Event Notification Report for June 14, 2024

EN Revision Imported Date: 6/14/2024

EN Revision Text: TWO OF THREE ESSENTIAL CHILLED WATER TRAINS DECLARED INOPERABLE

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

"At 0210 CDT 5/24/24, essential chiller 'A' train and cascading equipment was declared inoperable for maintenance to correct a temperature control malfunction.

"At 0720 CDT 5/26/24, essential cooling water 'B' train and cascading equipment (including 'B' train essential chiller) was declared inoperable due to a through wall leak discovered on the essential cooling water return header temperature element thermal well.

"This condition resulted in an inoperable condition on two out of three safety trains for the accident mitigating function, including the train 'A' and train 'B' high head safety injection, low head safety injection, containment spray, electrical auxiliary building heating ventilation and air conditioning (HVAC), and essential chilled water. All 'C' train safety related equipment remains operable.

"This was determined to be reportable within 8 hours as required by 10CFR50.72(b)(3)(v)(D).

"NRC Resident Inspector has been notified."

* * * RETRACTION ON 6/13/24 AT 1552 EDT FROM RAY RULEY TO BILL NYTKO * * *

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

"This is a communication to retract the 8-hour notification Event Notification (EN) 57146 reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) on 05/26/2024. Based on a subsequent engineering review of the conditions that existed at the time of discovery, it was determined that:

"1) The maximum postulated leak rate, conservatively estimated, from the 'B' Train essential cooling water return piping thermowell in the mechanical auxiliary building sump room would have been less than the administrative allowable limit for leakage in this room during a design basis accident,
"2) No adjacent safety related components or functions would have been adversely affected, and
"3) the return line leakage represented a negligible impact regarding essential cooling water system inventory and the system ability to cool required components.

"Therefore, it was recommended that the 'B' Train essential cooling water system with the as-found leakage condition be considered operable. Therefore, this event notification is being retracted.

"The NRC Resident Inspector has been notified."

Notified R4DO (Taylor)

AGREEMENT STATE REPORT - BRACHYTHERAPY MISADMINISTRATION

The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:

"The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024. The licensee is reporting that the total source strength administered differed by 20 percent or more from the total source strength documented in the post-implantation portion of the written directive."

SC Event Number: 240003


* * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

"For the medical event, the licensee is reporting that the total source strength documented in the post-implantation portion of the written directive is 5.54 millicuries per seed, and 221.6 millicuries total (forty seeds implanted). At the conclusion of the initial procedure on May 16, 2024, the licensee is reporting that all seeds as documented in the post-implantation portion of the written directive were administered. As of May 30, 2024, all seeds had been removed from the patient due to medical complications."

Notified R1DO (Bickett), NMSS Events Notification (email).


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 - LOST BRACHYTHERAPY SEEDS

The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:

"The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024.

"The licensee is reporting that on May 27, 2024, the seven (7) Cs-131 seeds that were removed from the patient are lost or missing. The other thirty three (33) seeds are accounted for."

SC Event Number: 240003

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

The exact source strength of the lost seeds was not provided, however, the licensee reported that the quantity was greater than 10 times but less than 1000 times the 10CFR20 Appendix C value for Cs-131.


* * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

"For the seven (7) Cs-131 seeds that were lost on May 27, 2024, the licensee is reporting the estimated activity at the time of removal and loss was approximately 2.5 millicuries per seed and approximately 17.5 millicuries total."

Notified R1DO (Bickett), NMSS Events Notification (email), ILTAB (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

The following information was provided by the licensee via email:

"At 1331 EDT on 6/13/2024, it was determined that a non-active licensed operator supervisor tested positive in accordance with the fitness for duty testing program. The individual's authorization for site access has been denied. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 6/17/2024

EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE

The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

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.


* * * UPDATE ON 04/26/2024 AT 0934 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following update was provided by the South Carolina Department of Health and Environmental Control via email:

"The licensee has submitted a 15-day written report. This event is still under investigation by the South Carolina Department of Health and Environmental Control.

"The internal identification number for this event is SC240001."

Notified R1DO (Werkheiser), NMSS_EVENTS_NOTIFICATION via email.


* * * UPDATE ON 06/14/2024 AT 1211 EDT FROM KORINA KOCI TO ROBERT THOMPSON * * *

The following information was provided by the licensee via email:

"Department Inspectors performed an on-site investigation on 05/23/24. Details of the event were consistent with the licensee's notification and written report. The licensee attributes the root cause of the failure to administer the full dosage to the administration lines due to administration line blockage, specifically a faulty needle in the plunger of the administration kit. This event is considered closed."

Notified R1DO (Eve), NMSS_EVENTS_NOTIFICATION via email.

LOST RADIOACTIVE SOURCE

The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:

At 0415 CDT, on 6/10/2024, the Radiation Safety Officer's (RSO) truck, which contained a Troxler 3440 nuclear gauge (serial number 66812), was stolen (loss of control). The RSO left the truck running with the keys in the ignition and the nuclear gauge secured inside when an individual decided to get in the drivers seat and drive away. When the RSO realized the truck was stolen, they immediately contacted Missouri local law enforcement. The nuclear gauge contains 44 mCi of Am241:Be.

* * * UPDATE ON 6/10/2024 AT 1032 EDT FROM LARRY BRADSHAW TO IAN HOWARD * * *

The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:

At 0902 CDT, on 6/10/2024, the truck was located and returned to the RSO with the Troxler gauge secure in its locked case. There was no indication of tampering with the case or the locks used to secure the Troxler gauge.

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

TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE

The following information was provided by the licensee via email:

"At approximately 1100 CDT on June 14, 2024, during routine fuel inspections required under Technical Specification 4.1.5, a fuel pin (serial number 11420) did not pass the go/no-go test for transverse bend. This measurement is described in Technical Specification 3.1.5.2.a as part of the fuel inspection conducted under the surveillance described in Technical Specification 4.1.5. Failure of an element to meet any one of the specifications listed in Technical Specification 3.1.5.2 specifies that the fuel element is considered 'damaged' and therefore may not be used in reactor operations.

"Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.

"There have been no indications of cladding failure on routine primary coolant analyses.

"The pin has been removed from service and will be replaced with a spare unused element.

"As required by Technical Specification 4.1.5.2, an inspection of the entire core fuel inventory will be initiated and will be completed prior to resuming routine operations.

"After the identification of the failure, the test rig calibration was confirmed and the pin was checked again, confirming the element failed the transverse bend specification.

"The reactor was not operating at the time of the event."

NRC Project Manager has been notified.

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"On June 16, 2024, at 1233 CDT, Waterford Steam Electric Station Unit 3 was operating at 93 percent power when an automatic reactor trip occurred. Immediately following the reactor trip, emergency feedwater (EFW) actuated automatically. The unit is currently in Mode 3. All control rods fully inserted. Decay heat removal is via the main condenser. Preliminary evaluation indicates that all plant systems functioned normally after the reactor trip, except steam generator (SG) feedwater pump 'A' tripped and SG '1' main feed regulatory controller went to manual. Steam generator water levels are being controlled with the SG feedwater pump 'B'. The cause of the trip is currently being investigated.

"This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as a valid actuation of the EFW system.

"The NRC Resident Inspector has been notified."