Event Notification Report for October 25, 2021

EN Revision Imported Date: 10/25/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST AND RECOVERED MINING GAUGE

The following was received from the Oregon Health Authority, Radiation Protective Services (Oregon RPS) via email:

"On October 8, 2021, during a low-level radioactive waste (LLRW) broker's visit to an Oregon scrap metal site to package and ship accumulated radioactive materials to a LLRW site, a fixed gauge was found among the items in storage. The technician notified the broker's office of the discovery and the broker notified Oregon RPS on October 11, 2021 at 1120 [PDT] hours. The gauge shows some wear with the gauge shutter lever broken but the shutter appears intact and closed with the source inside. Information on the gauge/source is as follows:

Manufacturer: Ohmart
Model 3340
Serial number: 70453

Source: Cs-137
Activity: 50 mCi
Source holder: SR-1A
Source manu: 3M
Source model: 4F6S
Source serial: S-601

Highest dose rate at contact: 70 mrem/hour (at collimated end)
Highest dose rate at 1 ft: 18 mrem/hour
Highest dose rate at 1 m: 2 mrem/hour

"The gauge was placed shutter-side down in a secured metal storage vault on site. Dose rate on the surface of the gauge measured at less than 2 mrem/hour. The licensee is in contact with the manufacturer to arrange disposal of the gauge.

"The gauge was originally installed in 1981 at a silver mining mill located south of Ely, NV. There were four additional gauges installed at the Nevada site at that time. RPS has contacted the Nevada Agreement State Radiation Control office and that office is investigating."

Oregon State Event Report No: OR-21-0051

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: 10/25/2021

EN Revision Text: AGREEMENT STATE - LOST I-125 RADIOACTIVE SEED

The following was received from the Iowa Department of Public Health (IDPH) via email:

"On October 5, 2021, the University of Iowa's radiation safety officer [RSO] contacted the Iowa Department of Public Health (IDPH) regarding a lost Iodine-125 (I-125) seed used for a localization of non-palpable lesion in breast tissue. The excised specimen containing two I-125 seeds had been received in pathology at 1704 CDT on 10/4/2021. The specimen was removed from container, surveyed with a Geiger counter, and imaged in the PathVision Faxitron by prosector. The radioactive seed localization (RSL) tracking sheet that came with the specimen from surgery indicated that two seeds were removed and two radioactive seeds were identified with associated biopsy clips via Faxitron imaging. The specimen was taken from the Faxitron to Grossing Workstation #3 and triaged by pathology staff. Triaging included weighing, measuring, and inking. Two cuts were made, one cut per biopsy site, in order to facilitate specimen fixation and to meet cold ischemia time requirement of one hour. A fixing tin was filled with formalin and the specimen was transferred to the fixing tin and appropriately labeled. Sharps waste were deposited in the sharps container at Grossing Workstation #3. Disposable materials used during triaging (absorbent pads, ink applicators, weigh boat, paper towels, gauze, and gloves) were deposited in the red biohazard waste at Grossing Workstation #3. Original specimen container and fixing tin were placed on the radioactive storage shelves by the Faxitron for overnight storage. Sometime between 1900 CDT 10/4/21 and 0700 CDT 10/5/21, housekeeping staff came in and collected trash and cleaned the floors. Laundry was collected between 0730 and 0800 CDT on 10/5/21.

"At 1100 CDT on 10/5/21, pathology staff brought the specimen to Grossing Workstation #5. They removed the specimen from the fixing tin, made multiple cuts into the specimen, laid out the slices on a Faxitron specimen tray, and attempted to image the specimen. The Faxitron malfunctioned and was not able to be brought to working order. Staff then laid out the specimen slices on the photo stand to take a photograph for a section diagram (instead of a Faxitron image for a section diagram). The photo was taken and the specimen was returned to Grossing Workstation #3. Photo stand was cleaned and waste from cleaning the photo stand was deposited in red biohazard trash at Grossing Workstation #5. A centrally located radioactive seed (seed #1) and associated biopsy clip were identified and removed from the specimen. Seed #1 was placed in a mesh bag and placed in a lead vial. The specimen at site of Seed #2 was then serially sectioned in an attempt to locate Seed #2 and its associated biopsy clip. The biopsy clip associated with seed #2 was found, but seed #2 was not found. The adjacent tissue was examined as well and without finding seed #2, the Geiger counter was then utilized to localize the second radioactive seed. The Geiger counter had no reading above background, indicating no seed present. Seed #1 was removed from the lead vial and scanned with the Geiger counter and had a reading of 5 mR/hr.

"Four lab staff immediately began looking for the radioactive seed, both visually and with the Geiger counter. They checked clothing and shoes of any staff who had been around the specimen. They checked the original specimen container as well as the fixing tin. Workstations #3 and #5 were thoroughly checked and re-checked, including trash cans, work surfaces, shelves, materials on shelves, drawers, sharps containers, sinks, floors, and associated carts. The walkway between workstations #3 and #5 and the Faxitron and photo stand were checked, as well as the floor and any trashcans along the way. Additionally, the Faxitron chamber table were checked as well as the associated shelf, floor and trash can.

"When Seed #2 could not be found by the lab staff, the pathology supervisor contacted the RSO as well as Nuclear Medicine to notify them of a missing radioactive seed. RSO called and discussed what occurred with the pathology supervisor and sent two members of the Radiation Safety section of University's Environmental Health & Safety, who surveyed the same areas as the lab staff had scanned, as well as the changing room and the area of the laundry hamper, but were unable to locate Seed #2.

"On October 6, the RSO surveyed all of the waste containers and bags that were in the [University of Iowa Health Care] (UIHC) biohazard waste storage room at UIHC. This consisted of three large containers and one very large container, containing dozens of biohazard waste bags in total. It could not be confirmed whether or not it was likely that the bag removed from surgical pathology between 1900 CDT on 10/4/21 and 0700 CDT on 10/5/21 would have still been in the waste storage area. The RSO did not note any readings above background on the survey meter used to do the survey, and given the potentially hazardous nature of the contents, did not pursue a closer examination of the biohazardous waste. Due to the large search and survey response from pathology, nuclear medicine, environmental health & safety, and RSO, it was determined that there is a high probability the seed was wrapped up in absorbent materials used in the triage process and placed into a biohazard waste bin and removed from the department overnight."

Iowa Event Number: IA210004

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: 10/26/2021

EN Revision Text: AGREEMENT STATE REPORT - FOUND GAUGE

The following summary was received via e-mail from the Oklahoma Department of Radiation Management [the department]:

On October 18, 2021 at 13:00 CDT, the licensee contacted the department to inform them that they had discovered a density gauge Model RLL 1, Sn 209689a, Cs-137 source, 0.9 millicuries as manufactured, in an incoming load of scrap. The date of manufacture was June 2008 and does not appear to be designed to have a shutter. Contact, no shutter, open side readings were 33 mR/hour while closed side readings at 3 feet were less than 1 mR/hour. The gauge had gotten past gate monitors but triggered an alarm on the conveyer belt. The licensee contacted the vendor who told them that the gauge was sold as a general license in Texas to be used for level detection on a dredge. The gauge is currently being held in a drum onsite under lock and key.

EN Revision Imported Date: 10/25/2021

EN Revision Text: VALID SPECIFIED SYSTEM ACTUATIONS OF UNIT 1 AND UNIT 3 EMERGENCY DIESEL GENERATORS

"At 1446 MST on October 20, 2021, a start-up transformer de-energized, resulting in a loss of power to the Unit 1 Train B 4.16 kV Class 1E Bus and the Unit 3 Train A 4.16 kV Class 1E Bus. The Unit 1 Train B Emergency Diesel Generator (EDG) and Unit 3 Train A EDG automatically started and energized their respective 4.16 kV Class 1E Buses.

"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 emergency AC electrical power systems.

"All systems operated as expected. Per the Emergency Plan, no classification was required due to the event. Units 1 and 3 both remain in Mode 1 at 100 percent power. Unit 2 is currently in a refueling outage and defueled. The 4.16 kV Class 1E Buses in Unit 2 were not affected by the de-energization of the start-up transformer since it was not aligned as normal power for Unit 2.

"The cause of the start-up transformer being de-energized is under investigation.

"The NRC Resident Inspectors have been informed."

EN Revision Imported Date: 10/25/2021

EN Revision Text: FITNESS-FOR-DUTY REPORT

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified."

EN Revision Imported Date: 10/25/2021

EN Revision Text: FITNESS-FOR-DUTY VIOLATION DUE TO DISCOVERY OF ALCOHOL IN THE PROTECTED AREA

"Plant cafeteria workers discovered that four gallons of cooking wine were included in a delivery to their inventory within the plant protected area. Security took possession of the sealed unopened containers and removed the alcohol from the protected area.

"The NRC Senior Resident Inspector has been informed."

EN Revision Imported Date: 10/25/2021

EN Revision Text: REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED

"At 0104 EDT on October 22, 2021, during the Beaver Valley Power Station, Unit 2 refueling outage, while performing examinations of the 66 reactor vessel head penetrations, it was determined that two penetrations could not be dispositioned as acceptable per ASME Code Section XI. Penetrations 28 and 40 will require repair prior to returning the vessel head to service. The indications were not through wall and there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. The examinations were being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D) and ASME Code Case N-729-6 to find potential flaws/indications before they grow to a size that could potentially jeopardize the structural integrity of the reactor vessel head pressure boundary. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

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

EN Revision Imported Date: 10/26/2021

EN Revision Text: SAFETY SYSTEM ACTUATION

"At 1804 CDT on 8/29/2021, Waterford 3 Steam Electric Station (WF3) experienced a Loss of Off Site Power event due to Hurricane Ida (See EN #55435). This event caused an automatic actuation of Emergency Diesel Generators Trains A and B. Both Emergency Diesel Generators started as designed and both are currently operating normally supplying power to their respective Class 1E Safety Busses. This automatic actuation is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A). Prior to the loss of offsite power, WF3 was in progress of performing a plant cooldown in accordance with procedural guidance. As part of this cooldown and after entering Mode 4, all Safety Injection Tanks were isolated. As a result of losing offsite power, Reactor Coolant System Temperature increased above 350F which is above the temperature requirements for Mode 4. Safety Injection Tanks are required to be unisolated and OPERABLE in Mode 3. Therefore, with no Safety Injection Tanks OPERABLE, this constituted an event or condition that could have prevented the fulfillment of a safety function and the unit entered Technical Specification 3.0.3. The unit was in Technical Specification 3.0.3 for approximately 43 minutes from 1805 CDT until 1848 CDT when Mode 4 conditions were re-established. This event or condition that could have prevented the fulfillment of a Safety Function is reportable in accordance with 10 CFR 50.72(b)(3)(v)(D).

"While continuing to perform the Reactor Coolant System Cooldown and prior to placing Shutdown Cooling Train in service, it became necessary to start one train of Emergency Feedwater. Emergency Feedwater Train A was manually started at 1847 CDT to feed the Steam Generators and was secured at 1947 CDT. Emergency Feedwater Train A started and operated normally during this period. This manual actuation is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A)."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1549 EDT ON OCTOBER 25, 2021 FROM CHANTEL HATTAWAY TO BRIAN P. SMITH * * *

"The purpose of this notification is to revise Event Notification Report (EN) 55436 to include a partial retraction. On August 29, 2021, Waterford Steam Electric Station, Unit 3 (WF3) experienced a loss of offsite power (LOOP) event due to Hurricane Ida. Prior to the LOOP, WF3 had shutdown to Mode 3 (Hot Standby) in anticipation of the LOOP and was performing a plant cooldown in accordance with procedural guidance. When Mode 4 (Hot Shutdown) was achieved, all Safety Injection Tanks (SITs) were isolated as part of the plant cooldown. After the LOOP, Reactor Coolant System (RCS) temperature increased and the Core Exit Thermocouples (CETs) indicated that RCS temperature had exceeded 350 degrees F. Based on the CETs, this was above the temperature requirements for Mode 4 and, as such, WF3 declared entry into Mode 3. The SITs are required to be unisolated and Operable in Mode 3. Since no SITs were Operable at that time, it was determined that this constituted an event or condition that could have prevented the fulfillment of a safety function and included this as part of the EN 55436 report in accordance with 10 CFR 50.72(b)(3)(v)(D).

"An engineering evaluation has subsequently been performed to validate whether the RCS temperature excursion following the LOOP actually reached 350 degrees F. As defined in WF3 Technical Specification (TS) Table 1.2, Operational Mode temperatures are a function of RCS average temperature (Tavg), not just the indicated temperature of the CETs. Based on the calculated Tavg using validated temperatures, it was concluded that 350 degrees F was not reached. Thus, WF3 remained in Mode 4 following the LOOP and there was no event or condition that could have prevented the fulfillment of a safety function that was reportable pursuant to 10 CFR 50.72(b)(3)(v)(D).

"The remainder of EN 55436 remains correct and unchanged."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Pick)

EN Revision Imported Date: 10/26/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE OF I-131

The following report was received via email:

"Rhode Island Department of Health was notified on May 2, 2019 by a representative from Rhode Island Hospital of a medical event that occurred during an attempted dosing of 25 mCi of I-131. On April 17, 2019, a patient was administered a capsule of I-131, but was unable to swallow and the capsule began to break down in the patient's mouth. As this was not the prescribed use of the radiopharmaceutical, the staff of Rhode Island Hospital transferred the capsule to a cup as the capsule was breaking down. The cup was then brought to the lead-lined safe in the hospital's nuclear medicine hot lab. During the transfer some of the I-131 that had begun to leak from the capsule spilled onto the floor and contaminated it with I-131.

"The floor of the injection room that had been contaminated with I-131 underwent decontamination. Before decontamination, the maximum counts/min (cpm) per 100 cm squared was equal to approximately 151,000 cpm. After decontamination the maximum amount in any location was 11,000 cpm. Similarly, before the protective covering was laid over the contaminated parts of the floor, the maximum dose rate as read by Ludlum Model 9DP was 70 mR/hour on contact. Rhode Island Hospital's Radiation Safety Officer (RSO) attempted to clean up the spill and then laid protective material over the floor and measured that the dose rate upon contact with a Ludlum Model 9DP ion chamber did not exceed 70 microR per hour. No other persons or surfaces were deemed to be contaminated after surface wipe tests and a thyroid scan bioassay. The following day, April 18, 2019, 25 mCi of I-131 was attempted to be administered orally in liquid form which the patient failed to swallow as well. This did not result in a spill. The State is not performing any additional action at this time.

"The referring physician, patient, and patient's legal guardians were notified that the dose of I-131 was not received to the patient. No overexposure occurred. This event was discovered due to be reported during the October 2021 IMPEP review of the Rhode Island Radiation Control Agency."

Rhode Island Event Number: RI-21-0002

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.