Event Notification Report for June 07, 2024

EN Revision Imported Date: 6/11/2024

EN Revision Text: PART 21 REPORT - CHECK VALVE FAILS BENCH TEST

The following is a synopsis of information received via email:

Flowserve Corporation identified a defect with their 0.5 inch model 1878 piston check valve during bench testing. The piston check valve with adjustable cracking pressure received by Duke Energy Catawba Nuclear Station failed bench test performance for designed cracking pressure with an allowable range of 180 - 220 psig. The valve is used to provide overpressure protection of containment penetration piping due to thermal expansion of fluid trapped between the containment isolation valves when the valves are closed. The valves are required to crack open before the maximum 220 psig setpoint to perform this function. Corrective actions include revising Flowserve's assembly and test procedures for the 0.5 inch model 1878 piston check valve.

Affected known plant: Catawba Nuclear Station

The name and address of the individual reporting this information is:

Aaron G. Goodbar
Nuclear Quality Assurance Manager
Flowserve Corporation
1900 S. Saunders St.
Raleigh, NC 27603
1-888-200-5389

AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

The following information was provided by the Arkansas Department of Health, Radiation Control, Radioactive Materials Program (the Agency) via email:

"The Agency was notified by the Radiation Safety Officer (RSO) for the University of Arkansas for Medical Sciences on Friday afternoon, June 7, 2024, to advise of a possible Y-90 TheraSphere misadministration where the patient did not receive all the prescribed dose. The administration was two doses to segment 5 of the patient's liver. The discovery was made when the tubing and waste from the procedure was surveyed after it was returned to the lab.

"The written report was received on Friday afternoon, June 14, 2024. On June 17, 2024, the Agency reviewed the information provided and determined that this event is a misadministration due to the following:

"The administered doses both differed from their respective prescribed doses by more than 0.5 Sv (50 rem) to an organ. The delivered dose of 95 Gy (9500 rem) was 198 Gy (19800 rem) less than the [prescribed] dose of 293 Gy (29300 rem) for dose number one; the delivered dose of 105 Gy (10500 rem) was 21 Gy (2100 rem) less than the [prescribed] dose of 126 Gy (12600 rem) for dose number two.

"[For] dose number one only, the total dose delivered differs from the prescribed dose by twenty percent or more. Dose number one was outside the treatment prescription range; 68 percent of the prescribed dose was not received. Therefore, [dose] number one is considered to be a misadministration in accordance with current emerging medical technology licensing guidance.

"Dose number two was just inside the treatment prescription range; 17 percent of the prescribed dose was not received.

"The referring physician and [the] patient were notified, and the patient has been scheduled for an additional treatment.

"The investigation is ongoing, and reporting will proceed in accordance with SA-300."

Arkansas Event number: AR-2024-004

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: 8/6/2024

EN Revision Text: CONTROL ROOM ENVELOPE FAILED SURVEILLANCE

The following information was provided by the licensee via email:

"At 0146 CDT on June 7, 2024, River Bend Station (RBS) was operating at 100 percent power when a loss of control room envelope (CRE) was declared due to failing to meet Technical Specification (TS) 3.7.2, Surveillance Requirement (SR) 3.7.2.4, during surveillance testing. Mitigating actions were established which included the ability to issue potassium iodide to control room staff. With mitigating actions in place, the dose consequence to control room staff continued to be less than the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event.

"The CRE is considered a single train system at RBS, therefore, this event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC resident inspector has been notified."

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

The failed surveillance (SR 3.7.2.4) was for unfiltered air in-leakage greater than 300 cubic feet per minute.

* * * RETRACTION ON 08/05/2024 AT 1456 EDT FROM DARREN FARTHING TO ROBERT THOMPSON * * *

"This event was initially reported under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function. The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that there was no adverse impact on the control room emergency ventilation system or the control room envelope (CRE) boundary's ability to perform its safety function. The CRE would not have been challenged to meet the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event. Consequently, this condition is not reportable as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC resident inspector has been notified."

Notified R4DO (Vossmar).