Event Notification Report for May 03, 2023

EN Revision Imported Date: 5/3/2023

EN Revision Text: 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: EN56348

* * * UPDATE ON 3/9/23 AT 0836 EST FROM THE SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL TO BILL GOTT VIA EMAIL * * *
The following summary was obtained via email from the South Carolina Department of Health & Environmental Control:
"The licensee submitted a 30-day written report on 03/09/23. The licensee reported no overexposures and that the gauging device will be disposed by 05/31/23. The licensee also reported that the gauging device contains 100 mCi of Cs-137 and not 10 mCi of Cs-137 as originally reported. This event is still under investigation."

Notified R1DO (Young), and NMSS Events Notification (via email).

* * * UPDATE ON 5/2/23 AT 0908 EDT FROM SOUTH CAROLINA DEPARTMENT OF HEALTH & ENVIRONMENTAL CONTROL TO SAM COLVARD * * *

"The gauging device was transferred for disposal on 4/13/23. This event is considered closed."

Notified R1DO (Dimitriadis), and NMSS Events Notification (via email).

EN Revision Imported Date: 5/3/2023

EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the licensee via phone and email:

"Per 10 CFR 35.3045(c), Veterans Health Administration (VHA) National Health Physics Program (NHPP) is reporting a possible medical event.

"Southern Arizona VA Health Care System [the facility], Tucson, Arizona, which holds Permit Number 02-06186-01 under the VA master materials license, reported discovery of a 'possible' medical event to NHPP at approximately [1500] CDT, April 19, 2023.

"A yttrium-90 microsphere therapy administration for liver cancer was performed on April 19, 2023. The intended treatment site was hepatic segment 4 of the right lobe of the liver. During the administration, performed under fluoroscopy guidance, the Authorized User (AU) / administering Interventional Radiology physician noted a change in the catheter position and elected to stop the administration. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity [15.06 mCi delivered vs. 21.6 mCi prescribed]. Post implant single-photon emission computerized tomography (SPECT) imaging verified that the dosage had been delivered to the correct location.

"The AU believes that the movement of the catheter qualifies as an emergent patient condition. The written directive was modified to include the reason for not administering the intended activity, the signature of an AU for yttrium-90 microspheres, and the date signed. NHPP in coordination with the facility and NRC will conduct further evaluation of this event to determine if the regulatory definition of emergent patient condition was met.

"The patient and the referring physician have been notified.

"At this time, short term harm to the patient is not expected.

"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.

"NHPP has notified the NRC Region III Project Manager."

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.

* * * RETRACTION FROM KIM WIEBECK TO BRIAN P. SMITH AT 1709 EDT ON 05/02/2023 * * *

The following information was provided by the licensee via email:

"Veterans Health Administration (VHA) National Health Physics Program (NHPP) placed a call to NRC Operations Center on May 2, 2023, to retract Event Number 56481 (NMED Item No. 230168).

"NHPP reported discovery of a "possible" medical event at Southern Arizona VA Health Care System, Tucson, Arizona, Permit Number 02-06186-01, on April 19, 2023.

"NHPP, in coordination with the facility and NRC, has conducted further evaluation and determined that the regulatory definition of emergent patient condition, in NRC's document, Yttrium-90 Microsphere Brachytherapy Sources and Devices TheraSphere and SIR-Spheres Licensing Guidance, was met. Therefore, this event is no longer classified as a "possible" medical event and the 15-day written reporting requirement of 10 CFR 35.3045(d) will not be completed."

NHPP has notified the NRC Region III Project Manager.

Notified R3DO (Peterson), R4DO (Gaddy), and NMSS Events Notification.

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

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

"On April 25, 2023, the licensee reported damage to a QSA 880D (number D7890, source serial number 72481M), camera containing 105.8 Ci of Ir-192. While using the device shooting a 3-inch pipe positioned on a cart, the pipe fell off the cart and landed on the guide tube. The guide tube was damaged and left the source capsule in the exposed position unable to retract or to be placed back in the collimator. Lead blankets were placed on the damaged area of the guide tube. Dose rate at the established boundary was confirmed to be 0 mR/hr. The licensee staff calculated doses received to the 4 employees involved in the retrieval as 98, 310, 570, and 750 millirem. Badges have been sent to Landauer for emergency processing. The source was able to be secured safely in the device, locked in the licensee's vault, and tagged out of service. The device will be sent to the manufacturer to be inspected.

"The Department will perform a reactive inspection. More information will be provided upon receipt."

PA NMED Event Number: PA230014

AGREEMENT STATE REPORT - LEAKING SOURCE

The information below was provided by the Georgia Department of Natural Resources via email:

"During a routine sealed source inventory and subsequent leak test performed on April 20, 2023, a physicist discovered that a Cs-137 vial source (initial calibration activity was 0.224 mCi, Cs-137, with serial number: 1710-68-15) was leaking. The source was wiped several times and counted in a Capintec CRC-55t well counter (serial number 561108) to ensure reproducibility of counts in the 662 keV window. Repeat wipe samples yielded the same counts and conclusively confirmed that the source was leaking. A picture was taken to document the visible damage of the vial. Area surveys and wipe tests performed in the location where the source was stored indicated no signs of contamination. The source has been taken out of service. As such, the leaking source has been fully contained and is currently secure in a hot lab. The licensee is currently in the process of obtaining quotes from several hazardous waste disposal companies in their region."

Georgia Radioactive Materials Program incident number: 64.

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE TO RADIOGRAPHER

The following information was provided by the LA Department of Environmental Quality (the Department) via email:

"[The Department] was notified by Acuren Inspection Radiation Safety Officer (RSO) via the Department radiation hotline at approximately 1400 [CDT] on April 26, 2023, concerning a possible excessive exposure. According to the RSO, a radiographer that has been working in Pennsylvania had his December badge come back with a dose of 8000 mrem. The December badge was sent to Landauer with the March badges and the reading was just received by Acuren. The RSO states that the radiographer works in the dark room processing film and leaves his badge in his bag with other tools. The radiographer believes his bag was used by someone else while performing industrial radiography and that is how the badge got exposed. Acuren will be performing an investigation."

LA event report ID No.: LA 20230007

MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 0423 EDT on 05/02/2023, with Unit 3 in Mode 1 at 14 percent power, the reactor was manually tripped due to securing all main feed pumps, due to sudden high differential pressure on their suction strainers. The trip was not complex, with all safety-related systems responding normally post-trip. No equipment was inoperable prior to the event that contributed to the event or adversely impacted plant response to the reactor trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the steam dumps, and startup feedwater is supplying the steam generators. Units 1, 2, and 4 were not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

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

LOSS OF COMMUNICATIONS

The following information was provided by the licensee via email:

"At approximately 1500 [EST] on 5/2/2023, it was determined that the commercial telecommunications capacity was lost to the Palisades Nuclear Plant (PNP) control room and technical support center due to an issue with the telecommunications provider. After discovery of the condition it was discovered that this loss also included the emergency notification system (ENS). Communications link via the satellite phone was tested satisfactorly. In addition, if needed, the satellite phone would be used to initiate call-out of the emergency response organization. The condition did not affect the ENS or commercial telecommunications capabilities at the offsite Emergency Operations Facility. The telecommunications provider has not provided an estimated repair time."

PNP will be notifying the NRC resident inspector.

EN Revision Imported Date: 5/4/2023

EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO LOSS OF REACTOR COOLANT PUMPS

The following information was provided by the licensee via email:

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"At 2144 MST on April 8, 2023, the Unit 1 reactor automatically tripped due to the loss of reactor coolant pumps stemming from the loss of 13.8 kV power to the pumps.

"Prior to the reactor trip, the main turbine tripped due to a loss of hydraulic pressure. The main generator output breakers did not automatically open on the turbine trip as expected so the control room operators opened the breakers per procedural guidance. Once the breakers were opened, the two 13.8 kV electrical distribution buses failed to complete a fast bus transfer, which resulted in the loss of power to the reactor coolant pumps, initiating the reactor trip. The control room operators manually actuated a main steam isolation signal per procedure, requiring use of the atmospheric dump valves.

"Following the reactor trip, all control element assemblies inserted fully into the core. No automatic specified system actuation was required or occurred. No emergency plan classification was required per the Emergency Plan. Safety related buses remained powered from offsite power during the event and the offsite power grid is stable. Unit 1 is stable and in Mode 3. Decay heat is being removed by the atmospheric dump valves and the class 1E powered motor driven auxiliary feedwater pump.

"The loss of hydraulic pressure, the main generator output breakers failing to automatically open and the fast bus transfer not actuating are being investigated.

"This event is being reported as a reactor protection system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B).

"The NRC Senior Resident Inspector has been informed.

"Unit 2 is in a refueling outage in Mode 5 and Unit 3 is in Mode 1 at 100 percent power."

* * * UPDATE ON 4/9/23 AT 0835 EDT FROM TANNER GOODMAN TO ADAM KOZIOL * * *

"This update is being made to report the manual actuation of the B-train auxiliary feedwater pump and manual main steam isolation signal (MSIS) actuation affecting multiple main steam isolation valves (MSIVs) following the reactor trip.

"This event is being reported as a reactor protection system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and a specified system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Senior Resident Inspector has been informed of the update."

Notified R4DO (Warnick)

* * * UPDATE ON 5/3/23 AT 1945 EDT FROM LORRAINE WEAVER TO JOHN RUSSELL * * *

"This update is intended to clarify the initial description of the event that occurred on 4/8/2023.

"Prior to the reactor trip, the main turbine tripped due to a loss of hydraulic pressure. The main generator output breakers did not automatically open on the turbine trip. The control room operators manually opened the breakers per procedural guidance. Once the breakers were opened, the two 13.8 kV electrical distribution buses de-energized. A fast bus transfer did not occur per design, which resulted in the loss of power to the reactor coolant pumps, initiating the reactor trip. The control room operators manually actuated a main steam isolation signal per procedure, requiring use of the atmospheric dump valves.

"The NRC Senior Resident Inspector has been informed of the update."

Notified R4DO (Gaddy)

AGREEMENT STATE REPORT - FOUND SOURCE

The following information was received from the Minnesota Department of Health (MDH), Radioactive Materials Unit via email:

"An unlicensed engineering company found a portable nuclear density gauge in their storage garage while cleaning. They state that they have never been licensed and have never acquired a gauge. [The company] estimates that it has been in the garage since the early 1990s without their knowledge. The gauge is currently being stored in the locked garage. The company has been instructed to place a second tangible barrier on the device while [MDH] continues to investigate and discuss next steps. The licensee reported this discovery to MDH on 4/25/2023, and MDH was able to verify the gauge make, model and activity on 4/27/2023. Below is the information we [MDH] currently have:
"- Company name: Widseth Engineering, Inc. (formerly Floan-Sanders, Inc.) 1600 Central Avenue NE, East Grand Forks MN
"- Gauge manufacturer: Soiltest, Inc. 2205 Lee Street, Evanston IL
"- Gauge Model: NIC-5 DT
"- Gauge Serial Number: 75C047
"- Sources (assay date August 1975): Am-241/Be: 60 mCi (decayed to 55 mCi); Cs-137: 10 mCi (decayed to 3.3 mCi)

"MDH is conducting an investigation and will provide more information in a report within 30 days."

MN State Event Report ID No. MN230002

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