Event Notification Report for December 21, 2022

AGREEMENT STATE REPORT - EQUIPMENT FAILURE TO HOUSE SOURCE

The following information was provided by the Texas Department of State Health Services via email:

"On December 12, 2022, the licensee reported that following a cardiac brachytherapy procedure the source train containing strontium-90 sources could not be fully retracted into the safe position. The device was placed into the emergency shielding box by a staff member. There was no exposure to the patient and there was no overexposure, based on calculations, to the individual who handled the device. The individual's ring and whole body dosimeters will be sent for processing to confirm. A manufacturer's representative responded later in the day and secured the sources into the fully shielded position and assessed the cause. He believed the hemostasis valve had been tightened a little too tight which caused a kink in the catheter that prevented the retraction.

"Device: Novoste Brachytherapy device manufactured by Best Vascular, model A-1000 series, SN: 87690

"Sources: 40 millimeter source train containing 16 Strontium-90 sealed sources with original activity of 34.88 millicuries (June 2002), source manufacturer AEA, model SICW.2, train SN: ZA-706.

"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No.: 9971
Texas NMED No.: TX220040

AGREEMENT STATE REPORT - OVEREXPOSURE EVENT
The following information was provided by the Texas Department of Health Services (the Agency) via email:
"On December 14, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) of a potential overexposure event. The RSO reported three of their radiographers were working at a remote site using a 30.4 curie cobalt 60 source. The exposure time for each exposure was two minutes. The distance from the source to the pipe was two feet. During the first exposure, one of the radiographers was between the source and the pipe being tested. The RSO stated the individual stayed in the area for about one minute. The radiographer operating the source was standing behind a brick wall and was unaware of the individual being in the area. The operator thought the others had cleared the area, and it was safe to perform the exposure. The individual who received the exposures stated the noise in the area was too loud to hear their alarming rate meter. The exposed individual's self-reading dosimeter was off scale. All radiographers' dosimeters have been sent to the licensee's dosimetry processor for reading. The RSO stated their calculations indicated the individual could have received 7 rem from this event. The RSO stated the individual exposed had received 12 millirem prior to this event. All three individuals have been removed from any duties that would require any additional exposure. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident no.: 9973
Texas NMED no.: TX220041

* * * UPDATE ON 12/16/22 AT 1522 CST FROM ARTHUR L TUCKER TO LAUREN BRYSON * * *
"On December 16, 2022, the licensee reported they had received the badge reading for the individual involved in this event. The Deep Dose Equivalent (DDE) on the badge was 5,450 millirem bringing the individuals DDE total for the year to 5,662 millirem. The Agency has requested the licensee determine if the badge was worn in the highest dose field during the event. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Drake) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"The Agency was contacted on 12/14/22 by the medical physicist for Alexian Brothers Medical Center to advise that a Y-90 microsphere administration conducted that morning resulted in a reportable under dose. The administered amount was 20.4 percent lower than that specified in the written directive. This was not a stasis case. The licensee has tried multiple times, but has so far been unable to reach the patient for notification. The referring physician has been notified. Agency inspectors have gathered preliminary information but will conduct a reactionary site visit on Tuesday, December 20, 2022. More information will be provided once it becomes available."

Illinois Event Number: IL220043


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.

60-DAY TELEPHONIC NOTIFICATION

The following information was provided by the licensee via email:

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) for an invalid actuation of a primary containment isolation signal affecting more than one system.

"On November 11, 2022, at 2333 hours EST, Peach Bottom experienced an unplanned loss of the #343 Off-Site Startup Source. Due to the temporary loss of power during automatic bus transfers, several systems experienced Primary Containment Isolation System (PCIS) Group II and Group III (GP II/III) isolation signals. Plant Systems impacted by isolation valve closure included: Reactor Water Clean Up (RWCU), Containment Atmospheric Control (CAC), Traversing In-Core Probe (TIP) Purge, Primary Containment Floor and Equipment Drains, and the Instrument Nitrogen system. All equipment responded as designed.

"Plant conditions which initiate PCIS GP II isolation signals are Reactor Vessel Low Water Level, High Drywell Pressure, RWCU system High Flow or RWCU Non-Regenerative Heat Exchanger High Outlet Temperature. The PCIS GP III actuations are initiated by the Reactor Vessel Low Water Level, Primary Containment High Pressure, Reactor Building Ventilation High Radiation or Refuel Floor Ventilation High Radiation. At the time of the event, none of these actual plant conditions existed; therefore, the actuation of the PCIS was invalid.

"The loss of the #343 Off-Site Startup Source was caused by a failed printed circuit card in the programable logic controller (PLC) for the 3435 breaker. There is no time-based maintenance strategy for PLC replacement. The PLC circuit card was replaced, and the breaker restored to full qualification and service. Preventive maintenance strategy will be enhanced to address the identified vulnerability.

"The licensee has notified the NRC Resident Inspector."

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

"At 0735 EST on December 19, 2022, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness-for-Duty (FFD) testing program. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."

MANUAL SCRAM DUE TO LOSS OF FEEDWATER PUMP

The following information was provided by the licensee via email:

"At 2101 [CST] on December 19, 2022, a manual reactor scram was initiated at Grand Gulf Nuclear Station (GGNS). Following the reactor scram, the high pressure core spray (HPCS) system was used to maintain reactor water level. The manual [reactor protection system] RPS actuation is being reported in accordance with 10 CFR 50.72(b)(2) and the HPCS actuation is being reported in accordance with 10 CFR 50.72(b)(3).

"At 2058, GGNS experienced a loss of a condensate booster pump. At 2101, the `A' reactor feedwater pump tripped and the reactor was manually scrammed. All control rods were fully inserted into the core.

"At 2104, the `B' reactor feedwater pump tripped and HPCS was manually started. HPCS was manually injected to maintain reactor water level at 2121. The `A' reactor feedwater pump was successfully restarted at 2126.

"GGNS is currently in Mode 3. Reactor level is being maintained with the `A' reactor feedwater pump and pressure is being maintained with the turbine bypass valves.

"The NRC Resident Inspector was notified."