Event Notification Report for November 26, 2021

EN Revision Imported Date: 11/26/2021

EN Revision Text: TRAVERSING IN-CORE PROBE A BALL VALVE INOPERABLE

"At 1320 EDT, during a Traversing In-Core Probe (TIP) run for a scheduled Local Power Range Monitors (LPRM) calibration, it was reported to the Main Control Room that TIP A would not fully retract to the In-Shield position. With TIP A unable to fully retract to the In-Shield position the TIP A Ball Valve was declared Inoperable due to not being able to close and meet its safety function in that configuration.
Furthermore the TIP A Shear Valve was previously declared Inoperable due to the Firing Fuses being removed. With the two valves Inoperable the penetration could not be isolated and Primary Containment boundary isolation could not be established.

"TIP A was subsequently manually hand cranked and placed back into its In-Shield position at 1333 EDT restoring TIP A Ball Valve Operable.

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(C) based on control the release of radioactive material.

"The Senior NRC Resident Inspector has been notified."

* * * RETRACTION ON NOVEMBER 24, 2021 AT 1232 EST FROM LEVI SMITH TO BRIAN P. SMITH * * *

"The purpose of this notification is to retract a previous report made on October 14, 2021 (EN 55522). At 1320 EDT on October 14, 2021 while performing Traversing In-Core Probe (TIP) Machine Gain Adjustment in support of Local Power Range Monitor (LPRM) calibration, an unplanned inoperability of the TIP 'A' Primary Containment Isolation Valve (PCIV) was reported pursuant to 10CFR50.72(b)(3)(v)(C) by EN 55522. On October 14, it was reported to the Main Control Room that TIP 'A' would not fully retract to the In-Shield position. With TIP 'A' unable to fully retract to the In-Shield position, the TIP 'A' Ball Valve PCIV was declared Inoperable due to not being able to close and meet its safety function in that configuration. The TIP 'A' Shear Valve PCIV was previously declared inoperable due to firing fuses being removed.

"Further investigation determined that a "FAULT: MOVEMENT LIMITED" error was received. This TIP error condition did not present a primary containment isolation issue in the event of a primary containment isolation signal. The Automatic TIP Control Unit (ATCU) is designed to command the TIP drive mechanism to continuously retract a TIP probe to the in-shield position in the event of a containment isolation signal with this condition. In the event of a containment isolation signal, the TIP machine would withdraw the TIP detector back to the in-shield position and the TIP A ball valve PCIV would have closed to perform its safety function. Therefore, the inoperability of TIP 'A' ball valve reported under criterion 10CFR50.72(b)(3)(v)(C) was not met, and EN 55522 is hereby retracted."

The NRC Resident Inspector has been notified.

Notified R3DO (Peterson)

EN Revision Imported Date: 11/26/2021

EN Revision Text: MEDICAL EVENT - DOSE ABOVE THE PRESCRIBED DOSE

The following was received from the licensee via email:

"The VA National Health Physics Program is reporting a medical event as defined in 10 CFR 35.3045.

"The medical event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA.

"The medical event occurred on July 13, 2021, and was discovered on November 16, 2021. The medical event involved the administration of approximately 152 millicuries of Iodine-131 sodium iodide to a patient. The patient received close to the activity intended by the authorized user physician. However, there was an error on the written directive form - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. Because the patient received the intended treatment, this medical event is not expected to cause any harm to the patient. The VA National Health Physics program has notified the NRC Project Manager, Bryan Parker of NRC Region III, for the VA Master Materials license."

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: 11/26/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - UNDER DOSE
The following is a synopsis of a report from the licensee:

On November 16, 2021 at approximately 1100 (EST) while delivering a Y-90 Thermosphere treatment to the liver, the vial septum failed under pressure. This resulted in not all the dose being delivered to the patient. The prescribed dose was 35.1 millicuries. The delivered dose was 14.4 millicuries. All the delivered dose was to the correct organ. No deleterious effects to the patient are expected.

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: 11/26/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL OVERDOSAGE

The following was received from the Wisconsin Radiation Protection Section (the State):

"On November 17, 2021, the licensee reported to the State a medical event involving Y-90 SIR-Spheres that was discovered that same day and occurred on November 16, 2021. Two administrations were prescribed to different segments of the left lobe of the liver, one of 0.4 GBq and one of 1.6 GBq. A calculation error occurred while converting these doses from GBq to milli-Ci which resulted in administered doses of 0.51 GBq and 2.3 GBq respectively; both of which are 27 percent above prescription. The State will continue to follow-up on the event."

No deleterious effects to the patient are expected. All dose was delivered to the intended organ.

Wisconsin Event Report ID Number: WI210008

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: 11/26/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDER DOSE

The following is a synopsis of a report received from the State of Washington, Office of Radiation Protection via email.
On Monday, November 15, 2021 a patient undergoing cancer treatment at University of Washington Medical Center, received an under dose of Y-90 TheraSpheres. The details of the intended dose to the liver (target organ) are yet to be provided. They will be forwarded when obtained.

Washington report number: TBD

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: 11/26/2021

EN Revision Text: Co-57 SOURCE MISSING IN TRANSIT

The following is a summary of a phone call with Ascension Borgess Hospital:

A Co-57 flood source was lost in transit with the following details:

Shipping Date: 2/22/2021
Expected Arrival Date: 4/7/2021

Source model #: MED3743
Source number: BM552018086101
Original activity: 20 mCi (4/26/2018)
Activity upon shipment (2/22/2021): 1.43 mCi
Calculated activity as of 11/11/2021: 735 microCi


Origination point: Kalamazoo, MI
Destination: Burbank, CA
The common carrier has been notified and started an investigation.
The licensee is developing corrective actions to prevent future occurrences


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: 11/26/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LOCKING MECHANISM MALFUNCTION

The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email:

"On 10/28/2021, Alabama licensee Vital Inspection Professionals, Inc. (RML 1118, Alabaster, AL) reported during the Agency's inspection that camera INC- 100 s/n 4481 appeared to have a malfunctioning locking mechanism. The licensee stated the malfunction was discovered on 10/20/2021 at a temporary job site. The licensee stated that the source appeared to be in the shielded position, and that personnel did not receive over exposures as a result of the faulty mechanism (consistent with inspection results). The licensee stated that the camera was taken out of service after the faulty mechanism was discovered. The licensee had a plan of action to send the camera for repair at the time of the inspection. The camera was loaded with an Ir-192 source, 100 curies on 9/27/2021."

Alabama Event 21-34

EN Revision Imported Date: 11/26/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE

The following was received by fax from the New York State Department of Health (NYSDOH):

"NYSDOH received a written report by mail of a leaking source. Suffolk Co. Public and Environmental Health Laboratory, [redacted], 725 Veterans Memorial Highway, Hauppauge, NY (NYSDOH Radioactive Materials License No. 1801) conducted routine leak testing on their two Agilent Technologies 8890 (03540A) GC [Gas Chromatograph] System (S/N US2106A027) ECO containing a 15 mCi (approx.) [Ni-63 source] G2397A (S/N U34601). Leak test samples were taken by the RSO on November 5th and sent to Agilent Technologies for analysis. The sample was processed on November 9th and preliminarily reported by Agilent to the Licensee on November 10th indicating that one of the ECO sources was leaking above the 0.005 uCi threshold. The Licensee RSO immediately obtained information from Agilent on the leaking source and copies of the preliminary reports. The Licensee provided NYSDOH with a written notification and report on November 10th by mail (received November 15th). The leaking quantity assessed at 45660 +/- 214 pCi. The GC unit was shut down and isolated. Agilent was notified (Radiation Safety Officer - RSO) to follow up on the leaking source and determine next steps. The system is less than one year old and still under service contract with Agilent.

"NYSDOH spoke with RSO upon receipt of this letter and GC/ECD was new as of March 2021. The defective detector (entire unit) has been isolated from service and Agilent is scheduled to arrive on 11/23/2021 to package and prepare unit for shipment. A radiological survey (contamination survey) was completed upon the isolation of the device showing radiation levels were consistent with background levels, indicating no fixed or removable contamination present.

"No further information on device or incident is available."


NY State Event Report ID No. NY-21-04

EN Revision Imported Date: 11/26/2021

EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID EMERGENCY DIESEL GENERATOR ACTUATION

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid specific system actuation.
At 0907 [EDT] on September 30, 2021, with Unit 1 in Mode 1, at 100 percent power, an actuation of the 1-1 emergency diesel generator (EDG) occurred during loss of voltage relay functional testing. The 1-1 EDG auto-start was due to human error during performance of the test procedure when the bus 1AE undervoltage signal was improperly defeated and a simulated undervoltage signal was applied. No actual undervoltage condition was present during this event. The 1-1 EDG automatically started as designed when the bus undervoltage signal was received. This was a complete actuation of an EDG to start and come to rated speed, and all affected systems functioned as expected in response to the actuation. Following the actuation, the relays were restored and the 1-1 EDG was shut down in accordance with plant procedures.

"This event is considered an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A).

"The actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. Therefore, in accordance with 10 CFR 50.73(a)(1), this telephone notification is provided within 60 days after discovery of the event instead of submitting a written Licensee Event Report.

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

PART 21 REPORT - HINGE PIN RETAINER PLUG DEFECTIVE ON DIESEL CHECK VALVE

The following is a synopsis of information received via facsimile:

The hinge pin retainer plug used on an emergency diesel generator (EDG) stainless steel check valve exhibited low breakaway torque and thus minimal resistance to loosening when subjected to engine operating vibrations. The EDG check valve is used specifically for lube oil (LO) applications in the gallery fill line between the LO cooler and main engine pressure pump discharge elbow. Consequently, if the plug were to completely dislodge, followed by the associated hinge pin, the pressure boundary of the LO system would be compromised and oil would discharge through the 3/16 inch opening.

The dedication procedure for this check valve is currently undergoing revision to incorporate a rework activity that will eliminate unintended plug loosening from future shipments. The vendor expects this to be completed by December 7, 2021.

The potentially affected components were shipped to the following plants: Beaver Valley, Browns Ferry, Dresden, and Surry.

Technical questions concerning this notification can be directed to Dan Roberts, Quality Manager and John Kriesel, Engineering Manager at (252) 977-2720.

60 DAY OPTIONAL TELEPHONIC NOTIFICATION FOR INVALID SPECIFIED ACTUATION OF CONTAINMENT ISOLATION TRAIN

"This 60-day telephone notification is provided in accordance with 10 CFR 50.73(a)(1) to report one invalid actuation of the Unit 1 Containment Isolation System Train "A" in accordance with 10 CFR 50.73(a)(2)(iv)(A).

"On October 17, 2021 at approximately 1358 [EDT], a DC breaker was opened to perform an inspection of a Containment Isolation (CI) rack. A CI signal was produced and resulted in a loss of Letdown during filling and venting the Reactor Coolant System (RCS) with the RCS at 344 psig. RCS pressure began to rise, and prompt actions were taken by the Control Room to secure a Charging Pump within 20 seconds. The RCS pressure rise continued and both Pressure Operated Relief Valves cycled at 409.9 psig as designed, lowering RCS pressure. The CI Train "A" was not part of a pre-planned sequence and the event resulted in the invalid actuation of Train "A" Containment Isolation valves in more than one system. All valves functioned successfully. The DC breaker was closed, CI signal reset, and associated CI valves re-opened. All systems functioned as required and returned to normal service.

"The NRC Senior Resident Inspector has been notified."

FITNESS-FOR-DUTY REPORT

A violation occurred concerning Comanche's Peak's Fitness-For-Duty Program. Two empty mini-bottles of alcohol were discovered in a trash can within the protected area. The event has been documented in the corrective action program.

The resident inspector has been notified.