Event Notification Report for May 19, 2022

BOTH TRAINS OF CONTROL ROOM AREA FILTRATION SYSTEM AND AREA VENTILATION AIR CONDITIONING SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 0905 CST on 05/20/2022, it was discovered both trains of Control Room Area Filtration and Area Ventilation Air Conditioning Systems were simultaneously INOPERABLE. Due to this INOPERABILITY, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v).

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

DAMAGED I-125 SEED

The following information was provided by the licensee via phone and email:

"During a surgical excision procedure [that occurred on 5/20/2022] in the operating room (OR), a lesion which was previously localized with an I-125 seed was extracted from the patient. A trunode [gamma probe] device was used to identify the location of the seed and to guide the surgeon for the dissection of the breast tissue. After the dissection, the physician visualized the seed on the outside of the tissue specimen while it was still within the breast. Once the specimen was removed and scanned, there were no counts obtained in the patient. The specimen was then placed in a faxitron [x-ray machine] and an image was taken, but no visualization of the seed [occurred]. The surgeon immediately scanned the breast tissue to evaluate if the seed had been left behind. There were zero counts within the breast. The physician then scanned the drapes and sponges and did not identify the seed. The surgeon then proceeded to scan the suction tubing and ultimately the manifold of the suction equipment and was able to identify the seed in the manifold. The OR team then contacted nuclear medicine [personnel] and informed them to secure the suction manifold and secure it in the specimen safe in the frozen room. The manifold was placed in a red biohazard bag and secured in the safe. The operating room and the suction equipment were then surveyed by the surgical techs; the room and equipment measurements were background.

"A nuclear medicine technologist retrieved the manifold from the safe and took the manifold to histopathology to remove the seed. The manifold had to be opened with a screwdriver and trained personnel in histopathology removed the seed. The seed was recovered, but it was in two pieces. One half was the titanium capsule, and the other half was the titanium capsule and the silver rod with the chemically affixed iodine-125. The two halves were then placed in a lead pig. The biohazard bag, manifold, and contents of the manifold measured radioactive and were labeled and placed in storage in the nuclear medicine hot lab.

"All personnel in histopathology and the nuclear medicine technologist were checked for radioactive contamination. Everyone was negative for radioactive contamination. The trash and work area were also tested and were negative. The nuclear medicine technologist then notified his direct report authorized user (AU), the surgeon, and the radiation safety officer (RSO). The AU and surgeon, after hearing the seed was in two halves, made the decision to recall the patient to the hospital to verify background for a third time. The survey was again background, and the AU determined to not initiate potassium iodide treatment regimen. The RSO and nuclear medicine technologist then surveyed the OR personnel, biohazard containers, surgical trash, and operating room. All measurements were background. Wipe tests were performed of the neptune suction machine and the I-125 source. The wipe test of the Neptune was background, and the wipe test of the source indicated to be I-125.

"The RSO has been in constant communication with an Ohio Medical Physicist Consultant (OMPC) health physicist, to make sure all protocols were followed correctly. The RSO also contacted the NRC regional III Health Physicist, to see if this is an incident that needs to be reported to the NRC. 10 CFR part 20, 30 and 35 were reviewed over the phone and it was determined at that time the broken seed was not a reportable event. The NRC regional III Health Physicist later emailed OMPC health physicist with two other reporting requirements for review to determine if a report was needed. After reviewing 10 CFR 30.50 and 10 CFR 35.3067 it was determined it was not a reportable event. The seed and the contaminated suction module will be stored in the nuclear medicine hot lab until it is deemed safe to dispose of properly."

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

The I-125 seed contained an estimated activity of 291 microcuries.

NON-AGREEMENT STATE REPORT - TECHNETIUM-99M SPILL

The following is a synopsis of information provided by the licensee via phone call:

At approximately 0200 on May 19, 2022, a spill of approximately 3 curies of Tc-99m occurred in the compounding room at the Pharmalogic Puerto Rico facility in San Juan, PR. The spill was contained to the compounding room (a restricted area). One worker received a skin contamination that did not require medical attention.

EN Revision Imported Date: 9/13/2022

EN Revision Text: PART 21 REPORT - POTENTIAL PREMATURE FAILURES OF VALCOR COIL SHELL ASSEMBLIES

The following is a synopsis of information received via facsimile:

Valcor Engineering Corporation (VEC) was notified via a letter dated 5/19/2022 that Catawba Nuclear Station (CNS) discovered two failed Coil Shell Assemblies, part number V52653-6040-7, which were removed from V70900-39-3-1 Solenoid Valves and returned to VEC for evaluation. VEC has not concluded this is a reportable condition in accordance with 10 CFR 21.22(d) and requires additional time to complete testing and evaluation.

VEC is submitting this 60-day Interim Report Notification per 10 CFR 21.21(a)(2).

VEC will complete the evaluation and provide a determination of reportability in accordance with Part 21 no later than 09/12/2022.

Currently, Catawba Nuclear Station is the only affected facility.

For additional information, please contact Mike Swirad, Valcor Engineering Quality Assurance Director (973-467-8400 x 7223)


* * * UPDATE ON 9/12/2022 at 1438 EDT FROM MICHAEL SWIRAD TO ERNEST WEST * * *

The following is a synopsis of information received via facsimile:

VEC is providing final notification with regard to defects in coil shell assemblies (part number V52653-6040-7) per 10CFR Part 21.21(d)(4).

The root cause of failure of this part was determined to be an internal short in the coil shell assembly.

In addition to Catawba, licensees affected are: Brunswick, Callaway Energy Center, Oconee, Braidwood, and Fitzpatrick.

Root cause of the failed component is inconsistency in the coil assembly manufacturing process.

VEC initiated internal and supplier corrective actions and all coil shell assemblies have been quarantined and VEC supplier was notified. All existing coil assemblies in stock will be reworked to conform to VEC drawings. Completion of rework expected within 60 days.

VEC is in the process of notifying all affected customers. Defect can not be visually or electrically identified. All coil assemblies that perform safety related function must be returned to VEC for evaluation/replacement.

For additional information, please contact Mike Swirad, Valcor Engineering Quality Assurance Director (973-467-8400 x 7223)

Notified R1DO (Young), R2DO (Miller), R3DO (Hanna), R4DO (Drake) and via email: Part 21 Reactors.