Event Notification Report for November 08, 2021

EN Revision Imported Date: 11/8/2021

EN Revision Text: FITNESS-FOR-DUTY REPORT

A non-licensed employee 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.

DOSE TO AN EMBRYO

The following is a summary of a phone call with Community Health Network:

A patient came in to receive a radiotherapy treatment of 148 mCi I-131 on September 30, 2021. The patient received a negative pregnancy test prior to the treatment. At a later date, the patient realized that she was pregnant and estimated the date of conception to be either September 29, 2021 or October 10, 2021. The radiation safety officer estimated the dose to the embryo to be 394 mSv (39.4 rem) based on a conception date of September 29. The estimated dose to the embryo would be 1.7 mSv (0.17 rem) based on a conception date of October 10. The licensee is reporting this event based on the conception date of September 29 because of the potential for higher dose to the embryo.

LOSS OF HIGH RADIATION AUDIBLE ALARM

"On November 5th, 2021, [1207 MDT] it was identified that a portable Area Radiation Monitor (ARM), which was performing the 10 CFR 70.24 safety function of the Criticality Accident Alarm System (CAAS) to energize clearly audible alarm signals if accidental criticality occurs, had been removed from the area in error.

"On July 20th, 2021, during routine CAAS maintenance, UUSA [Urenco USA] staff identified an area in which a CAAS alarm was not clearly audible. UUSA arranged the ARM as a compensatory measure which achieves an equivalent 10 CFR 70.24 safety function in the affected area. UUSA reported this event to the NRC under Event Notification 55480 in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation.

"Removal of this ARM resulted in an inability for radiation detectors to energize clearly audible alarm signals if accidental criticality occurs in the affected area. UUSA hereby reports this event in accordance with 10 CFR 70.50(b)(2), in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24)."

The licensee will notify the NRC Region 2 office.

STEAM SUPPLY CHECK FAILURE TO TURBINE DRIVEN AUXILLARY FEEDWATER

"During a Unit 2 refueling outage valve overhaul activity on the steam supply check valve from the number 2 steam generator to the turbine driven auxiliary feedwater pump, 2-MS-4B, the check valve was found with its disc separated from the disc arm. This failure would have resulted in the blowdown of both steam generators during a main steam line break in the steam generator number 2 main steam line upstream of the main steam isolation valves until the operators could isolate the faulted steam generator. On November 6, at approximately 1100 EDT evaluation determined that this condition constituted an unanalyzed condition that could impact containment pressure.

"There has been no radioactive release to the environment. The valve has been repaired. The check valve in the steam supply from the number 1 steam generator to the turbine driven auxiliary feedwater pump was inspected and found to be satisfactory. There has been no impact to Unit 3 which remains at 100% power.

"The Senior Resident has been notified.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B) as a condition that resulted in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety."

EN Revision Imported Date: 11/9/2021

EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE

During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.

On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).

The licensee will notify the NRC Region 2.

* * * UPDATE ON 11/8/21 AT 1502 FROM BLAKE BIXEMAN TO KERBY SCALES * * *
During the Apparent Cause Evaluation related to Event Notification 55480, an extent of condition was performed. This extent of condition revealed three historical examples of inaudible CAAS alarms that were not reported under 10 CFR 70.50(b)(2) as required by regulation.
These conditions occurred on April 12th, 2014, August 15th, 2014, and August 20th, 2015.

Corrective actions were implemented for these deficiencies during the approximate time period in which they were identified. The affected systems are currently compliant with 10 CFR 70.24 regulations. Details of this extent of condition are documented in UUSA's Corrective Action Program, EV 148663.

The licensee notified NRC Region 2 personnel.

Notified R2DO (Miller) and NMSS Event Notifications via email.

EN Revision Imported Date: 11/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED

The following information was received from the Arizona Department of Health Services (the Department) via email:

"On November 2, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, two IsoAid Advantage I-125 breast localization seeds were removed by surgery on October 29, 2021 and were verified to be included in the specimen. The specimen with the seeds was delivered to pathology on the afternoon of October 29, 2021. The seeds were not removed from the specimen until November 1, 2021 by pathology. At this time, pathology was only able to locate one of the I-125 seeds. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the one missing I-125 seed. [The missing I-125 seed was between 0.3 and 0.4 microcuries.] The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona Incident No: 21-008

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: 11/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED

The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:

"The Agency was notified at 12:46 CDT on November 2, 2021 by the University of Illinois at Chicago to advise of a lost/missing 2.5 mCi I-125 eye plaque brachytherapy seed. The amount and form of radioactivity contained in the seed would not be useful for illicit intent and there is no indication of intentional theft or diversion. The quantity, however, is reportable and will be transmitted to the US NRC electronically today.

"The Radiation Safety Officer, RSO, for the University of Illinois at Chicago (UIC) contacted the Agency to advise that a shipment of 21 eye plaque brachytherapy seeds from Theragenics Corporation received on September 27, 2021 was found to contain only 20 seeds upon opening of the package. The RSO reported that no damage to the package was observed and that the container holding the seeds was appropriately sealed. Surveys were performed of packing materials and the package receipt area to locate the potentially lost 2.5 mCi I-125 brachytherapy seed. The licensee's surveys and investigation did not result in locating the seed. Theragenics was notified on September 27, 2021 and initiated an investigation. A letter received by UIC from Theragenics on November 1, 2021 stated that no discrepancies were identified and the manufacturer/shipper maintained 21 seeds were shipped as ordered. An additional seed was ordered and received on September 28, 2021 from Theragenics and the patient treatment was successfully completed on September 30, 2021 to October 4, 2021.

"The incident is immediately reportable per 32 Ill. Adm. Code 340.1210(a). The matter was not reported timely by the licensee, which the Agency will address under separate correspondence. Additional information is being sought from the licensee at this time."

Illinois Item Number: IL210035

EN Revision Imported Date: 11/9/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"The licensee was at a temporary jobsite and stepped away from their vehicle. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case. The licensee notified the police and has begun actions to recover the gauge. The Division is waiting for additional information from the licensee. "

Utah Event Report ID Number: UT 210006

* * * UPDATE FROM SPENCER WICKHAM TO THOMAS KENDZIA AT 1259 EDT ON 11/4/21 * * *
The following information was received via e-mail:

"At the time of this notification (UT 210006) we did not have information pertaining to the gauge. Please see the following gauge information.
Model: Instrotek 3500, Serial Number: 3823, Cs-137: 11 mCi, Am-241: 44 mCi.

"The licensee has recovered the stolen gauge. The gauge was still locked and chained in the transport vehicle in it's transport package and had not been tampered with. The Division will update and send the NMED report once the event is closed."

Notified R4DO (KOZAL), NMSS Events Notification group (email), and ILTAB (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

OFFSITE NOTIFICATION

"At 1015 CST, a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-10, Auxiliary Boiler Fuel Oil Storage Tank. The tank was removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to historical information from a similar tank removal earlier this year (June 2021). The soil contamination levels are from the historic use of the tank. The contamination levels [of Volatile Organic Compounds] are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. There was no contamination noted in the groundwater samples. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40 CFR280.10(c)(4).

"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."

The licensee will notify NRC Region 4 personnel.