Event Notification Report for March 14, 2023

EN Revision Imported Date: 5/4/2023

EN Revision Text: FITNESS-FOR-DUTY REPORT - SUBVERSION OF THE FFD PROCESS

A non-licensed contract supervisor was confirmed to have violated the FFD policy by attempting to subvert the testing process. The individual's authorization for site access was immediately terminated.

The licensee notified the R4 Branch Chief (Josey)

* * * RETRACTION FROM TITUS FOLDS TO JOHN RUSSELL AT 1606 EDT ON 05/03/2023 * * *

The following information was provided by the licensee via email:

"The Medical Review Officer [MRO] was provided with additional information on the collection process in question. Based on this additional information, the MRO was unable to conclude with a high degree of certainty that an attempt to subvert the FFD collection process had occurred."

Notified R4DO (Gaddy) and via email the FFD Group.

AGREEMENT STATE REPORT - PATIENT TREATMENT SUSPENDED PRIOR TO COMPLETION

The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email:

"While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report."

NJ Event Report ID number: NJ-23-0001
* * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * *
"Additional information has been obtained related to the initial notification provided on 3/15/23.
"The dose administered to the patient was only approximately 2.9 percent of the dose prescribed.
"The prescribed dose was 15 Gy.
"The unit malfunctioned after only 3 of the planned 13 shots was completed.
"14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred.
"This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a)."
Notified R1DO (Bickett) and NMSS Events Notification.


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

EN Revision Imported Date: 4/3/2023

EN Revision Text: HIGH PRESSURE CORE INJECTION INOPERABLE

The following information was provided by the licensee via email:

"At 1000 EDT on March 14, 2023, during valve diagnostic testing, the high pressure core injection (HPCI) lube oil cooling water supply isolation valve did not stroke open. This failure resulted in the Unit 2 HPCI system being inoperable.

"This is being reported as a loss of an entire safety function condition in accordance with 10CFR50.72(b)(3)(v)(D)."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM BOB BINGMAN TO BILL GOTT AT 2208 EDT ON 04/02/2023 * * *

The following information was provided by the licensee via email:

"The purpose of this notification is to retract event notification (EN) 56409 reported on 03/14/2023.

"On March 09, 2023, Susquehanna Unit 2 entered a routine high pressure core injection (HPCI) maintenance outage. In support of this system outage, Technical Specification (TS) 3.5.1, Condition D was entered for an inoperable HPCI system. On March 14 as reported in EN 56409, the HPCI lube oil cooling water supply isolation valve did not electrically stroke open following engagement of manual clutch lever. Specifically, to support the maintenance evolution, electricians declutched the valve actuator to move it from the motor/electric operational mode to the manual operational mode as part of planned valve diagnostic data collection. In this testing configuration (i.e., manual operational mode), an attempt to electrically stroke the valve was made, resulting in the valve failure to stroke.

"Prior to this maintenance evolution, the HPCI lube oil cooling water supply isolation valve was found in the expected full-closed position with the motor/electric operational mode enabled, meaning prior to the HPCI maintenance outage, the affected valve was operating as designed and capable of performing all design functions. The described condition was therefore determined to be the result of the maintenance activity.

"NUREG-1022, Section 3.2.7, states: 'reports are not required when systems are declared inoperable as part of a planned evolution for maintenance or surveillance testing when done in accordance with an approved procedure and the plant's TS (unless a condition is discovered that would have resulted in the system being declared inoperable).'

"Following completion of investigation and repair, Susquehanna determined that, per NUREG-1022, Section 3.2.7, the event was not reportable. HPCI was declared inoperable as part of a maintenance evolution which was done in accordance with an approved procedure and the TS. The described condition was not a pre-existing condition that would have resulted in the system being declared inoperable prior to the planned maintenance activity."

Notified R1DO (Schroeder)

EN Revision Imported Date: 3/20/2023

EN Revision Text: LOSS OF RESPONSE CAPABILITIES

The following information was provided by the licensee via fax:

"On March 14, 2023, at 2000 EDT, in accordance with 10 CRFR 50.72(b)(3)(xiii). Yankee Nuclear Power Station Independent Spent Fuel Storage Installation (ISFSI) determined that the impacts of a severe winter storm have resulted in a major loss in off site response capability. Since approximately 0200, very heavy snow has fallen and greater than two feet has accumulated on site. All security related equipment has remained functional, and there have been no impacts to methods of offsite communications or emergency assessment capability. The concrete cask heat removal systems have remained operable in accordance with the NAC International multi-purpose container system (NAC-MPC) technical specifications. From approximately 0550 until 1840, offsite power was lost, and the site was powered by the security diesel generator. Periodically throughout the day, the Security Shift Supervisor was in contact with State and local police to ensure response capability. At the 2000 hours update, the law enforcement agencies reported that there were recent reports of trees and power lines being downed by the weight of the snowfall causing road closures and significantly impacting routes and response times to the site.

"The site remains fully staffed."

* * * UPDATE ON 3/17/2023 AT 1647 EDT FROM LLOYD BROOKS TO ERNEST WEST * * *

"On March 14, 2023, at 2000 EDT, in accordance with 10 CFR 50.72(b)(3)(xiii), Yankee Nuclear Power Station Independent Spent Fuel Storage Installation determined that the impacts of a severe winter storm resulted in a major loss in offsite response capability. Downed trees and power lines in conjunction with up to thirty-six (36) inches of snow prevented vehicle passage on normal response routes.

"On March 15, 2023, at approximately 1700 EDT, these roadways were passable, and employees and emergency vehicles regained normal access to the site. However, the Town of Rowe, Massachusetts police chief informed the site that the town remained in an emergency status and the roadways may need to be intermittently closed in order for utility workers to restore power lines and continue to clear tree limbs.

"On March 16, 2023, 1815 EDT, the Town of Rowe, Massachusetts police chief secured from the emergency. Therefore, this update is to inform the NRC that the Yankee Nuclear Power Station Independent Spent Fuel Storage Installation has similarly returned to baseline operations.

"NRC Region I management has been updated throughout the progression of the storm and recovery. A press release is not anticipated."

Notified R1DO (Bickett)

EN Revision Imported Date: 5/4/2023

EN Revision Text: REACTOR COOLANT SYSTEM (RCS) BOUNDARY DEGRADED CONDITION

The following information was provided by the licensee via email:

"At 2257 [CDT] on 3/14/2023 during the 2R22 refueling outage on Browns Ferry Nuclear Plant Unit 2, it was determined there was RCS boundary leakage from five of eight sensing lines that pass through containment penetrations X-30 and X-34 that did not meet the requirements of Section XI, of the ASME Boiler and Pressure Vessel Code. The condition will be resolved prior to plant startup. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

* * * RETRACTION ON 03/28/2023 AT 1059 EST FROM CASEY CARTWRIGHT TO THOMAS HERRITY * * *
The following information was provided by the licensee via email:

"The purpose of this notification is to retract a previous Event Notification, EN 56411 reported on 3/14/23.

"Following the initial notification, further analysis of the condition was performed. It was determined that the leaking pipe weld was ASME Section XI Code Class 2 piping which falls under the requirements of ASME Section XI Subsection IWC and not Subsection IWB. Therefore, this condition does not represent a serious degradation of the nuclear power plant, including its principle safety barriers. Based upon the above, the leaks identified on the ASME Section XI Code Class 2 equivalent Main Steam sense lines are not reportable under 10 CFR 50.72(b)(3)(ii).

"Therefore, the NRC non-emergency 10 CFR 50.72(b)(3)(ii) report was not required and the NRC report 56411 can be retracted and no Licensee Event Report under 10 CFR 50.73(a)(2)(ii) is required to be submitted."

Notified R2DO (Miller)

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received via email:

"On March 21, 2023, a report of misadministration was received by the Arkansas Department of Health from Baptist Health Medical Center, Little Rock at 0945 CDT.

"A 72 year old female came to the Baptist Health Little Rock Nuclear Medicine department for a radioactive iodine thyroid scan. The patient had been scheduled in our [Electronic Medical Record system] as a Total Body Iodine [TBI] Scan with Thyrogen. The patient was given the first dose of Thyrogen on Monday, March 13th. She came in the following day for her second dose of Thyrogen. At this time, the nuclear medicine technologist was informed that the patient still had her thyroid. The technologist called the radiologist and asked how long the patient needed to be off of Thyrogen to have an I-123 scan. The technologist was told to call the radiopharmacy and ask. The technologist was also told to call the ordering provider to clarify the order. The technologist communicated with the ordering provider's nurse. The ordering provider did not know what to do at this point other than to continue with the study. No explanation was given to the ordering provider about the TBI scan or the effects of I-131 on their patient. The technologist proceeded with dosing the patient on March 15th with 4.4 mCi of I-131. The patient came back on Friday, March 17th for imaging. At this point, the radiologist realized that the technologist had performed the incorrect study and misadministered I-131. The health physicist was notified, and on Monday, March 20th, estimated that since no uptake was performed, that the patient received, at minimum, 14,000 rads/500 Rem to her thyroid gland from the dose of I-131."

Arkansas Event Report ID No.: AR-2023-002

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.