Event Notification Report for October 22, 2021

EN Revision Imported Date: 10/22/2021

EN Revision Text: DEGRADED CONDITION IDENTIFIED WHILE UNIT SHUTDOWN

"On September 12, 2021, at 1728 EDT, with Unit 1 in Mode 5 (Cold Shutdown) while performing inspections of the North Anna Power Station Unit 1 reactor vessel head flange area, a weld leak was identified on the reactor vessel flange leak-off line that connects to the flange between the inner and outer head o-rings. Entered TRM 3.4.6 Condition B for ASME Code Class 1,2, and 3 components. With known leakage past the inner head o-ring, this condition is reported since the fault in the tubing is considered pressure boundary [Reactor Coolant System] leakage.

"This event is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(A) for any event or condition that results in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded."

The NRC Resident has been notified.

* * * RETRACTION ON 10/21/21 AT 1153 EDT FROM DENNIS BRIED TO BRIAN P. SMITH * * *

"The condition identified in EN 55457, pursuant to 10 CFR 50.72 (b)(3)(ii)(A) has been evaluated, and has been determined not to be Reactor Coolant System (RCS) pressure boundary leakage. As such, the 8-hour report is being retracted, as it is not an event or condition that results in, 'the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.'

"The leakage was subsequently determined to be in a tubing connection downstream of the reactor vessel inner O-ring. Leakage past a seal or gasket is not considered to be pressure boundary leakage, as defined by Technical Specifications."

The NRC Resident Inspector has been notified.

Notified R2DO (Miller)

EN Revision Imported Date: 10/22/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST NUCLEAR DENSITY GAUGE

The following was received from the Pennsylvania Department of Environmental Protection (DEP/Department) by email:

"The Department received notification from a licensee on October 13, 2021, that a Troxler 3430 portable gauge (serial number 18794) was lost. The gauge typically contains 9 mCi of Cs-137 and 44 mCi of Am-241:Be. The authorized user completed his work at approximately 1800 EDT and prepared to secure the gauge in a case on the back of his truck by ensuring that the source rod was locked. He departed the site without properly securing the gauge in its storage case. When the authorized user approached the center of Loganton, a person alerted him that the tailgate on the truck was down. The authorized user realized that the gauge was missing and traveled back to the work site. He did not detect the gauge along the return to the work site and inquired if anyone had seen the gauge at the work site. He noted that there was traffic from employees leaving a nearby factory at the end of their shift. The employee contacted the licensee Radiation Safety Officer and informed him of the incident. The State Police Barracks at Lamar were also alerted. The licensee deployed an additional employee to search for the missing gauge. The search was hampered by poor visibility in the darkness. The source has not been recovered at this time. A press release is in the process of being drafted, and the licensee will be offering a monetary reward for the safe return of the gauge. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided."

PA Event Report ID No: PA210015

* * * UPDATE ON 10/18/2021 AT 1503 EDT FROM JOHN CHIPPO TO LLOYD DESOTELL * * *
The following was received from the Pennsylvania Department of Environmental Protection (DEP) via email:

"The gauge was recovered on October 15, 2021, at a private residence unrelated to the licensee. An individual found it alongside Interstate 80, (a route not traveled by the employee who lost the gauge) took it home and contacted the Pennsylvania State Police. It is believed that the gauge was picked up from where the employee lost it and then discarded along this highway. The gauge was stored on the front porch of the residence where it was collected by the licensee, accompanied by the Pennsylvania State Police. The electronics were damaged, but leak testing revealed no radiological leakage. The gauge will be sent to a service provider for further evaluation and repair or replacement."

Notified R1DO (BICKETT), ILTAB (via email) and NMSS Events Notification group (via email).


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: 10/22/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED MINING GAUGE

The following was received from the Oregon Health Authority, Radiation Protective Services (Oregon RPS) via email:

"On October 8, 2021, during a low-level radioactive waste (LLRW) broker's visit to an Oregon scrap metal site to package and ship accumulated radioactive materials to a LLRW site, a fixed gauge was found among the items in storage. The technician notified the broker's office of the discovery and the broker notified Oregon RPS on October 11, 2021 at 1120 [PDT] hours. The gauge shows some wear with the gauge shutter lever broken but the shutter appears intact and closed with the source inside. Information on the gauge/source is as follows:

Manufacturer: Ohmart
Model 3340
Serial number: 70453

Source: Cs-137
Activity: 50 mCi
Source holder: SR-1A
Source manu: 3M
Source model: 4F6S
Source serial: S-601

Highest dose rate at contact: 70 mrem/hour (at collimated end)
Highest dose rate at 1 ft: 18 mrem/hour
Highest dose rate at 1 m: 2 mrem/hour

"The gauge was placed shutter-side down in a secured metal storage vault on site. Dose rate on the surface of the gauge measured at less than 2 mrem/hour. The licensee is in contact with the manufacturer to arrange disposal of the gauge.

"The gauge was originally installed in 1981 at a silver mining mill located south of Ely, NV. There were four additional gauges installed at the Nevada site at that time. RPS has contacted the Nevada Agreement State Radiation Control office and that office is investigating."

Oregon State Event Report No: OR-21-0051

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: 10/22/2021

EN Revision Text: AGREEMENT STATE - LOST I-125 RADIOACTIVE SEED

The following was received from the Iowa Department of Public Health (IDPH) via email:

"On October 5, 2021, the University of Iowa's radiation safety officer [RSO] contacted the Iowa Department of Public Health (IDPH) regarding a lost Iodine-125 (I-125) seed used for a localization of non-palpable lesion in breast tissue. The excised specimen containing two I-125 seeds had been received in pathology at 1704 CDT on 10/4/2021. The specimen was removed from container, surveyed with a Geiger counter, and imaged in the PathVision Faxitron by prosector. The radioactive seed localization (RSL) tracking sheet that came with the specimen from surgery indicated that two seeds were removed and two radioactive seeds were identified with associated biopsy clips via Faxitron imaging. The specimen was taken from the Faxitron to Grossing Workstation #3 and triaged by pathology staff. Triaging included weighing, measuring, and inking. Two cuts were made, one cut per biopsy site, in order to facilitate specimen fixation and to meet cold ischemia time requirement of one hour. A fixing tin was filled with formalin and the specimen was transferred to the fixing tin and appropriately labeled. Sharps waste were deposited in the sharps container at Grossing Workstation #3. Disposable materials used during triaging (absorbent pads, ink applicators, weigh boat, paper towels, gauze, and gloves) were deposited in the red biohazard waste at Grossing Workstation #3. Original specimen container and fixing tin were placed on the radioactive storage shelves by the Faxitron for overnight storage. Sometime between 1900 CDT 10/4/21 and 0700 CDT 10/5/21, housekeeping staff came in and collected trash and cleaned the floors. Laundry was collected between 0730 and 0800 CDT on 10/5/21.

"At 1100 CDT on 10/5/21, pathology staff brought the specimen to Grossing Workstation #5. They removed the specimen from the fixing tin, made multiple cuts into the specimen, laid out the slices on a Faxitron specimen tray, and attempted to image the specimen. The Faxitron malfunctioned and was not able to be brought to working order. Staff then laid out the specimen slices on the photo stand to take a photograph for a section diagram (instead of a Faxitron image for a section diagram). The photo was taken and the specimen was returned to Grossing Workstation #3. Photo stand was cleaned and waste from cleaning the photo stand was deposited in red biohazard trash at Grossing Workstation #5. A centrally located radioactive seed (seed #1) and associated biopsy clip were identified and removed from the specimen. Seed #1 was placed in a mesh bag and placed in a lead vial. The specimen at site of Seed #2 was then serially sectioned in an attempt to locate Seed #2 and its associated biopsy clip. The biopsy clip associated with seed #2 was found, but seed #2 was not found. The adjacent tissue was examined as well and without finding seed #2, the Geiger counter was then utilized to localize the second radioactive seed. The Geiger counter had no reading above background, indicating no seed present. Seed #1 was removed from the lead vial and scanned with the Geiger counter and had a reading of 5 mR/hr.

"Four lab staff immediately began looking for the radioactive seed, both visually and with the Geiger counter. They checked clothing and shoes of any staff who had been around the specimen. They checked the original specimen container as well as the fixing tin. Workstations #3 and #5 were thoroughly checked and re-checked, including trash cans, work surfaces, shelves, materials on shelves, drawers, sharps containers, sinks, floors, and associated carts. The walkway between workstations #3 and #5 and the Faxitron and photo stand were checked, as well as the floor and any trashcans along the way. Additionally, the Faxitron chamber table were checked as well as the associated shelf, floor and trash can.

"When Seed #2 could not be found by the lab staff, the pathology supervisor contacted the RSO as well as Nuclear Medicine to notify them of a missing radioactive seed. RSO called and discussed what occurred with the pathology supervisor and sent two members of the Radiation Safety section of University's Environmental Health & Safety, who surveyed the same areas as the lab staff had scanned, as well as the changing room and the area of the laundry hamper, but were unable to locate Seed #2.

"On October 6, the RSO surveyed all of the waste containers and bags that were in the [University of Iowa Health Care] (UIHC) biohazard waste storage room at UIHC. This consisted of three large containers and one very large container, containing dozens of biohazard waste bags in total. It could not be confirmed whether or not it was likely that the bag removed from surgical pathology between 1900 CDT on 10/4/21 and 0700 CDT on 10/5/21 would have still been in the waste storage area. The RSO did not note any readings above background on the survey meter used to do the survey, and given the potentially hazardous nature of the contents, did not pursue a closer examination of the biohazardous waste. Due to the large search and survey response from pathology, nuclear medicine, environmental health & safety, and RSO, it was determined that there is a high probability the seed was wrapped up in absorbent materials used in the triage process and placed into a biohazard waste bin and removed from the department overnight."

Iowa Event Number: IA210004

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: 10/22/2021

EN Revision Text: VALID SPECIFIED SYSTEM ACTUATIONS OF UNIT 1 AND UNIT 3 EMERGENCY DIESEL GENERATORS

"At 1446 MST on October 20, 2021, a start-up transformer de-energized, resulting in a loss of power to the Unit 1 Train B 4.16 kV Class 1E Bus and the Unit 3 Train A 4.16 kV Class 1E Bus. The Unit 1 Train B Emergency Diesel Generator (EDG) and Unit 3 Train A EDG automatically started and energized their respective 4.16 kV Class 1E Buses.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of emergency AC electrical power systems.

"All systems operated as expected. Per the Emergency Plan, no classification was required due to the event. Units 1 and 3 both remain in Mode 1 at 100 percent power. Unit 2 is currently in a refueling outage and defueled. The 4.16 kV Class 1E Buses in Unit 2 were not affected by the de-energization of the start-up transformer since it was not aligned as normal power for Unit 2.

"The cause of the start-up transformer being de-energized is under investigation.

"The NRC Resident Inspectors have been informed."

FITNESS-FOR-DUTY REPORT

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified."

FITNESS-FOR-DUTY VIOLATION DUE TO DISCOVERY OF ALCOHOL IN THE PROTECTED AREA

"Plant cafeteria workers discovered that four gallons of cooking wine were included in a delivery to their inventory within the plant protected area. Security took possession of the sealed unopened containers and removed the alcohol from the protected area.

"The NRC Senior Resident Inspector has been informed."