Event Notification Report for April 25, 2022

AGREEMENT STATE REPORT - SOURCE UNABLE TO RETRACT TO SAFE POSITION

The following was received from the Commonwealth of Virginia via email:

"On April 14, 2022 at 2249 hours EDT, the Office of Radiological Health Radioactive Materials Program (ORH) received an incident report from the licensee, Huntington Ingalls Incorporated Newport News Shipbuilding. The source, 79 curies of Ir-192, could not be retracted to its shielded position during radiographic work. The incident occurred on April 14, 2022 at about 1103, while a radiographic work was being performed in a permanent radiography booth to inspect a pipe for use upon a naval vessel at Newport News Shipbuilding. The incident occurred because the metal pipe fell off of the metal sawhorse, crushing the source tube and preventing full retraction back into the shielded position. The root cause of the pipe falling off of the sawhorse has yet to be determined. The radiography crew immediately closed the permanent radiography booth, took radiation surveys to ensure that with the door closed the radiation levels were below 2 mR/hr, and notified the Radiation Safety Officer (RSO). The site was supervised by the radiography crew constantly between the time of the incident until the source was retracted at approximately 1310 on April 15, 2022. The highest exposure of the crew from the pocket dosimeters was 5.5 mrem. In addition, the whole body dosimeters were sent to the licensee's internal dosimetry program for analysis. The results are not yet available. The RMP Southeast regional inspector responded to the incident and performed radiation safety assessment at the event site."

Virginia Event Report ID Number: VA220001

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the state of Nebraska, Office of Radiological Health via email:

"We [Office of Radiological Health] received Central Valley Agriculture GL0746's Annual Radioactive Material Current Inventory and they indicated that they were no longer in possession of 2 tritium exit signs. We spoke with them and they said that the Oak Street property had been sold several years ago and the building torn down. We contacted the new property tenant to confirm, and it was determined that the signs were not on the property, assumed to have been demolished with the previous building. Follow-up complete, no further investigation is needed."

Nebraska event number: NE220001

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

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following was received from the state of California Radiologic Health Branch (RHB) via email:

"On 4/14/22, Radiation Safety Officer (RSO) contacted RHB to report a Medical Event associated with a High Dose Rate (HDR) unit.

"Licensee's written notification on 4/15/22, stated the following:

"Sometime on Friday, April 8th [2022], an HDR therapist replaced a source transfer tube/catheter with a longer length transfer tube/catheter than intended for the three HDR treatments planned for that day. The difference in lengths was 123 mm. Since the treatment plan was with a shorter transfer tube/catheter, the source didn't make it all the way to the treatment locations and resulted in underdosing the three patients on that day, and likely delivering unplanned doses to non-treatment sites for the three patients. The error was discovered on Wednesday, April 13th, as another HDR therapist was getting ready for an HDR treatment. No HDR treatments had occurred since Friday, April 8. The first therapist wasn't certain if she changed the transfer tube/catheter in the morning or after the patients, but she thinks she likely changed it in the morning. The licensee is still evaluating the delivered doses to the patients treated on that Friday, but at least two of them are believed to have received an underdose that is reportable. The doses to non-treatment sites have not been fully evaluated. All three patients and their referring physicians were notified on Thursday, April 14th.

"RHB is continuing to follow up with the investigation."

California Event Number: 041422

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.

OFFSITE NOTIFICATION

The following information was provided by the licensee via email:

"At approximately 1300 EDT on April 21st, the New Hanover County Deputy Fire Marshal was notified that a roll up fire door located between a boiler room and the rad waste system malfunctioned in the open position. The door was approximately 3/4 closed. Compensatory measures were discussed with the Deputy Fire Marshall and then implemented. The door was repaired at approximately 1045 EDT on April 22nd. 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.

MANUAL REACTOR TRIP DURING CONTROL ROD TESTING

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

"On April 23, 2022, at 0224 [EDT] hours, with Unit 2 in Mode 1 at 100 percent power, two control rods dropped during control rod testing resulting in misalignment, which required a manual reactor trip in accordance with plant procedure. All safety systems functioned as expected. The Auxiliary Feedwater system actuated as designed to provide makeup flow to the steam generators. Operations responded and stabilized the plant. Decay heat is being removed by the steam generator power operated relief valves. 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). The automatic start of the Auxiliary Feedwater system is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). The cause of the dropped rods is being investigated. Unit 1 is not affected.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Electrical power is in normal off-site arrangement. All emergency electrical supplies are available.

ULTRASONIC EXAMINATION RESULTS - REACTOR VESSEL HEAD PENETRATION

The following information was provided by the licensee via email:

"At 0854 [CDT] on April 23, 2022, while performing volumetric inspections required by ASME Code Case N-729-6, a rejectable indication on Reactor Vessel Head Penetration 75 Core Exit Thermocouple (CETC) was identified. The indication is located inboard of the J-groove weld and is OD-initiated [outer diameter - initiated]. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

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

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The repair is scheduled during the refueling outage.