Event Notification Report for June 16, 2022

AGREEMENT STATE REPORT - UNDERDOSE TO TREATMENT SITE

The following information was received from the Washington State Department of Health via email:

"On 06/08/2022, Inland Northwest (INW) Multicare's radiation safety officer (RSO) reported a medical event had occurred. A Y-90 therasphere procedure was done on the previous day (06/07/2022), the procedure went according to plan, however after the procedure was completed the after injection surveys and quality assurance was done, it revealed that a portion of the microspheres did not come out of the tubing as designed. After calculation it was determined that the patient only received 26 percent of the target dose. The licensee immediately notified the manufacturer to see what happened. The manufacturer told them this is a known issue and has happened before. INW is writing up a full report and will submit it when completed."

WA incident no.: WA-19-004

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.

AGREEMENT STATE REPORT - STUCK SHUTTERS

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

"On June 8, 2022 inspectors [names redacted] went to Domtar Paper Company, LLC (SCRAM License Number 438) to perform a periodic re-inspection. During their inspection, they were presented with a copy of the inventory and their shutter check information. While reviewing the information, the inspectors saw that there were items on the checklist dated March 23, 2022, and March 30, 2022 that denoted the failed functionality of some of their gauge shutters. After discussion with radiation safety officer (RSO), it was determined that the shutters did, in fact, fail to operate as designed. There were other instances that were similar that the licensee stated that they will pull together and evaluate. At this time, the only information given by the licensee is the information below. The inspectors went to each of the source housings during the inspection and all shutters were all operational.

"The sources and housings are the following:
Kay Ray source housing model 7064P
Source model: 7700-5000 Serial number: 27007C Activity: 5 Curies

"Kay Ray source housing model 7064P
Source model: 7700-5000 Serial number: 27007F Activity: 5 Curies"

FITNESS-FOR-DUTY REPORT

The following information was provided by the licensee via email:

"A licensed operator supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant is on hold in accordance with the licensee's fitness-for-duty policy.

"The NRC Senior Resident Inspector has been notified."

MANUAL REACTOR TRIP AND AUTOMATIC AUXILIARY FEEDWATER ACTUATION

The following information was provided by the licensee via email:

"At 0724 EDT on 6/15/2022, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering Steam Generator levels due to a secondary plant perturbation in the Heater Drain System. All control rods fully inserted into the core and the Auxiliary Feedwater System automatically started as designed in response to the full power reactor trip. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves. Unit 2 is not affected and remains at 100 percent power and stable.

"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). Additionally, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater System.

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