Event Notification Report for December 07, 2021

EN Revision Imported Date: 12/7/2021

EN Revision Text: AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE POSITION ERROR

The following was received from the Virginia Department of Health, Radioactive Materials Program (the agency) via email:

"On November 24, 2021, the agency was notified by the [radiation safety officer] at the University of Virginia, by email at 1347 EST and by phone at 1355 EST, that a medical event involving an HDR [high dose rate brachytherapy] had occurred that day. During a prostate HDR Iridium-192 case, the patient was treated without any issues through the first channel. At the start of the second channel run, an error was received indicating that the source position slipped while at the 0.0 cm mark. The procedure was paused with no treatment to the patient through the second channel. A dummy wire test was run with no errors indicated. A second attempt at treatment with the source through the second channel was made and the same position error was indicated. The treatment was cancelled at that point. Having only received the first channel treatment, the patient received less than 5 percent of the total prescribed dose. The HDR unit is a Varian VariSource iX, serial number V3509. The source is an Alpha Omega Iridium-192, serial number 02-01-3798-001-191421-11617-25 with a current activity of 5.98 Ci. The licensee contacted Varian and stated that they believe it is likely an issue with the afterloader itself. The source was verified to be in the unit and no additional exposure to the patient or staff was received from the event. The licensee is working with Varian to schedule a repair visit.

"This report will be updated when the licensee submits their final investigation report."

Virginia Event Report ID No.: VA-21-0007

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: 12/7/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST NI-63 SOURCE

The following information was received from the state of New Jersey Department of Environmental Protection:

"The Radiation Safety Officer of Rutgers University informed the New Jersey Department of Environmental Protection that one sealed source device, with an installed source, cannot be found and is considered lost. The source in question is a Ni-63, electron capture detector source, serial number U1739, to be used in Agilent HP Gas Chromatograph, Model # HP6890, serial number US10204036 electron capture detection device. The source contained 15 mCi of activity. The device was present during the licensee's April, 2021 inventory. When the current inventory was being conducted, the device could not be found. The licensee stated that the lab where the device was located had a burst pipe in June, 2021. It is believed that the device was mistakenly discarded in July, 2021, as part of the clean-up. Rutgers will forward a written report within 30 days."

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: 12/7/2021

EN Revision Text: UNIT 3 AUTOMATIC TRIP

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"At 1203 MST on December 6, 2021, the Unit 3 reactor automatically tripped on low departure from nucleate boiling ratio. A part-strength control element assembly was being moved at the time of the trip.

"Unit 3 is stable and in Mode 3. In response to the reactor trip, all control element assemblies inserted fully into the core. Safety-related electrical power remains energized from off-site power sources and reactor coolant pumps continue to provide forced circulation through the reactor. Decay heat is being removed by the steam bypass control system and main feedwater system. Required systems operated as expected.

"No emergency classification was required per the Emergency Plan.

"The NRC Senior Resident Inspector has been informed."

Units 1 and 2 were unaffected by this transient.

EN Revision Imported Date: 12/7/2021

EN Revision Text: VALID SAFETY SYSTEM ACTUATION
"On December 6, 2021, at 1125 hours Eastern Standard Time (EST), during planned maintenance activities, electrical power was lost to the 4160V emergency bus E-3. The power loss to emergency bus E-3 affected both Unit 1 and 2. Emergency Diesel Generator #3 received an automatic start signal but was under clearance for planned maintenance. Emergency bus E-3 was re-energized at 1315 EST hours via offsite power.

"The loss of power to E3 resulted in Unit 2 Primary Containment Isolation System (PCIS) Group 2 (i.e., Drywell Equipment and Floor Drain, Residual Heat Removal (RHR) Discharge to Radwaste, and RHR Process Sample), Group 3 (i.e., Reactor Water Cleanup), Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems), and Group 10 (i.e., air isolation to the drywell) isolations. The actuations of PCIVs were completed and the affected equipment responded as designed. Per design, no Unit 1 safety system group isolations or actuations occurred. Other Unit 2 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start signal to the Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed. Safety systems functioned as designed following the de-energization of bus E-3.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of PCIS on Unit 2 and an automatic start signal to Emergency Diesel Generator #3.
There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Except for the Emergency Diesel Generator, which is out of service for planned maintenance, all equipment has been returned to its normal alignment.

* * * UPDATE FROM JJ STRNAD TO THOMAS KENDZIA AT 2028 EST ON DECEMBER 6, 2021 * * *

"The loss of power to E3 resulted in Unit 1 Primary Containment Isolation System (PCIS) Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems). Other Unit 1 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start signal to the Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed. Safety systems functioned as designed following the de-energization of bus E-3.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of PCIS on Unit 1."

All Unit 1 equipment was returned to its normal alignment. The NRC Resident will be notified.

Notified R2DO (Miller).