Event Notification Report for November 02, 2020

EN Revision Imported Date: 10/28/2020

EN Revision Text: AGREEMENT STATE REPORT - MISSING CATEGORY 2 MATERIAL

The following was received from the Commonwealth of Massachusetts (the Agency) via email:

"QSA Global reported via telephone at 1100 EDT on 10/22/2020 that a package shipped via common carrier on 10/9/2020, containing two Model A424-9 Ir-192 industrial radiography sealed sources within a Model 650L source changer, was reported as missing via telephone by common carrier at 0926 EDT on 10/22/2020. Common carrier trace already initiated and in progress, and tracking indicates last known package location was common carrier hub in Memphis, TN. This was a RQ UN2916, Yellow-II, Type B package with a Transport Index of 0.5 at time of shipment. Source changer SN 2238. Sources SN 11393M (65 Ci) and 11394M (33.1 Ci). This situation is an immediately reportable event per regulation. A search for the missing package by common carrier is ongoing. Agency currently considers this docket to still be OPEN"

Intended recipient is Gilligan Engineering Services, Prudhoe, Northumberland, Great Britain.


* * * UPDATE ON 10/27/2020 AT 1305 EDT FROM ANTHONY CARPENITO TO OSSY FONT * * *

The following update was received from the Agency via email:

"The licensee/shipper (QSA Global Inc.) on 10/23/20 reported to this Agency that the missing package was reported by the carrier as found in the carrier's Memphis, TN hub facility on 10/23/20. The package is being returned to the licensee/shipper for inspection.

"Agency expects this event docket to remain open until all details, including action docket numbers, are compiled, licensee's 30-day written report is received, and all relevant documentation is completed and reviewed."

Notified R1DO (Young) and NMSS Events Notification, NMSS Regional Coordinator (Rivera-Capella), and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

MANUAL REACTOR TRIP DUE TO AN UN-ISOLABLE LEAK ON THE TURBINE HIGH PRESSURE FLUID SYSTEM

"On November 1, 2020, at 0534 CST the reactor was manually scrammed due to an un-isolable leak on the Turbine High Pressure Fluid System. Initial power level when the leak was identified was 100 percent. Power was lowered commencing at 0525 in accordance with shutdown procedures. The Reactor Operator scrammed the reactor at 0534 from approximately 75 percent power. Following the scram, Reactor vessel water level lowered to approximately -20 inches on the Wide Range Instruments, and was subsequently recovered to normal post scram range (approximately 36 inches) using the Reactor Feedwater system. Group 2 Isolation occurred due to Reactor vessel level reaching the isolation setpoint (3 inches). The plant is stable in MODE 3 and proceeding to cold shutdown. The Main Condenser remained available throughout the evolution and condenser vacuum is currently being maintained by the Mechanical Vacuum Pumps. Pressure is being controlled using the steam line drains to the main condenser.

"All control rods fully inserted and there were no complications. All systems responded as designed. The Turbine High Pressure Fluid System has been secured.

"This event is reportable under 10 CFR 50.72(b)(2)(iv)(B) due to RPS Actuation-Critical and 50.72(b)(3)(iv)(A) Valid Specified System Actuation.

"The licensee has notified the NRC Resident Inspector."

LOSS OF SEISMIC ASSESSMENT INSTRUMENTATION

"At 0556 EST on 11/01/2020, Sequoyah received unexpected alarms for seismological recording initiated and [Units] 1/2 Safe Shutdown Earthquake response spectra exceeded. No seismic event was felt on site, the National Earthquake Information Center was contacted to confirm there was no seismic activity, and this was also confirmed on the U.S. Geological Survey website. The alarms were determined to be invalid, and they occurred due to a failure in the seismic monitoring system. This failure results in loss of ability to assess the Emergency Action Level for Initiating Condition HU2 'Seismic event greater than Operating Basis Earthquake (OBE) levels' per procedure EPIP-1.

"If an actual seismic event occurred, HU2 could not be assessed. However, compensatory measures have been implemented and include assessing OBE criteria based on alternative criteria contained in procedure AOP-N.05 'Earthquake' which provides conservative guidance when seismic instruments are unavailable.

"This is an eight hour, non-emergency notification for an event resulting in a major loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii). There is no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERS BY GREATER THAN 20 PERCENT



The following was received from the Georgia Radioactive Materials Program (the Program) via email:

"The Y-90 event [occurred] on October 23, 2020. The AU [(Authorized User)] notified the Assistant RSO [(Radiation Safety Officer)] on October 26 and then subsequently notified our Program on October 27, 2020. The reason for the delay notifying the Program was both the Radiation Safety Officer (RSO) and Assistant Radiation Safety Officer (ARSO) were furloughed on Friday [(October 23)] and they did not check their emails until Monday. They used Monday to gather information before contacting the State Program.

"The patient was administered with 1.58 GBq using a 10 mL syringe. The reason for the 10 mL syringe was a small gauge catheter was used. The line was subsequently flushed 3 times with saline solution to ensure the Y-90 was pushed through.

"After the procedure, the catheter was removed and surveyed along with the vial to determine residual activity. It was calculated that there was more residual [activity] than expected.

"Though it is has not been clearly determined the cause of the excess residual [activity], it is thought to be either not enough saline was used to push the Y-90 through or it got stuck in the catheter.

"The ARSO and the Authorized User will discuss the cause of the event, best way to prevent occurrence, and [perform] patient follow-up.

"The licensee will follow-up with a report within 15 days. In the interim, the licensee is required to submit a copy of the written directive, Y-90 procedure and checklist, and the rational why they used a small catheter gauge."

The actual dose delivered was 1.039 GBq (65.5 percent).

Georgia Incident No: 31

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.

AUTOMATIC REACTOR TRIP DUE TO CONTROL ELEMENT DRIVE MECHANISM CONTROL SYSTEM TIMER FAILURE

"On November 2, 2020, at 0419 CST, Waterford 3 experienced an automatic reactor trip due to a Control Element Drive Mechanism Control System timer failure while attempting to synchronize a second motor generator set. All control rods fully inserted.

"The plant is currently in Mode 3 and stable with normal feedwater feeding and maintaining both Steam Generators.

"The NRC Senior Resident Inspector has been notified."

The cause of the failure is still under investigation.