Event Notification Report for March 14, 2022

EN Revision Imported Date: 3/14/2022

EN Revision Text: AGREEMENT STATE - UNDERDOSE
The following was received from the Commonwealth of Pennsylvania, Department of Environmental Protection (DEP) via e-mail:

"On March 3, 2022 a patient was receiving a Lutetium-177 (Lutatherar) treatment. During treatment, the vial lost pressure resulting in the inability to deliver the majority of the dose to the patient. Remedial measures were attempted, such as Dermabond and the addition of air, however, the procedure still could not continue, and it was terminated. No contamination was found outside of the delivery box. The prescribed dose was 200 milliCuries and it is estimated that the patient received 1.4 milliCuries. An investigation into the cause of the event is underway by the licensee. No adverse effects to the patient are noted at this time and the patient and prescribing physician have been informed. The DEP will update this event as soon as more information is provided."

PA Event Report ID No: PA220009

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: 3/14/2022

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

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

"On 3/4/2022, the Department was notified by the licensee's RSO that while performing six shutter checks on its fixed gauges it discovered that the shutter on a fixed gauge was not functioning properly . The fixed gauge was a Vega America Model SH-2, s/n 8906CM, containing 200 mCi of Cs-137. The licensee has contacted the manufacturer and has scheduled a repair of the shutter. The gauge is located approximately 12 feet off the floor on the side of a vessel and is not readily accessible by employees.

"On 3/5/2022, the Department On-call duty officer met with [licensee] to gain access to the gauge and perform a radiation survey. The radiation on the surface of the gauge measured 16 mR/hr and measured 6 mR/hr at 1 foot. The on-call duty officer verified that the gauge is inaccessible to employees and that radiation exposures to members of the public (non-radiation workers) would be minimal."

EN Revision Imported Date: 3/14/2022

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the Arkansas Department of Health (the Department) via email:

"The Agreement State Radioactive Materials Licensee reported to the State of Arkansas, Arkansas Department of Health, on February 23, 2022, that a general licensed device listed on their specific license has tested positive on the leak test results. The Department provided correspondence to the licensee on February 25, 2022. The leaking sealed source was Ni-63, which is used in a Agilent Gas Chromatograph.

"The Department considers this event to be in process and will submit additional information until this event is closed."

State Event Report ID Number: AR-2022-003

EN Revision Imported Date: 3/14/2022

EN Revision Text: AGREEMENT STATE REPORT - POTENTIALLY RADIOACTIVE MATERIAL DISCOVERED

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

"The Department received a call from a concerned citizen over 3 potentially radioactive pieces of metal that he found in a toolbox that his father-in-law previously owned. When Department inspectors went onsite, the pieces of metal read between 2-8 mR/hr on contact. The metal pieces were removed by Department staff and are currently in secure storage. Exposures to individuals are unknown at this time and the origin of the metal is unknown. The Department will continue to investigate."

Arizona Incident Number: 22-005

EN Revision Imported Date: 3/14/2022

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

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

"The Department received notification from the licensee that a portable gauge was lost/stolen. A technician last saw the gauge on 03/04/2022 at a jobsite in Phoenix at 1320 [MST]. The technician then realized that the gauge was no longer in his possession on 03/07/2022 when he arrived at his first jobsite at 0730 [MST] in Tucson. The gauge is a Troxler 3430P, Serial Number 72511, containing approximately 8 millicuries of Cesium-137 and 40 millicuries of Americium-241:Beryllium. The Department has requested additional information and continues to investigate the event. The licensee has reported the gauge stolen to the cities of Tucson and Phoenix. The report numbers are as follows:

"City of Phoenix - #2022-00000355178, City of Tucson - #2203078513"

Arizona Incident Number: 22-006


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

PART 21 REPORT - TEMPERATURE TRANSMITTER FAILURES

The following is a synopsis of information received via facsimile:

Three defects were identified on an N7030 temperature transmitter, and all sub-models, manufactured by Ultra Energy. The first two defects were identified during product testing and are dependent on component tolerances and fabrication, these may not exist in all units. The third defect was identified during the safety investigation.

First, for transmitters configured to indicate a failed resistance temperature device (RTD) via an over-range signal, the transmitter could return an in-range reading when operating at a temperature near the bottom of the specified temperature range. Second, for transmitters configured to indicate a failed RTD via an under-range signal, the transmitter could return an in-range reading when operating near the bottom of the specified loop voltage range. Third, transmitters with a disconnected RTD could output noise in the presence of very high impedance (mega-ohm range) at the input terminals and in specific narrow temperature ranges (less than 10 degrees Celsius).

The first two defects could cause a sensor, which had failed, to appear to be functioning, although the reading would likely be obviously false and thereby highly unlikely to result in any risk to safety. The third condition might, depending on sensor noise filtering, result in a false temperature reading which was not obvious. This however requires multiple parameters to be in the correct ranges to trigger the latent defect and is also highly unlikely to result in any risk to safety.

Corrective actions include: a reduction in specified operating temperature and loop voltage range, a field fix for the high impedance condition, and supplying impacted facilities with an engineering bulletin. Additionally, devices in the process of being manufactured have been segregated and will be scrapped. Design modifications will be made prior to continuing manufacturing these temperature transmitters.

The facilities listed as being impacted are: Oconee Nuclear Station, Quad Cities NPS, and Prairie Island Nuclear Generating Plant.

Contact Gary Hawkins , Vice President Engineering, or Diane Steen, Director of Quality, with questions. (512) 434-2800.

Ultra Energy
707 Jeffrey Way
P.O. Box 300
Round Rock, Texas 78665

MAIN STEAM ISOLATION VALVE FAILED TO SHUT

The following information was provided by the licensee via email:

"At 0050 EST on 3/12/22, while shutting down for entry into a scheduled refueling outage, the station discovered that a single Main Steam Isolation Valve (4A MSIV) did not fully close on demand. All other equipment operated as expected.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v).

"The NRC Resident Inspector has been notified."

OFFSITE NOTIFICATION

The following information was provided by the licensee via email:

"At approximately 1045 EST on March 12th, 2022, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing the Fuel Manufacturing Operation (FMO) was impaired. High winds had caused a tree to fall on a power line. As a result, the electric fire pump was without power. The backup diesel fire pump remained fully operational and available to perform its safety function. Power was restored at approximately 1600 EST on March 12th, 2022, and the Deputy Fire Marshall was notified of system restoration. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will notify the State and NRC Region II.