Event Notification Report for September 08, 2022

EN Revision Imported Date: 9/8/2022

EN Revision Text: AGREEMENT STATE REPORT - GAMMA KNIFE MALFUNCTION

The following information was provided by South Carolina Department of Health & Environmental Control via email:
"The South Carolina Department of Health and Environmental Control was notified on 08/10/2022, during a follow-up of a routine inspection, that a Leksell Gamma Knife Perfexion gamma stereotactic radiosurgery unit had failed to function as designed. The licensee [Prisma Health Richland Hospital] is reporting that during routine maintenance that was conducted by the manufacturer on 11/01/2021, it was discovered that a sector was dragging and not transferring smoothly. The licensee is reporting that one of the sealed sources had slipped less than 1/8 inch within one of the source cavities of the Leksell Gamma Knife Perfexion unit. The sealed source is a Co-60 Elekta Model 43685 medical teletherapy source, with an estimated activity between 20-22 curies. The licensee is reporting the unit was repaired and source reseeded on 11/05/2021. The licensee is reporting no overexposures to workers, patients, or members of the public. All sealed sources were leak tested on 11/05/2021 and results indicated that no sources were leaking. This event is under investigation by the South Carolina Department of Health and Environmental Control."

* * * UPDATE ON 9/7/2022 AT 1158 EDT FROM ADAM GAUSE TO MICHAEL BLOODGOOD * * *
The following information was provided by South Carolina Department of Health & Environmental Control via email:

"The licensee has submitted a 30-day written report. The Co-60 Elekta Model 43685 medical teletherapy source serial number is NIW098 with an estimated activity of 20.6 Ci (0.7622 TBq) at the time of the event. On 11/05/2021, the manufacturer and service representative identified the bushing containing the source had slipped slightly from its sleeve. The bushing was visually inspected via remote camera and showed no damage. The bushing and source was reseeded into its sleeve on 11/05/2021. No patients were treated between 11/1/2021-11/10/2021. The licensee is reporting no overexposures or medical events. The licensee performed areas surveys (using a Fluke 451PYR, calibrated 04/08/21) on 11/03/21 and 11/05/21, records indicated dose rate readings that were consistent with the radiation levels in the sealed source and device registry for the Perfexion unit. The licensee also performed area contamination surveys/wipes (using a Capintec Captrac, calibrated 10/18/21) on 11/03/21 and 11/05/21, records indicated contamination levels below the licensee's removable contamination trigger limits. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

Notified R1DO (Defrancisco) and NMSS Event Notification via email.

EN Revision Imported Date: 9/7/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified by the Radiation Safety Officer (RSO) at Arkema via voicemail and email on 8/30/2022 at 1501 EDT, that on August 30, 2022, one fixed gauging device (Ronan Engineering SA1-F37, Serial Number M8107), containing 5 Ci of Cs-137 (source Serial Number not reported, assay date 08/1991) had developed a problem in that that the shutter arm was not moving freely to the closed position. The technician eventually moved the shutter arm to the closed position and verified radiation levels to be normal. The gauge is mounted on a tank, manned entry is currently restricted, and plant personnel have been notified that there is no access allowed to the vessel. No overexposures were reported due to the malfunction. All operational and maintenance activities related to the vessel will be delayed until the manufacturer (Ronan Engineering) repairs the shutter mechanism. The licensee has contacted the manufacturer/service provider to remediate this situation."

Kentucky Event ID Number: KY220004

*** UPDATE ON 9/2/22 AT 1031 EDT FROM KENTUCKY RADIATION HEALTH BRANCH TO BILL GOTT ***
The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:
The KY RHB was informed by the new RSO that the actual date that the shutter malfunction was discovered was April 29, 2022."
Notified R1DO (Gray). Notified via email: NMSS Event Notification

AGREEMENT STATE REPORT - LOST Y-90 MICROSPHERES

The following information was received from the Wisconsin Department of Health Services (the Department) via email:

"On August 31, 2022, the licensee notified the Department that they had lost control of licensed radioactive material. Per the licensee's report, on or about August 10, 2022, four sharps containers with yttrium-90 microsphere waste were inadvertently taken from the licensee's decay-in-storage room and placed in a locked room in the hospital's shipping department for disposal as biohazardous material. On August 15, 2022, the four sharps containers (approximately 60 millicuries of yttrium-90) were picked up by the hospital's biohazardous waste vendor, where they are assumed to have been autoclaved and disposed in a landfill. The licensee became aware of the loss on August 29, 2022. Based on the current activity of the sources (less than 1 millicurie) no attempt will be made to retrieve the material. No members of the public are expected to exceed public dose limits. A Department investigation is ongoing."

WI incident no.: WI220020

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 - LOST I-125 BRACHYTHERAPY SEEDS

The following information was provided by Illinois Emergency Management Agency, Radioactive Materials Branch (the Agency) via email:

"The Agency received a partial report via email from the licensee on September 1, 2022, indicating the potential loss of two brachytherapy seeds, accounting for a maximum estimated activity of 1.05 millicuries. The licensee has conducted an investigation and although the package appeared undamaged; believes the seeds may have been lost in transit from Atlanta Medical Center in Atlanta, GA. Requests for clarification and the nuclide (either I-125 or Pd-103) have not yet been returned. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. While incomplete, this incident has the potential to be reportable and will be communicated to the United States Nuclear Regulatory Commission Headquarters Operations Officers today.

"On August 8, 2022, Bard Brachytherapy received a package from the Atlanta Medical Center. The package contained sources that were outside of the primary container and were lodged in the packaging foam. The shipping box looked undamaged from the outside, but three of the four primary containers were loose or open inside. The licensee counted the sources in the package and found 28. The return sticker included in the box from Atlanta Medical Center listed that 30 sources should have been returned. Surveys were conducted of the packaging material, the receiving and returns processing areas, and the path between to verify that the unaccounted-for sources were not in the Illinois facility. The counts were verified with the shipper and the licensee confirms two brachytherapy seeds (likely I-125) were most likely lost in transit."

Illinois Incident Number: IL220031

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 - STOLEN PORTABLE GAUGE
The following information was provided by the Colorado Department of Public Health and Environment via email:
"A call was received on 9/1/2022, at approximately 1200 MST from the RSO [Radiation Safety Officer] for CTC-Geotek, Inc. reporting a theft of a portable nuclear gauge, Instrotek model 3430, serial number 32097, containing 10 mCi of Cesium -137 and 40 mCi of Americium - 241:Beryllium. The gauge was stolen from the back of an employee's truck that was parked at their residence. The truck was in the parking lot of their apartment complex. Bolt cutters broke the chains used to secure the gauge transport case to the truck. Local law enforcement was informed."

Colorado Event Report ID No.: CO220030



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: 9/8/2022

EN Revision Text: PART 21 REPORT - INCORRECT THREAD LENGTH ON LOCKNUTS

The following information was provided by the licensee via email:
"Identification of the manufacturer of the component that contains the defect:
Diversified Machine Components- Howden Part Number 00900490-00114N
LOCKNUT/NYLON
INSERT 1-1/8-12 STL-ZINC NUCLEAR
Howden PO075865
"During assembly of the nuts onto a rotor, Westinghouse stripped a nut. After removal it was discovered that the nut that stripped had a machined bore with incorrect thread length. The nuts supplied on the above purchase order were all supplied from one heat. Diversified Machine Components and Howden have been and continue to be in communication on this matter. The nuts on PO075685 have been returned to Howden for evaluation and remain on hold as nonconforming product.
"Howden issued NCR 3589 for Part Number 00900490-00114N Lock Nut which was received by Diversified Machine on 8/31/22. Howden has also issued Corrective Action request #HACAR336 also received by Diversified Machine on 8/31/22.
"At this time, based on initial evaluations Diversified Machine Components has supplied Howden with a total of five purchase orders which have been identified and submitted to Howden for review. The five purchase orders identified are: 16 Pcs. on PO052609, 16 pcs on PO052645, 16 pcs on PO056804, 16 pcs on PO068879 and 16 pcs on PO075685. The nuts on PO075685 have been segregated and the returned to Howden for evaluation.
"A Nonconformance Report has been issued which describes with as much information as possible to give a clear understanding and description of the nonconforming condition as found. The evaluation of the nonconformance report and the corrective action to be taken shall be completed by authorized personnel at Diversified Machine in a timely manner.
"Diversified Machine shall continue to communicate with Howden as required. If there are any questions pertaining to this communication, please feel free to contact me at 440-942-5701."

* * * UPDATE ON 9/7/2022 AT 1158 EDT FROM ADAM GAUSE TO MICHAEL BLOODGOOD * * *

The following information was provided by Diversified Machine Components via email:

"The basic component that contains the defect is part number 00900490-00114N. The lock nut has been machined with a counterbore removing half of the threads from the nut.
"After removal they discovered the nut that stripped was miss machined and only had threads in less than 1/2 of the bore."

Known affected plants:
Ameren Callaway Plant
ASCO NPP (Howden Customer - Ergytech, Inc.)

Notified R1DO (Defrancisco), R3DO (Orlikowski), R4DO (Pick) and via email: Part 21 Materials and Part 21 Reactors

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

The following information was provided by the licensee via email:

"At 2345 CDT, Unit 1 Reactor tripped due to a turbine trip. All auxiliary feedwater pumps started due to steam generator Lo Lo levels.

"Unit 1 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IPO-007A. The Emergency Response Guideline procedure has been exited. Decay heat is being rejected to the main condenser via steam dump valves.

"The cause of the Turbine Trip is currently under investigation."

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

NRC Resident Inspector has been notified. Unit 2 is unaffected by this event.

INVALID SYSTEM ACTUATION

The following information was provided by the licensee via fax:

"Auxiliary Feedwater Pump #12 actuation and isolation of the Steam Generator Blowdown for 'A', 'B' and 'C' Steam Generators.

"Per 10 CFR 50.73(a)(1), the telephone notification is made under 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation. On 7/28/2022 at 1705 CDT, the Unit 1 Control Room received alarm SPQD0183 'SG LO-LO LVL TRN B ACT' and actuation of the Auxiliary Feedwater Pump #12 and isolation of the Steam Generator Blowdown for 'A', 'B' and 'D' Steam Generators. This event was classified as an unplanned entry into Technical Specification Shutdown LCO equal to or less than 24 hours 'Simple Restoration', due to the availability of CRMP.

"This alarm occurred several times and with each occurrence the alarm was short lived (1 second or less). Operations placed Auxiliary Feedwater Pump #12 in the Pull-To-Lock position to prevent starting of the pump with each alarm occurrence. During troubleshooting it was determined that SSPS Logic 'R' train was generating the intermittent alarm condition. A Logic board and a Safeguard Driver board were replaced which was identified as the possible cause. Operations performed applicable sections of the Logic test to ensure SSPS 'R' train operable.

"The event had no effects/consequences on the unit. The Logic board and Safeguard Driver board in SSPS 'R' train were both replaced as the possible causes, and therefore both boards were sent to Westinghouse to determine which board was at fault."

The NRC Resident Inspector has been notified.

FITNESS FOR DUTY REPORT

A licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. Unescorted access for the individual has been denied at all Dominion Energy sites.

CONCURRENT REPORT FOR OFFSITE NOTIFICATION

"BWXT is making a concurrent report to the NRC for an OSHA [(Occupational Safety and Health Administration)] reportable event under 29 CFR 1904.39(b)(2). The report of a workplace injury requiring the hospitalization of an employee was made to OSHA at 1230 EDT on 4/28/2021. At this time the incident is under investigation. While repositioning a component on a cart, the cart shifted causing the component to pinch the operators thumb and index finger. The employee was transported and admitted to Lynchburg General Hospital by BWXT's emergency team for treatment."

It was determined that the individual did not have contamination.

The licensee notified the NRC Resident Inspector.

MISSING I-125 SEED

The following information was provided by the licensee via email:

"On June 22, 2022, West Virginia University Radiation Safety Department discovered that one Iodine-125 seed (Isoaid Model IAl-125A, titanium capsule sealed source, seed lot number 202280796) used in a Radioactive Seed Localization procedure was missing. The seed, with an activity of 268 microCi, was implanted into a lesion in the patient's right breast on June 16, 2022. A second seed, with the same activity, was implanted into the same lesion in the patient's right breast on the same day. A third seed, with the same activity, was implanted into a lesion in the patient's left breast on the same day. The surgery to remove the lesions was completed on the same day. On June 21, 2022, a Radiation Safety specialist picked up 2 seeds from the patient in question along with 7 seeds from different patients. At this time the Radiation Safety specialist did not have seed implantation records for all the seeds retrieved as they were not available at the Breast Care Center. On June 22, 2022, the specialist retrieved the seed implantation records and noted that the patient in question had a total of three seeds implanted and reported the seed as missing to the Radiation Safety Department Manager. An investigation determined that the seed arrived in the Pathology Gross Room but was likely inadvertently discarded in the trash or flushed down the sink."

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: 9/8/2022

EN Revision Text: SAFETY SYSTEM INOPERABILITY

The following information was provided by the licensee via email:

"At 2108 EDT on August 17, 2022 the Division 2 Mechanical Draft Cooling Tower (MDCT) fans were declared inoperable due to failure of the over speed fan brake inverter. The brakes prevent fan over speed from a design basis tornado. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The Division 2 EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) room cooler and Division 2 Control Center HVAC (CCHVAC) chiller. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. At the time of the event, Division I CCHVAC was inoperable for maintenance (but was running for a maintenance run) and the event caused an inoperability of Division 2 CCHVAC. This resulted in an inoperability of both divisions of CCHVAC. Failure of the Division 2 MDCT Fan brake inverter occurred due to a trip of the DC input breaker. The breaker was reset at 2128 EDT restoring Division 2 UHS Operability. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfilment of the safety function of structures or systems that are needed to mitigate the consequences of an accident based on a loss of a single train safety system and loss of both divisions of a safety system.

"The Senior NRC Resident Inspector has been notified"

* * * RETRACTION ON 09/08/2022 AT 0856 EDT FROM JEFF MYERS TO MIKE STAFFORD * * *

The following information was provided by the licensee via email:

"On 8/17/22 at 2108 EDT the Division 2 (Div. 2) mechanical draft cooling tower (MDCT) brake inverter input breaker tripped for an unknown cause. The result of the loss of power was the inoperability of the MDCT fan brakes which impacts the ultimate heat sink (UHS) (TS 3.7.2). The UHS cascades to the EECW (emergency equipment cooling water) (TS 3.7.2) which is a support system for Div. 2 CCHVAC (Control Cell) Chiller A/C system (TS 3.7.4). This resulted in the inoperability of the Div. 2 CCHVAC Chiller.

"The cause for the breaker to trip is an intermittent electrical transient. Immediate corrective action was to reset the breaker, and the long-term action is to implement a modification to mitigate susceptibility to voltage variations. Div. 1 has implemented this long-term mod and no unexpected trips have occurred to date.

"Div. 1 CCHVAC Chiller was previously inoperable from equipment issues which was repaired, and the unit was in service for a 24-hour confidence run. Although licensed personnel had not completed the administrative actions for documenting operability during the 24-hour confidence run to monitor parameters, the (post maintenance test) PMT related to the maintenance was already completed, which included a 4-hour run in accordance with surveillance 24.413.01, Div. 1 and Div. 2 Chilled Water Pump and Valve, to verify normal operation and motor current. These PMT's were completed prior to the identified inoperability of the Div. 2 UHS due to the tripped breaker on the brake power supply.

"At the time of the MDCT brake inverter trip, the Operations' Senior License and the Night Shift Manager were aligned that, although still operating as part of the 24-hour confidence run, the unit was in service and capable of performing its safety function, but the administrative tasks were not completed, the Limited Condition of Operation (LCO) sheet had not been cleared, and no log entries were made. Since the Div. 1 Chiller was, in fact, operable at the time of the trip of the breaker on the inverter, this would allow the use of Technical Specification (TS) 3.0.9 'Barriers'. Per Operations Department Expectation (ODE)-12 `LCOs' (standard guidance and expectations for preparing and implementing an LCO), Operations determined that the MDCT brakes are barriers to a tornado event and TS 3.0.9 could be utilized. By invoking TS 3.0.9, as long as all other supported systems in the other division are operable, Div. 2 supported systems relying upon the UHS can remain operable and the Automatic Depressurization System (ADS) and Reactor Core Isolation Cooling (RCIC) system can be used as backup to the High Pressure Coolant Injection (HPCI) system. Based on this information, there was no loss of safety function with CCHVAC A/C system or HPCI. Therefore, the NRC non-emergency 10CFR50.72(b)(3)(v)(D) report was not required and the NRC report 56054 can be retracted."

The NRC Resident Inspector has been notified.

Notified R3DO (Orlikowski)

AGREEMENT STATE REPORT - LOST EXIT SIGN

The following was received from the New Jersey, Dept. of Environmental Protection (NJDEP) via email:

"At 1300 hours on September 1, 2022, the Radiation Safety Officer of Bristol Meyers Squibb (BMS) was in the process of disposing of all their radioactive exit signs when they went to a storage room and found one to be missing. NJDEP was notified immediately. The Exit sign in question is manufactured by SRBT, S/N 152299, originally containing 20 Ci of H-3 and had an expiration date of 2010. BMS will forward a written report within 30 days concerning the loss and their investigation."

NJ incident number: Not applicable at this time.


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