Event Notification Report for February 21, 2023

AGREEMENT STATE REPORT - STUCK SHUTTER GAUGE

The following summary was obtained via phone and email from the South Carolina Department of Health & Environmental Control [the Department]:

On February 9, 2023, at 1534 EST, the Department was notified by WestRock Charleston Kraft, LLC of a shutter on an Ohmart SH-F1 gauging device (serial number 67584) containing 10 mCi of Cs-137 that was stuck in the open position. The shutter was found during the licensee's six month inventory and shutter check. The gauge is in an isolated area not heavily trafficked.

The vat that the gauge is attached to leaks directly onto the gauge, so it was previously recommended that the gauge be covered. The recommendation did not help. The contractor surveyed the gauge and got no higher than 2 mR/hr at a foot. The inspector concurred after using his [model] 14-C [detector] (serial number 99961). The numbers were approximately 4 mR/hr on the outside surface of the covering. It has been decided by the licensee that because it is in a very unobtainable location, they will leave it in the open and operating position until they remove the entire vat from service in March or April.

South Carolina Event Number: (pending)

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the Wisconsin Radiation Protection Section via email:

"On February 10, 2023, the licensee reported a medical event which had occurred the previous day. A patient was being treated with a high dose rate remote after loader unit and the fraction required 17 needles. After the first 15 needles had been treated, the licensee noticed that the patient's needles had been pulled out approximately 2 cm from where they had been placed due to unexpected movement of the patient's bed. The licensee has not yet determined how the patient's bed moved, as the patient was sedated during treatment. Needles 16 and 17 were re-inserted and the dose to those needles was delivered as intended. The authorized user had prescribed 13.5 Gy to the treatment site for this fraction, and the licensee estimates that only 30 percent of the treatment volume received the prescribed dose. The referring physician and the patient's family have been notified."

Event Report ID No: WI230001

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 - DOSE DELIVERED TO THE WRONG TREATMENT SITE

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

"On February 13, 2023, the Agency was notified that a patient was prescribed to receive 35.74 mCi (1.32 GBq) of Y-90 microspheres to the right lobe of the liver. The dose was given to the left lobe (wrong lobe) of a patient during treatment on February 13, 2023. The dose delivered (36.48 mCi (1.35 GBq)) to the left lobe was within 20 percent of the prescribed dose. The dose that was delivered to the left lobe is also within 20 percent of the dose that would have been prescribed for the left lobe in 2 weeks according to the physician. The treatment was clinically insignificant to the patient as both lobes were to be treated with a pending remapping of the second lobe to confirm the dosage but both have similar tumor volumes. More information will be provided as it is obtained in accordance with SA-300.

NMED National Number: TX230005

Texas Incident Number: 9889

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.

OFF-SITE NOTIFICATION OF AN ON-SITE FATALITY

The following information was provided by the licensee via email:

"On February 16, 2023 at 0859 EST, a contract worker at McGuire was transported off-site for treatment at an off-site medical facility. Upon arrival at the off-site medical facility, medical personnel declared the individual deceased at 0915 EST.

"The fatality was not work-related and the individual was inside the Radiologically Controlled Area. An on-site survey confirmed that neither the individual nor the individual's clothing were contaminated. A notification will be made to the Occupational Safety and Health Administration.

"This is a four-hour notification, non-emergency for an on-site fatality and notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified."

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

At 0743 EST on February 16, 2023, it was determined that a contract supervisor failed a random fitness-for-duty (FFD) test. The individual's authorization for site access has been terminated.

The NRC Resident Inspector has been notified.

DEGRADED CONDITION

The following information was provided by the licensee via email:

"On February 17, 2023 during the planned U2R22 outage on Browns Ferry Nuclear Plant Unit 2, personnel entered the Unit 2 drywell for leak identification. Personnel discovered a cracked weld on the 2A recirculation pump discharge isolation valve drain line. At 0439 CST on February 18, 2023, following engineering evaluation, this drain line was determined to be ASME Code Class 1 piping.

"This constitutes an 8-hour NRC notification in accordance with 10 CFR 50.72(b)(3)(ii)(A) - Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.

"The NRC Resident Inspector has been notified."

SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via fax or email:
"At 0105 EST on February 19, 2023, with the James A. FitzPatrick Nuclear Power Plant (JAF) at 100 percent power, a valid high main steam line radiation signal was received. An actuation of a fire protection foam system caused migration of high conductivity water into a low conductivity sump. Organic compounds were introduced into the primary coolant and resulted in a temporary increase in nitrogen-16 which was detected by main steam line radiation monitors and actuated primary containment isolation signals in more than one system. The reactor water recirculation sample system isolated. The signal also went to the normally isolated main steam line drain system and condenser air removal system. The event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A). The elevated radiation condition no longer exists. Health and safety of the public was not impacted by this event."

The NRC Resident Inspector was notified.

EN Revision Imported Date: 2/24/2023

EN Revision Text: OFFSITE NOTIFICATION TO STATE AGENCY

The following information was provided by the licensee via fax:

"At 1618 EST on February 20, 2023, North Anna Power Station notified the Virginia Department of Environmental Quality (DEQ) that water discharged into Lake Anna following hydrostatic testing of tanks associated with a new on-site sewage treatment plant had exceeded the project's general permit (VAG83) pH value.

"Hydrostatic test water discharge activities to Lake Anna began on February 20, 2023 at 0900 EST. A pH sample was collected at 0955 EST on February 20, 2023 and determined to have a pH of 9.1 which exceeded the maximum permit pH of 9.0. Discharge ceased after the reading was collected. Approximately 354 gallons were discharged to Lake Anna. A follow-up ambient pH sample result of 7.8 was collected on February 20, 2023 at 1401 EST from Lake Anna in the vicinity of the discharge pipe. No evidence of dead fish, foam, or other negative environmental impacts were observed.

"This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'"

* * * UPDATE ON 02/23/2023 AT 1342 EST FROM BOB PAGE TO IAN HOWARD * * *

The following is a summary of information provided by the licensee via telephone:

The licensee called to correct the pH sample results from a pH of 9.1 to a pH of 9.93.

Notified R2DO (Miller) via phone