Event Notification Report for May 04, 2021

This material event contains a "Less than Cat 3" level of radioactive material.

EN Revision Imported Date: 5/4/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN RADIOLOGICAL DEVICE

The following was received via email from the State of Georgia.

"[The licensee] called and reported a gauge stolen off the back of one of their work trucks on April 22, 2021. The technician responsible for the gauge was working on the Augusta Airport project. The gauge was left locked and chained in the back of his truck in the motel parking lot overnight. The technician last saw the gauge at 1900 EDT on April 21, 2021. When [the technician] went to the truck [on April 22, 2021] the chain and lock had been cut and the gauge removed. The local Sheriff has been informed and the case number is 21-112409. This has been assigned and more information is forthcoming.

Troxler Model Number: 3400
Serial Number: 22667
Activity: Cs-137 (10mCi); Am-241/Be (40 mCi)

Georgia Radioactive Materials Program NMED Report Incident # 40


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: 5/4/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following is a summary of an email received the State of Washington:

The licensee reported a medical event involving an underdose administration of Y-90 Theraspheres on April 16, 2021. The event resulted in an underdose to the liver. Two vials of Y-90 were to be delivered to two different locations in the liver, however surveys after injection of both vials revealed not all activity in vials made it into the patient. The planned activity for each dose was 0.79 GBq. Post treatment measurement of percent dose delivered for dose `A' and dose `B' was 60 percent and 76 percent, respectively. Gamma camera imagining confirmed no Y-90 Theraspheres in the dose-vial. However, imaging visualized activity retained in the delivery tubing. Routine post-imaging demonstrated microsphere distribution in liver segments 4A and 4B. The activity delivered was 0.465 GBq and 0.594 GBq, respectively.

Washington State Incident Number WA-21-008.

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: 5/4/2021

EN Revision Text: OFFSITE NOTIFICATION

"At approximately 1822 EDT on April 26th, the New Hanover County Deputy Fire Marshal was notified that the outer fire doors on the first and third floor of the Dry Conversion Process (DCP) elevator shaft malfunctioned and were left in the open position to allow for the elevator repair contractor to observe the issue. The DCP elevator is located on the South wall of DCP which is a credited fire barrier. A fire watch was initiated and maintained until the elevator doors were restored to service at approximately 1330 EDT on April 27th. The New Hanover County Fire Marshal was notified at 1410 EDT that the doors were returned to operational status and that the fire watch had been terminated. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

NRC Region 2 and the North Carolina Radiation Protection Office will be notified of this event.

EN Revision Imported Date: 5/4/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE

The following information was received from the Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee that a portable gauge was stolen. A technician locked a portable gauge in the back of a truck and the truck was locked inside the users garage at their home overnight. When the gauge user came out to go to work the next day, the chain had been cut and the gauge and the gauge transport box were missing. The gauge is a Troxler 3430, Serial Number 34160, containing approximately 8 millicuries of Cesium-137 and 40 millicuries of Americium-241:Beryllium. A police report has been filed. The Department has requested additional information and continues to investigate the event."

Arizona Incident No.: 21-004

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: 5/4/2021

EN Revision Text: CONCURRENT REPORT - IMMEDIATE REPORT TO THE TEXAS DEPARTMENT OF STATE HEALTH SERVICES

"Low level waste shipment bound for WCS [(Waste Control Specialists)], Andrews, Texas was involved in a minor traffic accident. The trailer sustained light damage to the rear of the trailer. No damage to the shipment contents was identified during visual inspection. Driver was released by the officer working the accident. Accident occurred near Dallas, Texas. The licensee notified the NRC Resident Inspector."

EN Revision Imported Date: 5/4/2021

EN Revision Text: PART 21 - FAILURE OF SIZE 1 AND 2 FREEDOM SERIES FULL VOLTAGE REVERSING STARTERS

The following is a summary of information received from Paragon Energy Solutions:

On 3/29/2021, Dominion - North Anna Station has identified instances where size 1 and 2 starters have failed to function as expected in assemblies that were originally supplied by Nuclear Logistics LLC (NLI). The mechanical interlock exhibited binding that prevented the contactor from closing when energized. The identified failed starters are utilized in an application of operating Motor Operated Valves (MOV). This is an intermittent duty application.

The issue was identified on Eaton Starter Model AN56DN*, AN56GN*, CN55DN*, CN55GN* style starters and contactors with supplied date codes T4514 (week 45 of year 2014) and T4215 (week 42 of year 2015). Paragon is in the process of identifying the date codes to provide the specific information to the identified plants.

The following plants were supplied starters from September 2014 through October 2018: Beaver Valley, Columbia, Ergytech, Harris, Millstone, NEK KRSKO, North Anna, Prairie Island.

The component design that exhibited the failure was revised by the original equipment manufacturer (Eaton) in October 2018. There have been no reported failures of the interlock mechanism in vintages manufactured before September 2014 or after October 2018.

These recommendations are based on the specific application: The reversing starters and reversing contactors are typically wired in a configuration that will electrically lock out one of the contactors when the other one is being energized to prevent both contactors from being energized at the same time. Therefore, the mechanical interlock is not required to prevent both contactors from being closed at the same time when the electrical interlock configuration is being implemented. In this scenario, the mechanical interlocks are not required and can be removed.

The motor control centers that contain the mechanical interlock should be monitored to ensure that there is no binding during operation.

The evaluation being performed by Paragon is expected to be completed by May 29, 2021.

Tracy Bolt
Chief Nuclear Officer, CNO
817-284-0077
Paragon Energy Solutions, LLC
7410 Pebble Drive
Ft. Worth, TX 76118

* * * UPDATE ON AT 1559 EDT ON 5/3/2021 FROM TRACY BOLT TO BRIAN LIN * * *
The following revision was received from Paragon Energy Solutions via email and corrects the identified date code and includes the size and serial number of the starter that failed:

The issue was identified on supplied Size 1, 73262-025-00028 (Date Code: T4515 - 45th week of 2015) and Size 2, 73262-028-00001 (Date Code: T4215 - 42nd week of 2015).

Notified R1DO (Young), R2DO (Miller), R3DO (Orlikowski), R4DO (Deese), NMSS Events Notification, and Part 21 Group via email.

UNANALYZED CONDITION
"At 0930 EDT on 5/3/2021, it was determined that during entries into the Fermi 2 Reactor Building Steam Tunnel (RBST) on 4/17/2021, 4/18/2021, and 4/21/2021 that the door was not controlled according to site procedures. The RBST door is credited as a hazard barrier for various high-energy line break (HELB) scenarios. On the identified dates, the RBST door was left open for brief periods during maintenance related activities in the RBST. This condition is not bounded by existing analyses as the door is assumed to be closed throughout a HELB event. The time period that the door was open was less than one hour in each case, as stay times in the room are inherently limited by industrial and radiological conditions. Individuals remained in the area to close the door if needed, but existing analyses do not address the ability to perform those actions under all HELB scenarios.

"There is no impact to the health and safety of the public or plant personnel as the door is currently closed and latched and access into the area has been restricted to normal ingress and egress per site procedures, which ensures consistency with existing analyses. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). Investigation into the cause is ongoing. Preliminary review of the extent of this condition identified entries into the RBST on other occasions during the past three years where the conditions may also have not been bounded by existing analyses. The additional occasions where the door may have been held open were on 9/22/2018 (MODE 3), 10/26/2018 (MODE 1 ), 11/2/2018 (MODE 1), and 3/21/2020 (MODE 3). Each of these instances was also less than one hour with the exception of the occurrence beginning on 10/26/2018 which lasted approximately 10 hours to support packing leak repairs on a HPCI [High Pressure Coolant Injection] Outboard Isolation Valve."

The licensee notified the NRC Resident Inspector.