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.