Event Notification Report for February 24, 2022

EN Revision Imported Date: 2/24/2022

EN Revision Text: LOSS OF METEORLOGICAL DATA ACQUISITION SYSTEM
The Licensee provided the following information via email:

"On January 27, 2022 at 1038 CST, with Cooper Nuclear Station in Mode 1, 100 percent power, the meteorological tower primary and backup data acquisition system failed, which resulted in a loss of meteorological data to the plant. Information technology personnel investigated and restored the primary system to service. Meteorological data to the plant was restored at 1105 CST on January 27, 2022. This notification Is being made due to a loss of emergency assessment capability In accordance with 10 CFR 50.72(b)(3)(xiii).

"The NRC Resident Inspector has been Informed."

* * * RETRACTION ON FEBRUARY 23, 2022 AT 1658 EST FROM LINDA DEWHIRST TO LLOYD DESOTELL * * *

The following information was provided by the licensee via fax:

"This notification is being made to retract event EN 55715 that was reported on January 27, 2022. Based on further investigation, the Emergency Plan and Emergency Plan Implementing Procedures provide acceptable alternative methods for performing emergency assessments that are in addition to the data obtained from the primary and backup meteorological tower information. It was determined that no actual or potential major loss of emergency assessment capability existed per 10 CFR 50.72(b)(3)(xiii). This is consistent with NUREG 1022, Revision 3, Supplement 1 and NEI 13-01, Revision 0. The NRC Resident Inspector has been notified of the retraction."

Notified R4DO (O'Keefe)

EN Revision Imported Date: 2/24/2022

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO AN INCORRECT TREATMENT SITE

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

"The Department [DEP] received notification from a licensee on February 15, 2022, of medical event involving dose to an incorrect treatment site. An Elekta/Nucletron Remote Afterloader containing 6.421 Curies of iridium 192 (serial number V3/ 10799) with a Valencia skin applicator was to treat the lower third nasal dorsum with 600 cGy. However, the prescribing physician specified the right nasal sidewall. Therefore, the patient received 600 cGy to her lower 3rd nasal dorsum and not right nasal sidewall. The patient and prescribing physician were informed on February 14, 2022. The patient is being monitored and at this time no adverse effects are evident. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided."

Pennsylvania Event Report Number: PA220007

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: 2/24/2022

EN Revision Text: AGREEMENT STATE REPORT - SAFETY EQUIPMENT FAILURE

The following information was provided by the Texas Department of State Health Services (the Agency) by email:

"On February 16, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that one of his crews [at a temporary job site in Baytown, TX] were unable to retract an 89 Curie iridium - 192 source back into a QSA 880D exposure device. The radiographers were performing radiography when a pipe fell on the guide tube crimping it to the point that the source assemble could not pass through it. The radiographers isolated the area and contacted the company's RSO. A retrieval team went to the location and was able to recover the source within the hour of the start of the event. No member of the public received an exposure from the event. The radiographers did not exceed any exposure limits. The radiographer's dosimetry will be sent for processing."

Texas Incident #: 9914

EN Revision Imported Date: 2/24/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following information was provided by the the state of Illinois via email:

"During a 2/16/22 inspection, inspectors discovered an unreported medical event at The Carle Foundation (IL-01156-01) that occurred on December 30, 2021. No adverse patient impact reported. This was reported to the Headquarters Operations Officers on 2/17/2022.

"DETAILS: Agency inspectors performed a routine inspection on 2/16/2022, of The Carle Foundation d/b/a The Carle Foundation Hospital. During a review of Y-90 Theraspheres procedures on the afternoon of 2/16/2022, inspectors noted an unreported medical event which occurred on December 30, 2021. Inspectors noted that on 12/30/2021, a written directive to deliver 0.30 GBq Y-90 Theraspheres to the left hepatic artery was prepared; however, only 0.11 GBq (37 percent) was delivered. The licensee reported using a smaller microcatheter than usual.

"No further treatment to the patient is planned. The authorized user advised that the dose delivered was medically satisfactory for this case.

"The event remains under investigation."

Item Number: IL220005

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: 2/24/2022

EN Revision Text: AGREEMENT STATE REPORT- STUCK SHUTTERS ON TWO FIXED GAUGES

The following information was provided by the state of South Carolina Department of Health and Environmental Control (the Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via phone at 1626 [EST] on 02/16/2022, that shutters were stuck in the open position on two different fixed gauges. The licensee is reporting that one of the fixed gauges is a Cs-137 Berthold Model LB 7440D gauging device, serial number 1678-6-88, with an activity of 150 mCi. The licensee is reporting that the second fixed gauge is a Cs-137 Berthold Model LB 7440D gauging device, serial number 1003-4-96, with an activity of 50 mCi. The licensee is reporting that the locking mechanisms for both shutters is disabled and won't allow for the shutters to close. The licensee is reporting that the gauging devices are still mounted to vessels. A Department inspector was dispatched to the facility on 02/17/22, and found the gauging devices as the licensee described. Dose rate readings using a NDS ND-2000A (calibrated 9/14/21) indicated readings as high as 1.8 mR/hr on the surface of the Cs-137 Berthold Model LB 7440D gauging device, serial number 1003-4-96, with an activity of 50 mCi. Dose rate readings using a NDS ND-2000A (calibrated 9/14/21) indicated readings as high as 2.2 mR/hr on the surface of the Cs-137 Berthold Model LB 7440D gauging device, serial number 1678-6-88, with an activity of 150 mCi. The gauges are located in a controlled area within the licensee's facility. A licensed consultant was scheduled to arrive at the licensee's facility on 02/17/22, to remove the gauges, attach a replacement shutter, and place the gauging devices in storage at the licensee's facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

EN Revision Imported Date: 2/24/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER FIXED GAUGE

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via email at 1250 [EST] on 02/17/22, that during routine shutter checks a shutter was identified as stuck in the open position on a fixed gauging device. The licensee is reporting that the fixed gauge is a Cs-137 Ohmart Model SH-F1 gauging device, serial number 67581, with an activity of 100 mCi. The licensee is reporting that the gauging device is currently mounted to a vessel, in a low-traffic, and controlled area. The licensee is reporting that they will not be issuing any entry permits into the vessel until they have remediated the shutter. The licensee is reporting that the manufacturer of the gauging device has been contacted for repair. Department inspectors will be dispatched to the facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

EN Revision Imported Date: 2/24/2022

EN Revision Text: MANUAL REACTOR TRIP

The following information was provided by the licensee via fax or email:

"At 22:07 [EST] on 2/21/2022 with Unit 2 in Mode 1 at 68 percent power, the reactor was manually tripped due to lowering water level in the 2A Steam Generator. The trip was not complex with all systems responding normally post-trip.

"Operators responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Units 1 and 3 were not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non- emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

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