Event Notification Report for November 13, 2023

EN Revision Imported Date: 11/13/2023

EN Revision Text: PART 21 INTERIM REPORT - DEVIATION IN THE CALIBRATION CERTIFICATES FOR AN ACOUSTIC EMISSION INSTRUMENT

The following is a summary of information provided by the MISTRAS Group via fax:

On June 10, 2021, calibration certificates for an acoustic emission (AE) instrument were found to have been falsified (reference Notice of Violation 99902109/2023-201-02). The AE system was used for testing of lift rigs used for reactor head and internals. A 10 CFR Part 21 evaluation was initiated on June 15, 2021, and is now essentially complete. The final report will be made available by November 1, 2023.

The following reactor plants were affected: DC Cook, Kewaunee, Surry, Millstone, North Anna, Robinson, Oconee, Arkansas Nuclear One, Beaver Valley, Turkey Point, St. Lucie, Seabrook, Shearon Harris, Vogtle, Farley, Sequoyah, Watts Bar, and Prairie Island.

For questions, contact Donald D. Smith, Quality Assurance Director, MISTRAS Group, Inc., (630) 418-7301, donald.d.smith@mistrasgroup.com

***UPDATE ON 10/31/2023 AT 1403 EDT FROM DONALD SMITH TO ERIC SIMPSON***

The following information was provided by the licensee via phone:
The final report will be delayed. The final report will be made by November 10, 2023, instead of the original date of November 1, 2023.

Notified R1DO (Bickett), R2DO (Miller), R3DO (Ruiz), R4DO (Roldan-Otero), and via email: Part 21 Reactors.

***UPDATE ON 11/10/2023 FROM DONALD SMITH TO ADAM KOZIOL***

MISTRAS Group Quality Assurance Director submitted evaluation of nonconformance report.

Notified R1DO (Eve), R2DO (Miller), R3DO (Ruiz), R4DO (Warnick), and Part 21 Reactors (email).

AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES

The following information was received from the Washington State Department of Health via email:

"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.

"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."

Washington Incident Number: WA-23-029

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 - Y-90 UNDERDOSE

The following information was received via email:

"The Chief Physicist at Kaiser Permanente Medical Care Program of Southern California contacted the Radiologic Health Branch on November 2, 2023, at approximately 1757 PDT to report a medical event that occurred on the same day in Los Angeles, CA. The patient was underdosed during a radioembolization treatment for liver cancer that involved the administration of yttrium-90 (Y-90) TheraSpheres microspheres. The prescribed dose to the patient was 900 Gy, but the dose delivered to the patient was only 90.2 Gy due to a kink in the microcatheter used to deliver the Y-90.

"Kaiser Permanente will conduct an investigation to gain a better understanding of the details of the event."

CA event ID number: 110323

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 - LOST TROXLER GAUGE

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

"On November 4, 2023, the Department was notified by the licensee that one of its technicians had lost a Troxler 3430 moisture/density gauge. The gauge contains one 40 millicurie Am-241 source and one 8 millicurie Cs-137 source. The licensee reported that a technician was waiting in their truck to perform a test at a temporary job site when they were told by the job supervisor that the work was done for the day. The technician drove home and when they reached their home, realized they had left the gauge, which was inside its transportation box, sitting on the tailgate of the truck and it was now missing. The licensee did not know if the cesium source rod or transport case was locked. The technician retraced their route twice, but it was already dark, and they did not see the gauge. The technician notified his radiation safety officer that they had lost the gauge. The licensee will notify local law enforcement of the event. The licensee stated they will begin searching for the gauge as soon as it is light out. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10064

Texas NMED Number: TX230050

* * * UPDATE ON 11/5/2023 AT 1052 EST FROM ART TUCKER TO ERNEST WEST * * *

"On November 5, 2023, the Department contacted the licensee and requested the status of the gauge. The licensee stated that they had performed additional searches for the gauge this morning but did not find the gauge. The licensee stated they had contacted the Harris County, Texas, Sheriff's Department. The licensee stated they would offer a reward for the gauges return. The licensee was advised to contact local pawn shops and watch social media platforms like eBay and Craig's List. The licensee was advised to contact local fire departments about the gauge and provide its contact information. The licensee stated the gauge was labeled with its contact information. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Roldan-Otero), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email

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

AGREEMENT STATE REPORT - LOST NUCLEAR GAUGE

The following information was received from the Wisconsin Department of Health Services (the Department) via email:

"On November 06, 2023, at 1408 CST, the Department received a notification from the licensee that a Peco Controls Corporation gauge (serial number 5450LA) containing 100 mCi of Am-241 had been determined to be missing while conducting inventory of gauges in storage. This is all the information that is known at this time. The Department will follow up and provide additional information as it becomes available."

Wisconsin Event Report ID No.: WI230021

* * * UPDATE ON 11/10/23 AT 1605 EST FROM MEGAN SHOBER TO ERIC SIMPSON * * *

The following update was received from the Wisconsin Department of Health Services (the Department) via phone and email:

"On November 10, 2023, the licensee determined that an additional four Peco Controls Gamma 101P gauges were missing (serial numbers 0550LX, 9145LV, 9142LV, and 9580LV). Each gauge contained 300 millicuries of Americium-241. Department inspectors were onsite and physically verified the remainder of the licensee's inventory.

"In addition, the model number of the gauge declared missing on November 6, 2023 was confirmed to be a Gamma 101P."

Notified R3DO (Ruiz), NMSS Event Notifications, ILTAB, and CNSC via email.

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

ALERT - SEISMIC EVENT FELT ONSITE

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

"An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility and felt inside the control room. A release of hazardous material has not occurred."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

On 11/08/2023 at 0337 MST, Urenco USA declared an Alert (EAL 5.1A) due to a seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 0559 EST (0359 MST). No radioactive release has occurred. A 5.2 magnitude earthquake occurred in western Texas with an epicenter 36.7 km west-southwest of Mentone, Texas. Plant personnel are conducting walkdowns of the site.

The State and local authorities have been notified.

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)

* * * UPDATE ON 11/8/2023 AT 1153 EST FROM JIM RICKMAN TO SAMUEL COLVARD * * *

TERMINATION OF SEISMIC EVENT ALERT

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

"The earthquake of 5.2 magnitude in western Texas was felt in the control room. No release of UF6 was detected. Building inspections have been completed with no damage identified. This event has been terminated at 0937 MST and has entered into the recovery process. The State and local authorities have been notified."

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Miller), NMSS (Brenneman), IRMOC (Grant), OPA (Burnell).


The following additional information was obtained in accordance with Headquarters Operations Officers Report Guidance:
US Geological Survey (USGS) updated the seismic event to 5.3 magnitude at 10:27 on 11/08/23.

MANUAL ACTUATION OF AUXILIARY FEEDWATER SYSTEM (AFW)

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

"At 0645 EST, on November 8, 2023, with Unit 2 in Mode 3 at zero percent power, a manual actuation of the auxiliary feedwater system (AFW) occurred during a planned plant cooldown. The reason for the AFW manual-start was a trip of the 22 steam generator feed pump due to a high casing level. The 23 AFW motor driven pump was manually started in accordance with implementation of AOP-3G, Malfunction of Main Feedwater System to restore steam generator levels.

"There was no impact to Unit 1. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

No other systems were affected. No other compensatory or mitigation strategies implemented. Plant cooldown was the only significant evolution in progress. No impact to other technical specifications or limiting conditions for operation. All systems functioned as required. The electric plant is being supplied by offsite power with all diesel generators available. No significant increase in plant risk. There was nothing unusual or not understood.

FITNESS-FOR-DUTY REPORT

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

A controlled substance was found in the protected area. The NRC Resident Inspector has been notified.

MANUAL REACTOR SCRAM

The following information was provided by the licensee via email:

"At 0118 EST, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually scrammed due to degrading main condenser vacuum. The scram was not complex, with all systems responding normally post-scram. The main turbine bypass valves opened automatically to maintain reactor pressure.

"Operations responded and stabilized the plant. Reactor water level is being maintained via feedwater pumps. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 2 is not impacted.

"Due to Reactor Protection System actuation while critical, this event is being reported as a four-hour and eight-hour non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"Unit 1 reactor is currently stable in mode 3. An investigation is in progress into the cause of the degrading condenser vacuum. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

ESSENTIAL CHILLER TRAINS INOPERABLE

The following information was provided by the licensee via email:

"On 11/10/23 at 0642 CST, essential chiller 'B' train and cascading equipment was declared inoperable due to chill water temperature exceeding limits.

"At 1413 CST, essential chiller 'C' train and cascading equipment was declared inoperable due to discharge pressure exceeding limits.

"This condition resulted in an inoperable condition on two out of the three safety trains for the accident mitigating function including the 'B' and 'C' train high head safety injection, low head safety injection, containment spray, electrical auxiliary building HVAC, control room envelope HVAC, and essential chill water. All 'A' train equipment remained operable.

"This was determined to be reportable within 8 hours as required by 10 CFR 50.72(b)(3)(v)(D)."

The NRC Resident Inspector has been notified.

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Plant is in a 72 hour limiting condition for operation per technical specification 3.7.7. Restoration of 'B' train anticipated on 11/11/23 mid day.

UNANALYZED CONDITION

The following information was provided by the licensee via email:

"At 1545 CST on November 10, 2023, personnel at Waterford Steam Electric Station Unit 3 determined that 19 conduits in the engineered safety features actuation system (ESFAS) auxiliary relay cabinets A and B did not have the required fire seals for bay separation. This condition meets the criteria involving an unanalyzed condition that significantly affects plant safety.

"The plant is currently defueled. Decay heat is being removed by normal spent fuel cooling system operations. ESFAS is not required to be operable in the current plant mode.

"This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition that significantly degrades plant safety.

"There was no impact to the health and safety of the public or plant personnel.

"The NRC Region 4 Branch Chief [Dixon] has been notified."

OFFSITE NOTIFICATION

The following information was provided by the licensee via email:

"On November 12, 2023, at 0300 EST, a Watts bar contractor was transported offsite for medical treatment due to a work-related injury. Upon arrival at an offsite medical facility, medical personnel determined the injury required the individual to be admitted into the hospital and will be kept overnight. The individual was inside of the Radiological Controlled Area, however was free released with no contamination.

"The injury and hospitalization were reported to the Occupational Safety and Health Administration (OSHA) under 29 CFR 1904.39(a)(2). The contracting agency informed OSHA at 1319 EST. Watt Bar Operations personnel were officially notified by the contracting agency of the report made to OSHA at 1945 EST.

"This is a four-hour notification, non-emergency for a 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."