety related breaker during functional testing. Following the reactor trip the Steam Feed Rupture Control System automatically initiated on low Steam Generator 1 level, actuating both turbine-driven Auxiliary Feedwater Pumps. The operators subsequently started the high pressure injection pumps manually per procedure in response to overcooling indications.

"Operations responded and stabilized the plant. Decay heat was initially being removed via the Main Condenser. During post-trip response actions, while attempting to shut down the Auxiliary Feedwater Pumps, a low pressure condition was experienced in Steam Generator 2, resulting in isolation of the Main Condenser and steam being discharged through the Atmospheric Vent Valves for decay heat removal. There is no known primary to secondary leakage.

"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). This event is also being reported in accordance with 10 CFR 50.72(b)(2)(iv)(A) as a four-hour, non-emergency notification of emergency core cooling system (ECCS) discharge into the reactor coolant system, and in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an eight-hour, non-emergency notification of an event that results in a valid actuation of the Auxiliary Feedwater System.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

PART 21 INITIAL REPORT - DEVIATION IDENTIFIED LOOSE ZINC ANODES INSTALLED IN HEAT EXCHANGERS FOR DIESEL GENERATORS

The following is a summary of the defect described in an initial report received from the vendor via facsimile:

The vendor notified the NRC of a defect involving two instances of loose or dislodged zinc anodes (P/N 1335BEM2P) supplied by the vendor. The anodes are installed in the cooling water enter and exit and return channels of the jacket water heat exchanger of the emergency diesel generator. Each heat exchanger contains eight zinc anode assemblies that consist of a zinc rod threaded into a steel pipe plug. The zinc acts as a sacrificial anode to protect the pressure boundary metals from degradation due to galvanic corrosion. In the case of a loose or dislodged zinc anode, the zinc rod may become foreign material that remains trapped in the vessel, potentially impacting and damaging the tube ends where they project from the tube sheet. Alternatively, an anode located in the exit channel may by carried away from the heat exchanger and potentially damage downstream components.

The corrective action being recommended are as follows:

"It is recommended to perform an inspection to verify tightness at the zinc rod to pipe plug interface. The rod should be threaded into the pipe plug snug tight and, if required, may be tightened to a maximum of 15 ft-lbs. If desired, the zinc rod may be removed and eliminated from the assembly leaving only the steel pipe plug. Inclusion of the zinc anode is not required for the EDG heat exchanger application at TVA-Browns Ferry."

This component was supplied to the Browns Ferry Nuclear Power Plant.

Point of contact: Dan Roberts
Quality Manager
Engine Systems Inc.
175 Freight Rd.
Rocky Mount, NC 27804
(252) 977-2720

FIRE SUPPRESSION SYSTEM IMPAIRED

"At approximately 1730 (EDT) on July 9, 2021, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing the Fuel Manufacturing Operation (FMO) was impaired. The backup diesel fire pump experienced a cooling system failure. As a result, the diesel fire pump was placed in the manual 'Off' position. The diesel fire pump could still be operated manually in an emergency for a short time. The electric fire pump remains fully operational and available to perform its safety function. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

From the discussion between the licensee and the Headquarters Operations Officer, the vendor plans to be onsite Monday July 12, 2021 to conduct repairs.