Event Notification Report for May 25, 2023

AGREEMENT STATE REPORT - FAILED SHUTTER

The following information is a summary provided by the Illinois Emergency Management Agency via email:

During a routine inspection on May 17, 2023 at Flexsys America, L.P. in Sauget, IL, an inspector identified a February 2022 equipment failure involving a fixed gauge that resulted in a stuck-open condition of the shutter (300mCi Cs-137 sealed source, model A-2102, serial number 3654CP). This incident was reportable to ONS-RAM within 24 hours under 32 Ill. Adm. Code 340.1220(c)(2). No personnel exposures occurred as a result. Corrective action was taken with repairs to the mechanism performed by the manufacturer and the gauge was returned to operable condition. The initial reporting requirement was not met by the licensee and will be addressed through inspection correspondence. This matter was reported to the NRC within the required timeframe.

Illinois report number: IL230010

AGREEMENT STATE REPORT - CONTAMINATED WORKER

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

"On May 18, 2023, The University of Texas MD Anderson Cancer Center (the licensee) reported to this Department that they had discovered a technician and package with contamination of around 12,000 dpm [disintegrations per minute]. The licensee's technician picked up the bag (package) with their bare hands. They then did a wipe test of the bag and found that it was contaminated. They also discovered that both their hands were contaminated. They washed repeatedly which reduced the contamination on their hands but did not eliminate it. The licensee believes that the remaining contamination has been absorbed into their skin and that it is no longer removable. The technician has gone home with instructions to continue wearing gloves. The technician is pregnant, and the licensee plans to perform a thyroid check tomorrow.

"The bag had elevated readings at the handle, but the contamination seemed to mostly be at the top right of the bag where the zipper handle was located. The licensee has not found contamination in any other areas of their facility. The licensee used a well counter to try to determine the isotope and believes it is either 5 microcuries of technetium-99m or 2 microcuries of iodine-123. A comparison of activities of the following day will determine which isotope it is since there is a significant difference in half-lives. The container with the ordered 10 millicuries of iodine-123, which was inside the bag, was wiped and found to not be contaminated.

"The nuclear pharmacy that supplied the bag and material inside the bag did wipe tests of the driver's hands, the steering wheel, pedals, the rack the bag would sit on, and the hand truck that the package would have been placed on. They did not find any radiation above background. They also performed wipes and surveys within their facility and again did not find any contamination.

"The worker who prepared the material at the pharmacy in the morning only drew iodine-123 for this single package. All other iodine-123 packages were pre-prepared. The pharmacy sent around 45 packages out in the morning to many medical facilities. None have reported contamination. The truck only carries packages from this single pharmacy.

"The Department has asked both facilities to continue to look for contamination and has recommended that the technician wear cotton gloves inside of the other gloves to hopefully get the hands to sweat the material out into the cotton."

Texas incident number: 10020.

TECHNICAL SPECIFICATION VIOLATION

The following information was provided by the University of Missouri-Columbia Research Reactor (MURR) via phone and email:

"During a normal reactor start up on 5/23/2023, while still approaching criticality, reactor power peaked slightly above 100 kW with a single control blade 1.4 inches below the other three control blades. This is a violation of Technical Specification (TS) 3.2.b which states that above 100 kW, the reactor shall be operated so that the maximum distance between the highest and lowest shim blade shall not exceed 1 inch.

"As part of a normal reactor startup, three control blades were at 23 inches and the core was approaching criticality. As the fourth control blade was being pulled to the bank height, the Lead Senior Reactor Operator stated power was approaching 100 kW, alerting the Reactor Operator to the TS of no more than a one-inch height differential between control blades. Reactor power slowly increased. The Reactor Operator stopped shimming out on Control Blade 'A' and shimmed the other three rods inward individually to stop the power rise. He continued to then pull Control Blade 'A' out while leveling power by shimming the other three rods in. The control room continued the startup. No other issues occurred during the approach to full power (10 MW).

"After the startup, the Lead Senior Reactor Operator raised a concern that it was possible power peaked slightly above 100 kW with Control Blade 'A' at 1.4 inches below the other three control blades. Strip charts confirmed power peaked at 103.5 kW during this time. Total duration in this unapproved control blade configuration was less than one minute.

"The Reactor Manager was informed of the problem, and he informed the Interim Facility Director. MURR Licensee Event Report (LER) 13-03 discusses a similar event. Calculations performed for that event show that a control blade can differ by as much as 4 inches from the bank with no adverse effects to the core. MURR reactor operations were continued.

"MURR will follow up with an LER to address this issue."

NOTIFICATION TO ANOTHER GOVERNMENT AGENCY

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

"On 5/22/23, Xcel Energy performed a notification to the state of Minnesota Duty Officer, in accordance with Minnesota Statute 115.061, regarding 300-600 gallons of pumped ground water that overflowed from a holding tank and returned to the ground area from which it was pumped. The groundwater being pumped is related to recovery activities associated with the event reported on November 22, 2022 (EN 56236). This notification is being made solely as a four-hour, non-emergency report for notification to other government agency. An update is being provided to the Monticello community and published on Xcel Energy's website. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of public or plant personnel. The NRC Resident Inspector has been notified."

PART 21 - DEFECT IDENTIFIED IN EMERGENCY DIESEL GENERATOR GOVERNOR

The following is a synopsis of information provided by the Engine Systems, Inc (ESI) via fax:

Component Description: Woodward Governor, Part No. 9903-722, Serial No. 18847017

Problem Description: An EGB-35P governor/actuator (governor) installed on a customer's emergency diesel generator failed soon after installation. Investigation revealed a piece of foreign material, a loose buffer plug, inside the governor that caused the failure. Since the governor is used to maintain fuel rack position of the diesel engine, failure of the governor would prevent the emergency diesel generator from performing its safety-related function during an event.

Affected Plants: Brunswick Nuclear Plant

Corrective Actions for Brunswick Nuclear Plant: No action required. The affected governor has been returned to ESI.

Corrective Actions for ESI: The governor will be refurbished under ESI's 10 CFR 50 Appendix B program and certified for continued use at Brunswick Nuclear Plant. To prevent reoccurrence, ESI will revise the dedication requirements to enhance existing foreign material inspection practices to include a visual inspection where the buffer plug was located within the governor. The revisions are expected to be complete within 30 days but in all cases prior to future shipments.

FITNESS-FOR-DUTY REPORT

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

"On May 24th, 2023, at approximately 0710 MDT, a non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The individual's plant access has been terminated in accordance with station procedures.

"The NRC Resident Inspector has been notified."