Event Notification Report for May 31, 2022

EN Revision Imported Date: 5/31/2022

EN Revision Text: AGREEMENT STATE REPORT - DISCOVERED FIXED GAUGE

The following information was received from the Oklahoma Department of Environmental Quality (DEQ) via email:

"On 5/17/2022, the state of Arkansas notified Oklahoma DEQ's Radiation Management Section that a DOT [(Department of Transportation)] Special Permit 10656 had been issued for a trailer that originated in Sallisaw, Oklahoma. The load was surveyed at the scrap metal facility in Arkansas and sent back to Oklahoma. It arrived back to Sallisaw today and was surveyed by the owner of the salvage yard. The owner of the salvage yard found a Thermo Measure Tech Model 5201 fixed gauge containing 50 mCi of Cs-137, serial number R4473. The source housing appears to be intact. When the gauge was removed from the trailer no additional radiation was measured on the trailer. The facility owner was instructed to isolate and secure the gauge. The owner stated that he would place it in a drum and lock it in a concrete shed."

DOT Approval Number: AR-OK-22-007

* * * UPDATE ON 05/27/2022 AT 1023 EDT FROM LIBBY MCCASKILL TO OSSY FONT * * *

The following information was provided by the DEQ via email:

"The manufacturer of the gauge provided [DEQ] with the name of the company that purchased the gauge; they are still a valid company based out of New Jersey. [DEQ] has contacted them and are waiting for a response.

"[DEQ] searched NMED [(Nuclear Material Events Database)] but did not find any reported loss or theft of this gauge.

"Source: CM-3539; Serial: B4473 [(different than previously reported)]; Model: 5201; Isotope: Cs-137; Activity: 50; Units: mCi; Tag Activity: 50; Tag Assay: 10/16/2003; Capsule: 696984; Customer: EXCAVATING MATERIALS & EQUIPMENT; Order: 275976; PO#: DG-111505; License #: L03524; Ship date: 2/9/2006"

Notified R4DO (Pick) and NMSS Events Notification via email.

* * * UPDATE ON 05/27/2022 AT 2318 EDT FROM MIKE BRODERICK TO BRIAN SMITH * * *

The following information was provided by the DEQ via email:

"Using the manufacturer-provided information, we found that the gauge had been transferred to Illinois. The Illinois Agreement State program found that it had been sold to Mid America Dredging in Good Hope, IL. The state of Illinois is following up with their registrant and presumably will report on events. Oklahoma DEQ will assist as needed."

Notified R3DO (Lafranzo), R4DO (Pick), and NMSS Events Notification via email.

EN Revision Imported Date: 5/26/2022

EN Revision Text: AGREEMENT STATE REPORT - TARGET TISSUE MISSED

The following was received from the Pennsylvania Department of Environmental Protection (the Department) via email:

"On May 19, 2022, the licensee informed the Department of an incident involving Cobalt 60 in a Leksell (R) Gamma Knife Perfexion. It is reportable as per 10 CFR 35.3045(a)(1).

"On May 18, 2022, a patient underwent treatment of four lesions in the brain. Upon review of the treatment, the physicist noticed that all four lesions were missed by approximately 0.5 centimeters and healthy brain tissue was treated. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.

"The Department will perform a reactive inspection. More information will be provided as received."

Event Report ID No: PA220018

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 05/25/2022 AT 0949 EDT FROM JOHN CHIPPO TO OSSY FONT * * *

The following updated was received from the Department via email:

"The patient had MRIs and CT Scans. Those images were fused by the neurosurgeon and radiation oncologist. Upon completion of the treatment, they discovered that although the targets were moved with the second image fusion, the shots and contours were not. This resulted in the treatment being 0.5 cm off for all 4 targets. Prescribed dose was 20 to 21 Gy, delivered dose to target tissue was 8 to 15 Gy, maximum dose to healthy tissue is estimated to range from 21.82 to 27.09 Gy. More information is expected once the licensee completes their investigation."

Notified R1DO (Eve) and NMSS Events Notification via email.

EN Revision Imported Date: 5/25/2022

EN Revision Text: EXTERNAL FIRE

The following information was provided by the Illinois Emergency Management Agency (Agency) via email:

"The Agency was contacted on the morning of May 24, 2022, to advise that a fire had occurred at approximately 1900 CDT on Sunday, May 22, 2022, at a Renewable Energy Group, LLC. Renewable Energy Group, LLC (Facility) is a biodiesel refinery located in Seneca, IL.

"The fire reportedly impacted two Vega model SHLD-1 generally licensed devices containing 10 millicuries of Cs-137 each. Serial numbers are unknown at this time and the registrant has not been able to make any radiation measurements or leak tests. It is noteworthy, the sealed source device registry sheet indicates the manufacturer subjected these devices to the 'Accident Condition Fire Test' in ANSI N43.8-2008. The resultant accident condition indicates it would not lose shielding when subjected to 538 degrees Celsius (1000 degrees Fahrenheit) for five minutes. Regardless, Agency staff have been dispatched to determine the status of shielding, potential contamination and source security.

"The facility representatives have been advised to contact the manufacturer or a licensed service provider to have the gauges removed and properly packaged for service/disposal. Provided the device is not moved from its current mounting, the pipe (with the device attached) may be relocated to facilitate source security. Facility representatives advised there is no safety concern at the remaining structure. The licensee was required to report within 24 hours, but missed the reporting deadline. Updates will be provided as they become available."

IL Reference Number: IL220016

* * * UPDATE ON 5/24/22 AT 1605 EDT FROM GARY FORSEE TO KAREN COTTON * * *

The following update was provided by the Illinois Emergency Management Agency via email:

"Details: Two Vega Americas Inc., model SHLD1 fixed gauges were confirmed to have been impacted by fire. Serial number A-T604 did not appear to have its integrity compromised. Serial number A-T509 exhibited an exposure rate of approximately 350 - 400 mR/hour near contact. Large area wipes showed no indication of contamination. An exclusion zone was established at approximately 4 feet in diameter and six feet above the damaged gauge. (The second floor was far enough as to not warrant exposure concerns). In order to prevent public exposures, it was determined the gauges should be isolated. Consistent with the sealed source device registry, both devices will remain mounted to their pipes - and the pipe/gauge assembly will be moved to a secure location. The devices were bagged to prevent the spread of any contamination that could not be detected by large area wipes. Serial number A-T509 will be inverted to direct the unshielded beam into the ground. Inspectors are overseeing the work and will verify the gauges are locked and access restricted until appropriately licensed personnel can dismount and properly package the devices for disposal.

"Safety Analysis: No evidence of removable contamination. Exposure rates were elevated, but no personnel had been exposed. Pending placement of the devices into secure storage in an orientation that will shield the source, the Agency does not anticipate any exposures in excess of regulatory limits.

"Reportability: Device A-T509 met the reportable criteria in 32 Ill. Adm. Code 340.1220(c)(4). The incident was reported to the [(NRC Headquarters Operations Officer)] HOO at 1209 CST today under event number 55912. A written report is due from Renewable Energy Group, LLC within 30 days that details suspected root cause and corrective action. The [(Nuclear Material Events Database)] NMED report will be updated and electronically transmitted to [(Idaho National Laboratory)] INL."

AGREEMENT STATE REPORT - SOURCE HOLDER AFFECTED BY MOLTEN METAL

The following was received from Tennessee Division of Radiological Health via email:

"On May 22, 2022 at 1048 [CDT], molten metal came into contact with the source holder. Damage occurred to the lifting ears of the gauge. The source was not affected by the event. The source and holder are locked away with other gauges with the shutter in the closed position. No elevated readings were detected after the event. NuCor Steel is going to contract with Radiometrix in Ohio to transfer the source to a new gauge. The following is the technical information on the gauge:

"Manufacturer: Berthold; Model: LB 300 MLT; Gauge SN: 45132-004-10003; Isotope: Co-60, 3.405 mCi; Source SN: 1344-08-09; Source Model: Berthold P 2608-100

"Any corrective actions will be updated with a report within 30 days."

State Event Report ID Number: TN-22-037

SPURIOUS SIREN ACTUATION

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

"On May 26, 2022, at 0753 CDT, the Grand Gulf Nuclear Station was notified of a spurious actuation of a single Alert Notification System siren in Tensas Parish, Louisiana. The actuation occurred during siren testing conducted at approximately 0630 CDT - no emergency conditions are present at Grand Gulf Nuclear Station.

"A press release from Entergy is not planned at this time.

"This condition is reportable under 10 CFR 50.72(b)(2)(xi) as a notification of an offsite government agency.

"The NRC Senior Resident Inspector has been notified."

OFFSITE NOTIFICATION FOR INADVERTENT DISCHARGE OF HALON

The following information was provided by the licensee via email:

"On 5/25/2022 at 1354 [CDT], during the replacement of two detectors, a halon actuation occurred which resulted in an unintentional release of approximately 384 pounds of halon gas into an enclosed room in the Unit 1 Electrical Auxiliary Building. There was no impact to plant operations or plant personnel. The room was verified by station Safety Personnel to be safe for normal access.

"On 5/27/2022 at 2038 [CDT], Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of an event which met the requirements of "Emission Event" for the TCEQ of a halon release that exceeded the reportable quantity threshold of 100 pounds in a 24 hour period. The halon discharge was contained within the site protected area. Therefore, this event is not significant with respect to the health and safety of the public.

"The licensee has notified the NRC Resident Inspector."