Event Notification Report for June 24, 2022

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the Minnesota Department of Health (MDH) via email:

"We (MDH) received an initial report on 6/15/22 at 1515 CDT of a reportable medical event. The event occurred at the University of Minnesota, license number 1049, in Minneapolis on 6/14/22. The event involved a treatment with Y-90 SirSpheres where 2.2 GBq was ordered but a 5.1 GBq unit dose was delivered and administered. The licensee is working through dose calculations. No additional details are available at this time. Follow up information will be sent when it becomes available."

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 - LOSS OF TWO TRITIUM EXIT SIGNS

The following is a synopsis of information received via E-mail:

Upon inventory inspection, Frenchman Valley discovered that two tritium exit signs that had been in their possession had been replaced. The property was then thoroughly searched twice and the signs were not located. The whereabouts of the signs are unknown and no replacement records were found.

The signs were manufactured by Isolite. Both signs were model SLX60. The serial numbers were 12-01067 and 12-01068 with each sign containing 8 Curies of tritium.

Nebraska Item Number: NE220002


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 - SOURCE DETACHED FROM PORTABLE GAUGE

The following information was received via E-mail:

"During the morning of 6/16/22, a portable gauge user noticed that the tub and the radioactive source were detached from the gauge cable and stuck approximately 5 ft. underground when the user was trying to retrieve the tub and the source back to the gauge. The portable gauge is a CPN model 503, serial number 50543, containing 50 mCi of americium-241:beryllium. The sealed source is not compromised.

"This event occurred in Kersey, Colorado."

Colorado Event Report ID No.: CO220017

AGREEMENT STATE REPORT - SHIPMENT LOST THEN FOUND

The following was received from the Illinois Emergency Management Agency (IEMA) via email:

"Representatives for Bard Brachytherapy contacted IEMA at close of business on 6/16/22 to report a shipment of I-125 brachytherapy seeds in route from their Carol Stream, IL facility to Tortola in the British Virgin Islands could not be accounted for after a flight change in Miami, FL. The shipment consisted of two overpacks: One containing five boxes with 350 seeds and a cumulative activity of 241 mCi, and one containing four boxes with 385 seeds and a cumulative activity of 265 mCi. The licensee shipped the packages on 6/7/2022 to O'Hare airport where they were received [and] placed on a commercial flight to Miami. After arrival at Miami, the packages missed two different flights scheduled for Tortola. After an inquiry by the licensee, the carrier reported the package could not be immediately accounted for.

"The incident was reported to IEMA shortly before 1600 CDT and then notification was received at 1627 CDT that the packages were located. This matter is considered closed.

"There were no breaches to packages reported and no resulting public exposures. The packages remained incident to transportation and secure.

"Due to the activity involved (A > 1000x the value in Appendix C to 10 CFR Part 20), the loss is immediately reportable under 32 Ill. Adm. Code 340.1210 and 10 CFR 20.2201(a)(1)(i). Unlike missing shipments of lesser activity, a review of SA-300, Appendix A reporting requirements doesn't give the same caveat that the package must still be missing at the time of reporting."

Illinois # IL220020

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

EN Revision Imported Date: 6/22/2022

EN Revision Text: CONTROL ROOM VENTILATION AND CONTROL AREA CHILLED WATER SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 2240 on 06/21/2022, it was discovered that both required trains of Control Room Ventilation and Control Area Chilled Water System were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(v)(d).

"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 'B' train was restored at 2315.

LOSS OF AN ITEM RELIED ON FOR SAFETY

The following information was provided by the licensee via email:

"The plant is in a safe condition.

"On June 21, 2022, while performing a routine management observation, an employee noticed that only a single individual was performing the administrative actions required to implement both [items relied on for safety] IROFS 50b and IROFS 50c. These IROFS are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61. Since only one individual was performing the administrative action, the independence of the IROFS was not being maintained and the performance requirement of 10 CFR 70.61 was not being met. At the time of the event, there were not any heavy vehicles that threatened damage to equipment.

"[Urenco USA] (UUSA) is reporting this event per 10 CFR 70. Appendix A(b)(2).

"All work that requires utilizing person(s) to control the proximity of vehicles to equipment that could release UF6 has been stopped. This issue has been entered in UUSA's corrective action program as EV 152996."

The licensee will notify the NRC Regional inspector.

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the state of New Jersey, Radioactive Materials Program via email:

"The Radiation Safety Officer [RSO] of Bristol Myers Squibb notified the NJ Department of Environmental Protection that two H-3 exits signs were unable to be located and cannot be found. The RSO believes that the signs were improperly disposed of during facility renovations as demolition waste. The licensee conducted an in-depth exit sign inventory but was unable to locate the two exit signs.

"Loss of material was confirmed on 5/27/2022."

Equipment: H-3 exit sign, SRBT model BR-20-BK, serial numbers C083389 and C083421, 21.6 Ci per exit sign.

State Event Report ID Number: NJ-22-New

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.

EN Revision Imported Date: 6/27/2022

EN Revision Text: PART 21 REPORT - POTENTIAL DEFECT IN QUICK DISCONNECT CONNECTOR CABLE ASSEMBLIES

The following is a synopsis of information received via facsimile:

On April 24, 2022, a potential defect was discovered in a configuration of the 1 « inch Quick Disconnect Connector (P/N: 913602-111) cable assemblies supplied to Duke [(McGuire Nuclear Station)] under procurement document 30129014. During post installation testing by Duke, it was found that one of the cable wires was shorted to ground. This damage could cause the cable assembly to not perform its intended safety function. Upon further investigation, Duke found 9 other cable assemblies to have similar damage. Duke returned the identified cable assemblies to Curtiss Wright who is investigating the issue. Although some testing and verification activities have been completed, additional testing and research is necessary and in progress. The current testing and research is projected to take 30 days and a follow-up letter with results and status will be provided by July 24, 2022.

Currently, McGuire Nuclear Station is the only affected facility.

For additional information, please contact Jim Tumlinson, Director of Operations (256-425-8037), Christopher Covan, Quality Assurance Manager (256-624-7301), or Tim Franchuk of Quality (513-201-2176).

EN Revision Imported Date: 6/27/2022

EN Revision Text: LOW PRESSURE CORE SPRAY INOPERABLE

The following information was provided by the licensee via telephone:

"At 1257 EDT on June 24, 2022, it was discovered the Low Pressure Core Spray System (LPCS) was inoperable. At Perry, the Low Pressure Core Spray System is considered a single train system in Modes 1, 2, and 3; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). Inoperability of the Low Pressure Core Spray system was caused by a loss of power to the LPCS Minimum Flow Valve during surveillance activities.

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

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 6/27/2022

EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO MAIN STEAM ISOLATION VALVE CLOSURE

The following information was provided by the licensee via email:

"At 2012 CDT, Waterford 3 Steam Electric Station, Unit 3 was operating at 100 percent power when an automatic reactor trip occurred due to Main Steam Isolation Valve MS-124B going closed unexpectedly. Subsequently, both main feedwater isolation valves shut. Emergency Feedwater (EFW) was automatically actuated. Preliminary evaluation indicates that all plant systems functioned normally after the reactor trip. The unit is currently stable in Mode 3. All control rods fully inserted as expected and all other plant equipment functioned as expected. This was an uncomplicated trip.

"This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW system.

"The NRC Resident Inspector has been notified."

AUTOMATIC REACTOR SCRAM DUE TO MAIN TURBINE TRIP

The following information was provided by the licensee via email:

"At 2338 EDT, on June 24, 2022, with the unit in Mode 1 at 100 percent power, the reactor automatically scrammed due to an RPS actuation following a Main Turbine Trip. The cause of the turbine trip is not known at this time. The scram was not complex, with systems responding normally post-scram.

"Operations responded and stabilized the plant. Reactor water level has been recovered and maintained at the normal level. Decay Heat is being removed by the Main Steam system to the main condenser using the Turbine Bypass Valves. All Control Rods inserted into the core. The transient occurred with no surveillances or activities in progress. Investigation into the cause of the Turbine Trip is in progress.

"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 low reactor water level caused an isolation of Primary Containment (Groups 4/13/15) as expected. The Primary Containment Isolation Event is being reported under 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified."