Event Notification Report for November 22, 2021

EN Revision Imported Date: 11/22/2021

EN Revision Text: MEDICAL EVENT - UNDERDOSAGE DUE TO HDR AFTERLOADER MALFUNCTION

The following information was received via E-mail:

"On November 12, 2021, the Department (Arizona Department of Health Services) was notified by the licensee that during an HDR treatment, an error message showed up after the first 15 channels were delivered. The error message was '8C:2 Dummy park switch or drive failure.' The Varian Medical System help desk was contacted for the error message without resolution. The field service engineer was called and suggested to power down the afterloader unit and reboot it, which did not resolve the problem. To avoid putting the patient under general anesthesia any longer, the Authorized User decided to stop the treatment and left the remaining four (4) channels untreated. The prescribed dose was 14 Gy and the estimated dose given was 10.2 Gy. The afterloader unit was a Varian Varisource iX, with an activity of 7.5 Ci of Iridium-192. The Department has requested additional information and continues to investigate the event."

Arizona Incident: 21-010

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: 11/22/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - LOST OR STOLEN MOISTURE DENSITY GAUGE

The following is a synopsis of information received via telephone:

Upon arriving at a jobsite in West Indianapolis, the technician went to remove a Troxler gauge for use. Upon opening the toolbox in the bed of the truck, the technician found that the Troxler gauge was missing from its case. The toolbox is bolted to the bed of the truck, however the locks for the toolbox and case were found not to be locked.

At the present time, the licensee is not sure whether the Troxler gauge was stolen or possibly left at the last jobsite where it was used this past Saturday. The licensee is dispatching individuals to the last jobsite to search for the Troxler gauge. The licensee has also reported this event to the Indianapolis Police Department.

The Troxler gauge is a Model 3430 moisture density gauge, serial number 23266. The Troxler gauge contains 0.3 GBq of Cs-137 and 1.48 GBq of Am-241.

The licensee will provide updated information when available.

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: 11/22/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via E-mail:

"One exit sign, model SLX60 was reported as lost when the State requested registration for 17 exit signs shipped to Pindustry for installation."

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: 11/22/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE DURING Y-90 ADMINISTRATION

The following information was received via E-mail:

"On Saturday, November 13, 2021 at 1420 PST, a CDPH-Radiologic Health Branch inspector was notified by E-mail that a medical event had occurred on November 12, 2021, at UCLA during a Y-90 liver cancer treatment. The signed written directive was included in the notification.

"The prescribed dose for 'Segment Left' was 70 Gy (6 GBq) and the dose delivered was 68.8 Gy (or 98.29 percent of the prescribed dose). The prescribed dose for 'Segment Right' was 120 Gy (3 GBq) and the dose delivered was 78.3 Gy (or 65.25 percent of the prescribed dose).

"The authorized user administered two vials of BTG Nordion Inc. TheraSphere Y-90 glass microspheres beginning approximately 1200 PST. Vial number 101 went to the right lobe and vial number 30 went to the left lobe of the liver.

"Radiation surveys of the waste containers occurred at 1516 PST and 1519 PST respectively, and the radiation level from vial number 30 was higher than expected. UCLA's medical physicist was consulted at 1630 PST November 12, 2021, who determined that a medical event had occurred.

"UCLA will be investigating the cause of the underdose and make a 15-day written report."

California 5010 Number: 111221

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: 11/22/2021

EN Revision Text: Non-Work Related On-Site Fatality

"At 2238 Eastern Standard Time (EST), on 11/17/2021, a Watts Bar Nuclear Plant contractor was transported offsite for treatment at an offsite medical facility. The offsite medical facility notified Watts Barr Nuclear Plant at 2310 EST that the individual had been declared deceased.

"The fatality was not work-related and the individual was inside of the Unit 1 Radiological Controlled Area. The individual was confirmed not to be contaminated.

"This is a four-hour notification, non-emergency for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

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

The licensee will notify OSHA.

EN Revision Imported Date: 11/22/2021

EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE DUE TO ISOLATION VALVE FAILURE TO AUTOMATICALLY OPEN

"On November 18, 2021, during the performance of High Pressure Coolant Injection (HPCI) surveillance testing, 23MOV-19 (HPCI PUMP DISCH TO REACTOR INBD ISOL VALVE) did not go open as expected while performing the sensed low water level portion of the test. The ability to manually open 23MOV-19 from the control room was unaffected as such, the HPCI system remained available for use. Failure of 23MOV-19 to open automatically prevents the HPCI system from performing its safety function as such this condition renders HPCI inoperable but available and is being reported as a condition that could have prevented the fulfillment of the safety function of a system needed to mitigate the consequences of an accident per 10CFR50.72(b)(3)(v)(D)."

HPCI inoperable placed the licensee in a 14-day limiting condition for operation for Tech Spec 3.5.1.c.

The NRC Resident Inspector was notified.

EN Revision Imported Date: 11/22/2021

EN Revision Text: MANUAL REACTOR TRIP AND AUTOMATIC AUXILIARY FEEDWATER ACTUATION

At 1046 EST on November 21, 2021, with Calvert Cliffs Nuclear Power Plant Unit 2 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering levels in both steam generators following a loss of the 21 and 22 steam generator feed pumps. An Auxiliary Feedwater System actuation occurred to restore steam generator water levels. The trip was not complicated, with all systems responding normally. Decay heat is being removed by the Auxiliary Feedwater System. Calvert Cliffs Nuclear Power Plant Unit 1 is unaffected and remains in Mode 1 at 100 percent power.

Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification. RPS actuation, per 10 CFR 50.72(b)(2)(iv)(B). Additionally, the automatic actuation of the Auxiliary Feedwater System is being reported as an eight-hour, non-emergency notification, Specific System Actuation, per 10 CFR 50.72(b)(3)(vi)(A).

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