Event Notification Report for July 23, 2021

EN Revision Imported Date: 7/23/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED VARIED BY MORE THAN 25 PERCENT

The following was received from the Ohio Department of Health via email:

"A patient whose thyroid had been removed was to receive treatment for the remaining nodules. The WD [(written directive)] prescribed 30 mCi I-131 NaI. However the licensee ordered and administered 100 mCi. The expected whole body dose is 26.64 rem and dose to the bladder wall is 225.7 rad."

Item Number: OH210006

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: 7/23/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received from the Texas Department of State Health Services via email:

"On July 13, 2021, the licensee discovered a stuck shutter in the open position during a 6 month shutter test. This is the normal operating position and there is not expected to be any additional dose outside of normal operations to workers or public."
"The device was a Vega SH-F2B density/level gauge (serial number 3578CR), with a 200 mCi CS-137 source (serial number 3578CR)."
Texas incident number: I-9869

EN Revision Imported Date: 7/23/2021

EN Revision Text: STOLEN TROXLER GAUGE

On July 14, 2021, a technician left a job site unknowingly leaving a Troxler gauge on the tailgate, which subsequently fell off. The project supervisor was informed of the incident at approximately 1445 EDT. A local business has still images of an individual in a truck picking up the gauge on the side of the road and driving off. Local law enforcement was called, and an investigation is underway. The Troxler gauge, model number 35/40, 25423, contained 8 mCi of Cs-137 (serial number 75-8257) and 40 mCi of Am-241:BE (serial number 47-21754). The Transport Index is 0.6.

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

EN Revision Imported Date: 7/23/2021

EN Revision Text: OFFSITE NOTIFICATION DUE TO EXCEEDING NPDES LIMIT

"While preparing for the June 2021 Discharge Monitoring Report (DMR), Environmental was entering data per the lab results that were sent from Pace Analytical for the June DMRs. On June 1, 2021, a National Pollutant Discharge Eliminating System (NPDES) sample was collected at outfall 001A to test for copper, there is a NPDES permit condition to monitor for copper on a quarterly basis. The lab report was returned to Fermi Environmental on June 15, 2021. The results came back at 41.2 micrograms/liter. Fermi's NPDES permit maximum limit is 40 micrograms/liter for outfall 001A. Due to the June 1, 2021 sample exceeding the permit limit, a second sample was collected on June 21, 2021 as a verification sample and the copper results came back July 13, 2021. Those results came back at 5.9 micrograms/liter which is within the permit limit. Environmental was aware of the June 1, 2021 copper exceedance limit but failed to recognize the reporting requirement at the time of the discovery because it was thought that the exceedance would be reported through the DMR submittal. The June DMRs are due on July 20, 2021.

"At approximately 1740 EDT on July 15, 2021, a Fermi environmental engineer was preparing and reviewing the Discharge Monitoring Report and identified that a recent sample result for outfall 001A was outside of the NPDES permit limit for Copper. The Copper sample result was 41.2 micrograms/liter with a limit of 40 micrograms/liter. Subsequent discussions with Environmental personnel determined that this issue should be reported to the state of Michigan Department of Environment, Great Lakes and Energy (EGLE). A discussion is planned with EGLE on July 16, 2021. This notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) based on the planned notification to EGLE."

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 07/22/2021 AT 2141 FROM MARGARET OFFERLE TO OSSY FONT * * *

The licensee initially reported the lab report was returned to Fermi Environmental on June 15, 2021. The date of receipt was June 16, 2021.

The licensee will notify the NRC Resident Inspector.

Notified R3DO (Pelke).

EN Revision Imported Date: 7/26/2021

EN Revision Text: AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE STUCK SHUTTER

The following information was received via E-mail:

"At 1400 CDT on July 16, 2021, the State was contacted by a representative of the licensee to report a radiation event that had been identified at 1530 CDT on July 15. The licensee was performing routine checks on a fixed gauge device. As part of the checks, they ensure that the shutter is able to be opened and closed. The individual servicing the gauge identified that the shutter was unable to be closed. All indicators are functioning as required to alert that the gauge is open. Staff who work in the area have been instructed that the device is unable to be closed, and to avoid working around the gauge even when it is not being utilized.

"The device is a Mahlo Model 11-200933, SN: 11-011988-ah-4868. It contains an Eckert and Ziegler Pm-147 source, SN: AH-4968. It has an assay date of 4/15/16, 1000 mCi. It currently contains approximately 250 mCi.

"No exposures of any individuals are suspected. The manufacturer was notified and is currently coordinating with the licensee to get a service engineer on site. The department will continue to follow-up with the licensee as arrangements are made."

Wisconsin Event Report ID No.: WI210006

EN Revision Imported Date: 7/23/2021

EN Revision Text: AUTOMATIC REACTOR SCRAM

"At 1826 EDT on July 21, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed due to a trip of the Main Turbine.

"Unit 1 reactor was operating at 100 percent reactor power with no evolutions in progress. The Control Room received indication of a Main Turbine trip with both divisions of RPS [Reactor Protection System] actuated and all control rods inserted. The Reactor Recirculation Pumps tripped on EOC-RPT [end of cycle recirculation pump trip]. Reactor water level lowered to +8 inches causing Level 3 (+13 inches) isolations. No ECCS [Emergency Core Cooling Systems] or RCIC [Reactor Core Isolation Cooling system] actuations occurred. The Operations crew subsequently maintained reactor water level at the normal operating band using Reactor Feed Water.

"The reactor is currently stable in Mode 3 with main condenser available. Investigation into the trip of the Main Turbine is in progress.

"The NRC Resident Inspector was notified. A voluntary notification to PEMA will be made.

"This event requires a 4 hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B)."

EN Revision Imported Date: 7/26/2021

EN Revision Text: UNANALYZED CONDITION OF FIRE SAFE SHUTDOWN EQUIPMENT

"On July 20, 2021, at 1707 EDT, an apparent non-compliance with 10 CFR 50, Appendix R, section III.G.2 (separation of redundant fire safe shutdown equipment) was identified. This issue was initially categorized as not affecting train separation or the ability of the equipment to perform their Design Basis functions. The original concern was entered into the licensee's Corrective Action Program as CR1177199.

"Subsequently, on July 22, 2021, at 1751 EDT, a further review of the affected control circuits for the Unit 1 and Unit 2 Emergency Diesel Generator (EDG) output breakers and emergency bus feeder breakers identified a concern that breaker position interlocks routed to or through non-safety related components or spaces may affect the ability to provide emergency power on the affected unit due to impacts on the control power circuits during an Appendix R fire associated with a loss of offsite power.

"The following are the affected fire areas:
- Unit 1 and Unit 2 Turbine Buildings
- Unit 1 and Unit 2 Cable Spreading Rooms
- Unit 1 and Unit 2 Normal (307) Switchgear Rooms

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). This is also reportable as a 60-day written report pursuant to 10 CFR 50.73(a)(2)(ii)(B). This event was entered into the licensee's Corrective Action Program as CR 1177399.

"The NRC Resident Inspector has been notified of this event."

EN Revision Imported Date: 7/26/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was received via E-mail:

"MaineHealth Maine Medical Center reported a leaking Cs-137 source (Eckert & Ziegler Model RV-137-200U, Serial No.: 1490-24-6) that contained an estimated activity of 5.84 MBq (157.8 microCi). The incident was discovered during a semi-annual leak test performed on 10/19/2020. Leak test results revealed 950.9 Bq (0.0257 microCi). The Cs-137 contamination was contained in the drawer the source was stored in. The assumption was made that the source was still leaking and MaineHealth sealed it in its storage lead pig. The outer surface of the lead pig was cleaned and wiped, resulting in removable contamination of less than 200 dpm. The pig was placed in a plastic bag as an extra means of containment and the bag was sealed and labeled. All other items that were contaminated or potentially contaminated in the clean-up process were also placed in a plastic bag, sealed, and labeled. The drawer was cleaned and a final wipe test confirmed that removable contamination was below 200 dpm. The staff who used the source were notified that it was considered out of service and should not be handled or used. The source remained stored in the hot laboratory pending finalization of plans for repair or disposal."

Maine Event Report ID No.: ME 20-004

EN Revision Imported Date: 7/26/2021

EN Revision Text: AGREEMENT STATE REPORT - POSSIBLE OVER-EXPOSURE TO RADIOGRAPHER

The following information was received via E-mail:

"On July 19, 2021, the licensee notified the Agency [Texas Department of State Health Services] that one of its radiographer's personal dosimetry badge results for the monitoring period of June 2021 indicated a deep dose equivalent (DDE) of 5,114 millirem. The radiographer had terminated his employment with the licensee on July 6, 2021. The licensee has contacted the radiographer by phone and the radiographer stated he did not know how it could have happened. The licensee is investigating to determine if the dose was to the radiographer or to the badge only. The licensee also reported that the radiographer had more than one day of work and that the dose to this badge did not occur all within a 24 hour period. An investigation into this event is ongoing."

Texas Incident No.: 9870

EN Revision Imported Date: 7/26/2021

EN Revision Text: TEMPORARY LOSS OF CONTROL OF RADIOGRAPHY EXPOSURE DEVICE

The following is a synopsis of information received via e-mail:

The Mistras Director of Radiation Safety was notified by a Mistras radiographer (working in Prudhoe Bay, Alaska) that an exposure device had been left unsecured in a truck in an ammo can with no lock and without the alarm set. The truck had then been turned in to the Tarmac shop for maintenance.

The Tarmac shop discovered the device in the truck around 0200 AST. Upon discovery of the device, they immediately closed the truck and notified security. They did not handle the device.

The device was retrieved by approved Mistras personnel and placed into the vault at MCC Camp. After being notified of the event, the Director personally verified that the exposure device was secured in the vault. The exposure device involved is Serial Number: D10742, containing 81 Curies of Ir-192.

The location of the event in Prudhoe Bay is a secured location with no access to or from the camp without proper security clearance. The Tarmac shop services all vehicles on the North Slope as they are owned by a Mistras customer.

OFFSITE NOTIFICATION DUE TO FISH KILL

"At approximately 1040 CDT, July 23, 2021, the Minnesota State Duty Officer was notified by Xcel Energy Environmental Services of a fish kill in the Prairie Island Nuclear Generating Plant discharge canal. The fish kill resulted from a change in temperature due to the loss of power to the plant cooling tower pumps. The cause of the power loss is under investigation.

"This notification is being made as a four-hour, non-emergency notification in accordance with 10 CFR 50.72(b)(2)(xi).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

SURVEILLENCE FREQUENCY EXCEEDED FOR ICE CONDENSER TEMPERATURE

"At 1238 EDT on July 25, 2021, the Unit 2 Ice Bed became INOPERABLE due to SR [Surveillance Requirement] 3.6.12.1 exceeding its surveillance interval. LCO [Limiting Condition for Operation] 3.6.12 was declared not met as required by SR 3.0.1.

"SR 3.6.12.1 to verify maximum ice bed temperature is less than or equal to 27 degrees F could not be completed due to a failed temperature recorder. The results of the backup method of temperature verification were verified satisfactory at 1258 EDT and the LCO condition was then exited.

"The ice bed is a single train system which functions to control radiation release and mitigate the consequences of an accident by scrubbing radioactive iodine and providing a heat sink to limit containment pressure within design limits, therefore the requirements of 10 CFR 50.72 (b) (3) (v) (C) and (D) were met.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."