Event Notification Report for August 31, 2021

EN Revision Imported Date: 8/31/2021

EN Revision Text: AGREEMENT STATE REPORT - PRESCRIBED DOSE EXCEEDED

The following is a summary of information received from the State of Oregon:

Licensee miscalculated and administered more radiation to a patient's spine than the prescription allowed. Radiation dose to the patient was intended to be 800 centigray but the actual dose delivered exceeded this by 21%.

Oregon Emergency Response System Incident Number: 2021-2250

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.

* * * RETRACTION ON 24 AUGUST 2021 AT 1550 EDT FROM DARYL LEON TO KAREN COTTON * * *

The following is a synopsis of information received via e-mail from the state of Oregon via e-mail:

After obtaining direct information from the responsible party, the radiation dose above the prescribed 800 centigray was from an x-ray generating device and is therefore a nonreportable event to NRC but is being investigated at the State (Oregon) level. This is not a reportable event to the NRC.

Notified R4DO (KOZAL) and NMSS Events (by email).

EN Revision Imported Date: 9/1/2021

EN Revision Text: POINT BEACH - EXTERNALLY CONTAMINATED PACKAGE

The following was received from the Point Beach Station Radiation Protection Manager (RPM) via phone call to the Headquarters Operations Officer:

Per 10 CFR 20.1906(d)(1), the Point Beach Station RPM reported to the NRC receipt of a package of radioactive material (new fuel shipment) with removable surface contamination greater than NRC reporting limits. The package was received Tuesday, August 24, 2021, at 0645 CDT. The package was surveyed and it was determined that the external surface of the package contained removable contamination that exceeded the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. The measured level of removable contamination was 337.3 dpm/cm2 for beta-gamma emitters and contained Cobalt 60. The licensee's corrective actions were to conduct additional smears of the package, trailer, and truck, and to frisk the truck driver to ensure no further contamination. No contamination has been identified.

EN Revision Imported Date: 9/1/2021

EN Revision Text:
AGREEMENT STATE REPORT - UNDERDOSE

The following information was obtained from the Illinois Emergency Management Agency (Agency) via email:

"The licensee's radiation safety officer contacted the Agency to advise that a patient scheduled to receive Y-90 microsphere therapy (SirSpheres) for hepatocellular cancer on August 24, 2021, received only 77% of the dose prescribed in the written directive. This administration called for only 16.2 mCi of activity. The licensee's radiation safety officer is reviewing the delivery system as well as the specifics of the administration to determine root cause. The licensee suspects a clogged catheter but is currently investigating. No personnel or area contamination was reported. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. No untoward medical impact was expected to the patient.

"Agency inspectors will perform a reactionary inspection on Friday, August 27, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."

Illinois Item Number: IL210027

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: 9/1/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL LEFT AT RECYCLING CENTER

The following was received from the Maryland Department of Environment Radiological Health Program via email:

"On August 17, 2021, at about 1215 EDT, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone by the Operations Manager of the Montgomery County Shady Grove Transfer Station and Recycling Center located at 16101 Frederick Rd, Derwood, Maryland 20855 that a "B17 Bomber", radioactive material was thrown into a scrap metal bin. The MDE/RHP responded the same day and investigated the "B17 Bomber", which was later identified as Sextant Bubble Type (with Altitude Averaging Device) AN-5851-1, Part number 3014-1-B and Serial Number AF-42-0676, Contract number AC-26968 and manufactured by Bendix Aviation Corporation navigation instrument which contain Radium - 226 source with estimated nominal activities of 2 microcuries.

"The Sextant Bubble Type navigation device was dropped by unidentified person(s) at an unknown date and time and was discovered by the Montgomery County Shady Grove Transfer Station and Recycling Center staff when screened for radiation on August 17, 2021. The device was isolated and stored at the temporary hazardous materials storage in the facility by the Operations Manager. The device was later transferred to the local radioactive waste management company, the RSO, Inc. for disposal on August 20, 2021.

"MDE/RHP will finalize a reactive investigation."

EN Revision Imported Date: 8/31/2021

EN Revision Text: NOTIFICATION OF UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER

Waterford 3 shut down the reactor in preparation for Hurricane Ida landfall prior to this event.

At 1812 CDT, Waterford 3 declared a notification of unusual event under EAL S.U. 1.1 due to a loss of offsite power as a result of hurricane Ida. Plant power is being provided via emergency diesel generators. The NRC Activated at 2016 EDT with Region IV in the lead.

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, DHS Nuclear SSA (email), FEMA NWC (email), and FEMA NRCC SASC (email).

EN Revision Imported Date: 9/1/2021

EN Revision Text: SAFETY SYSTEM ACTUATION

"At 1804 CDT on 8/29/2021, Waterford 3 Steam Electric Station (WF3) experienced a Loss of Off Site Power event due to Hurricane Ida. This event caused an automatic actuation of Emergency Diesel Generators Trains A and B. Both Emergency Diesel Generators started as designed and both are currently operating normally supplying power to their respective Class 1E Safety Busses. This automatic actuation is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A). Prior to the loss of offsite power, WF3 was in progress of performing a plant cooldown in accordance with procedural guidance. As part of this cooldown and after entering Mode 4, all Safety Injection Tanks were isolated. As a result of losing offsite power, Reactor Coolant System Temperature increased above 350F which is above the temperature requirements for Mode 4. Safety Injection Tanks are required to be unisolated and OPERABLE in Mode 3. Therefore, with no Safety Injection Tanks OPERABLE, this constituted an event or condition that could have prevented the fulfillment of a safety function and the unit entered Technical Specification 3.0.3. The unit was in Technical Specification 3.0.3 for approximately 43 minutes from 1805 CDT until 1848 CDT when Mode 4 conditions were re-established. This event or condition that could have prevented the fulfillment of a Safety Function is reportable in accordance with 10 CFR 50.72(b)(3)(v)(D).

"While continuing to perform the Reactor Coolant System Cooldown and prior to placing Shutdown Cooling Train in service, it became necessary to start one train of Emergency Feedwater. Emergency Feedwater Train A was manually started at 1847 CDT to feed the Steam Generators and was secured at 1947 CDT. Emergency Feedwater Train A started and operated normally during this period. This manual actuation is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A)."

The licensee notified the NRC Resident Inspector.

EN Revision Imported Date: 9/1/2021

EN Revision Text: MISSING ELECTRON CAPTURE DETECTORS

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

A container in transit to the licensee was discovered to be missing from a warehouse in Elkton, Maryland. The package contained ten sealed electron capture detectors. Each detector contained 15 millicuries of Ni-63 for an aggregate amount of 150 millicuries. The licensee is in contact with the carrier and continuing to investigate.

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

* * * UPDATE ON 08/27/2021 AT 1522 EDT FROM ATNATIWOS MESHESHA TO OSSY FONT * * *

The following update was received from the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email:

"On August 26, 2021, at about 0825 EDT, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone by the Radiation Safety Officer (RSO) of Agilent Technologies, Inc., located at 2850 Centerville Road, Wilmington, Delaware 19808, stating that ten (10) radioactive materials were lost during transportation. The MDE/RHP spoke to the RSO who stated that Agilent Technologies, Inc. lost ten (10) Electron Capture Detectors (ECD), Model 2397 which contain nickel-63 sealed sources with estimated nominal activities of 15 millicuries. The ECDs are to be used in applications for chromatography, ion generators. The sources were manufactured on January 12, 2021, and the products are registered under NRC Sealed Source and Device Registry for the finished product, G2397A as Generally Licensed materials.

"The case has been reported to the NRC (Event Number 55430) by the RSO of the company. Agilent Technologies, Inc. is licensed by the NRC to conduct research and development as defined in 10 CFR 30.4, manufacture, test with authorized sources of H-3 and Ni-63 as per Materials License number 07-28762-01 and for distributions of Generally Licensed materials, Materials License number 07-28762-02G.

"Agilent Technologies suspected that the sources were lost on Friday, August 20, 2021, or even before, and most probably at common carrier transfer station, in Maryland. Agilent Technologies' imported shipment contained the lost ten (10) Ni-63 sources that were transported by land from Chicago to Wilmington, Delaware through Maryland. The shipment is managed by a company called Kintetsu World Express, USA and [carried out by a] common carrier.

"MDE/RHP will finalize a reactive investigation."

Maryland Event No. 5

Notified R1DO (Greives), ILTAB, and NMSS Event via email.

LICENSED OPERATOR VIOLATED FFD POLICY

On August 4, 2021 a Licensed Reactor Operator violated the station's FFD policy. The employee's unescorted access to South Texas has been terminated. The event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

The NRC Resident Inspector will be been notified.

LOSS OF COMMUNICATIONS CAPABILITY

At 1340 CDT on August 31, 2021, Waterford 3 Nuclear Generating Station discovered a condition impacting functionality of the ENS and commercial telephone lines. This issue was evaluated and determined to be a major loss of communications capability because the condition affected the ability to directly communicate between the NRC and the Control Room. Satellite phone capability was established at 1410 CDT. Additional communication capability was restored at 1609 CDT. Communication capability via the Emergency Notification System (ENS) was reestablished at 1923 CDT.

This condition does not affect the health and safety of the public or plant personnel.

The NRC Resident Inspector has been notified.