Event Notification Report for September 06, 2022

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ENGINEERED SAFETY FEATURE ACTUATION SIGNAL

The following information was provided by the licensee via email:

"This 60-day telephonic notification is being made in lieu of a licensee event report submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to an invalid engineered safety feature actuation signal.

"On September 6, 2022, at Waterford 3, while performing a plant protection system (PPS) power supply check, technicians observed an abnormally high voltage output. When the technicians opened the PPS bay cabinet door to adjust the voltage, they then observed low voltage indications. The direct cause of this issue is believed to be vibration induced relay chattering or an intermittent connection issue when opening the rear doors of PPS cabinets. This resulted in half the logic being met for the Engineered Safety Feature Actuation Signal (ESFAS) signals to fully actuate. The ESFAS signal opened the following valves: EFW-228A (EFW to SG 1 Primary Isolation), EFW-229A (EFW to SG 1 Backup Isolation), EFW-228B (EFW to SG 2 Primary Isolation) and EFW-229B (EFW to SG 2 Backup Isolation). This was a partial actuation of ESFAS. Affected plant systems functioned successfully.

"The inadvertent actuation was caused by a spurious signal and was not a valid signal resulting from actual parameter inputs. The 1992 Statements of Consideration define an invalid signal to include spurious signals including jarring of a cabinet door. In accordance with 10 CFR 50.73(a)(1) a telephone notification is being made in lieu of submitting a written licensee event report. The NRC Senior Resident Inspector has been notified. These events did not result in any adverse impact to the health and safety of the public."

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 MICROSPHERES

The following was submitted by the MA Department of Public Health (Agency) by email:

"On 9/8/2022, 0930 EDT, [the] licensee reported potential medical event under license 60-0432 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 18 to 22.8 percent or more. A portion of the Y-90 0.5 GBq microsphere therapy treatment delivered to patient liver on 9/6/22 remained in the delivery system causing delivery of 0.386 GBq to 0.41 GBq Y-90 of the prescribed 0.5 GBq. The error was reported to the RSO the next morning. The licensee stated the cause, including possible clogged catheter, has not yet been determined. The prescribing physician has been notified. Notification of the referring physician and patient is pending. The licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment is expected due to this situation. Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation.

"The investigation is ongoing. The Agency considers this event docket to still be open.

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 - STOLEN AND RECOVERED TROXLER GAUGE

The following information was provided by the California Department of Public Health (CDPH) via email:

"Twining Inc. reported the theft of a Troxler model 3430 # 30952 portable soils gauge to the Sacramento CDPH office via California OES (Office of Emergency Services) on 9/8/22. The gauge contains two sealed sources: Cs-137, 0.30 GBq (8mCi) and Am-241/Be, 1.48 GBq (40mCi). The theft occurred around 2230 PDT on 9/6/2022, from the gauge operator's home. A police report was made to a deputy with the Riverside County Sheriff's office on the morning of 9/7/2022. The gauge had an airtag attached to it for tracking purposes.

"On 9/22/2022, Maurer Technical Services, who calibrates these types of soils gauges was contacted by a person who indicated he had this gauge. The caller's name, phone number and address in Riverside were obtained. Maurer Technical verified the gauge's serial number belonged to Twining, Inc. and their office was notified. Staff from Twining's Riverside office went to pick-up the gauge and it was transferred back to the Ventura office, where it was evaluated and leak tested on 9/25/2022 (found to be not leaking). The Riverside County Sheriff's office was informed that the gauge was recovered. Additionally, the Radiologic Health Branch was also notified that the stolen gauge had been recovered.

"On 9/29/2022, it was discovered that a supervisor at ICE RHB had received the initial notification from the CDPH duty officer, but due to competing demands, failed to forward the report to the RHB South office for follow-up action and reporting to the NRC."

CA Event Number: 092222

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