Event Notification Report for October 28, 2021

EN Revision Imported Date: 10/28/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:

"On October 20, 2021, the licensee informed the Department of a failure of a shutter. It is reportable per 10 CFR 31.5(b)(5).

"On March 26, 2019, the licensee identified a defective linear actuator assembly on one of its Beta Control Mk 1.0 (serial number 559 / KP983) devices. The device contains 267 mCi (9.9 GBq) of Kr-85. The defect prevented the source from returning fully to its home shielded position. After initial discovery, a service provider manually moved the device to fully align with the shutter assembly. At a later date, it was discovered the unit had drifted out of alignment again. At this time a service provider installed a plate directly on the device effectively sealing the unit, regardless of alignment with shutter assembly. No exposures resulted from this event.

"The Department will perform a reactive inspection. A service provider has already corrected the problem."

Event Report ID No: PA210016

EN Revision Imported Date: 10/28/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK/BROKEN SHUTTER

The following was received from Pennsylvania, Bureau of Radiation Protection (the Department) via email:

"On October 5, 2020, the licensee identified a failed return spring on one of its NDC 103 (serial number 3020641) devices. The device contains 148 mCi (5.55 GBq) of Am-241. The written report received from the service provider on Oct 5, 2020 stated that the secondary shutter device for the device in question failed to close. The primary shutter assembly remained operational at all times. The secondary shutter assembly defect was addressed and corrected by the service provider at the earliest possible time (next scheduled machine downtime event). No overexposures resulted from this event.

"The Department will perform a reactive inspection. A service provider has already corrected the problem."

Event Report ID No: PA210017

EN Revision Imported Date: 10/28/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE

The following report was received from the Illinois Emergency Management Agency [the Agency] via email:

"The Agency was contacted on the afternoon of 10/21/21 by the University of Chicago to advise of a reportable medical event that occurred the day before. A human research subject was reportedly administered 79.8 mCi of a prescribed 100 mCi dose of I-131 under the therapeutic portion of a study protocol. There is no root cause available at this time, although the licensee suspects an inadequate volume of saline flush. Inspectors will evaluate any other contributing factors including equipment, personnel involved and unique procedures for this study protocol. At this time, the licensee is not expecting any adverse impact to the patient and they are following up with the study sponsor to determine if additional treatment is required. The referring physician has been notified and the licensee is aware of the requirement to notify the patient. This matter is reportable under 32 Ill. Adm. Code 335.1080(a) for a dose differing from the prescribed dose by 20 percent or more. The administration was started at 1420 CDT on 10/20/21 and the matter reported to the Agency at 1219 CDT on 10/21/21. The reporting criteria has been met. In accordance with Agency policy, inspectors will perform a reactionary inspection within 10 days of the incident."

Illinois Report Number: IL210032

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.

AUTOMATIC ACTUATION OF THE 1B EDG LOAD SEQUENCER ON BUS UNDERVOLTAGE CONDITION

"At 1429 EDT on October 27, 2021 with Unit 1 in Mode 6 at 0 percent power, the 1B Emergency Diesel Generator (EDG) Load Sequencer was actuated by a valid undervoltage condition on the 1B 4160V Essential Bus that occurred during 1B Sequencer calibration activities. Valid signals were sent to both the 1B EDG and Unit 1 Auxiliary Feedwater (CA) systems. Neither system automatically started as they were both removed from service for maintenance activities at the time.

"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 the 1B EDG and Unit 1 CA systems.

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