Event Notification Report for February 10, 2023

EN Revision Imported Date: 2/10/2023

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was provided via email:

"On July 12, 2022, the licensee notified the Agency that around 1230 CDT, a Humboldt 5001EZ Moisture Density Gauge containing a 40 milliCurie Americium-241 source and a 10 milliCurie Cesium-137 source was stolen out of the back of a company truck. The licensee reported that the technician returned to the site office, he unlocked the moisture density gauge transit case. He then got distracted and went into the office. When he went back outside the case was still chained to the truck but when he opened the case the gauge was missing. The gauge was unlocked. LLE [Local Law Enforcement] was notified. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: 9939

* * * UPDATE ON 2/9/23 AT 0946 EST FROM TEXAS DEPT OF STATE HEALTH SERVICES (THE AGENCY) TO KAREN COTTON * * *

"On July 12, 2022, the licensee notified the Agency that a Humboldt 5001EZ moisture density gauge, serial number 3716, was stolen out of the transport case in the back of a pickup at the licensee's site office. The gauge contained an 10 millicurie cesium-137 source and a 40 millicurie americium-241/beryllium source. The technician had unlocked the transport case, got distracted and went into the office. When he came back outside the gauge was no longer in the case. The investigation was completed on August 17, 2022, and two violations were cited. On February 2, 2023, the Agency was notified by the NRC that a Moisture Density Gauge was posted for sale on eBay. The Agency contacted the seller and determined that it was the stolen gauge and the licensee retrieved the gauge on February 8, 2023. The seller found the gauge in a dumpster behind a retail store. The gauge was inspected and a leak test was conducted. The gauge operates properly."

Notified R4DO (Gaddy), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email.

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

AGREEMENT STATE REPORT - LOST SOURCE

The following information was received from the Minnesota Department [the Department] of Health via email:

"The Department was notified on January 13, 2023, of a lost 1.59 GBq (43 mCi) W-181 [tungsten-181] source in a Check-Cap C-scan colorectal cancer screening device. The Check-Cap C-scan was administered to a patient with the expectation the patient would recover the device at home when it exited the body. The device was not recovered and instead flushed down the toilet at the patient's residence."

Minnesota Event Number: MN230001

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

AGREEMENT STATE REPORT - STOLEN GAUGE

The following report was received via email from the Texas Department of State Health Services [the Agency]:

"On February 3, 2023, the licensee notified the Agency of a stolen moisture density gauge. The gauge was left chained to the back of a truck at a [Borger, TX] hotel overnight. At around 0700 CST, the technician found the chains cut. The incident was reported to the local police department [and the State and local emergency management coordinators]. The licensee reported that the gauge was in the safe position within a Type A Package which had both sides of the package locked. The licensee reported that the gauge is a CPN-MC1-DR model that contains 50 millicuries of americium-241 and 10 millicuries of cesium-137. The serial [number] for the gauge and the two sources was reported to be MD40301932. Further information will be provided per SA-300 when obtained."

Texas Incident No: I-9985
Texas NMED No.: TX230003

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

AGREEMENT STATE REPORT - SEALED SOURCE GAUGES INVOLVED IN A FIRE

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

"The Agency was contacted on February 3, 2023, by Jiva Resources in Sauget, IL to advise that five Cs-137 gauges had been impacted by a fire in September 2022. A Jiva Resources representative called and initially reported the five radioactive gauges as stolen 'in the last week.' When Agency staff returned his call that same morning, the devices had been located but were identified as having been involved in a fire back in September 2022. While the container (sealed drum) holding the gauges was impacted by the fire, it is unclear if there was any impact to the gauges. The devices include two Ohmart model SH-F1 gauges (serial numbers 2879GK and 1652GK) and three Vega model SR-A gauges (serial numbers 2174GK, 2878GK, and 63008). All contain 20 millicuries of Cs-137 except for serial number 63008 which contains 30 millicuries of Cs-137. It should be noted the SH-F1 housings are identified in the Sealed Source and Device Registry as being fireproof (rated above 800 degrees Celsius for 30 minutes) while the SR-A housings are lead-filled cylindrical steel shells, which are noted for retaining the source should the lead shielding melt out. Exposure rates should be less than 5 mR/hr at one foot - which will be confirmed by Agency staff. Leak tests will be conducted and source security assessed. Additional regulatory requirements regarding proper disposal, storage, leak testing and reporting will be investigated as well."

* * * UPDATE ON 02/06/2023 AT 1248 EST FROM GARY FORSEE TO LLOYD DESOTELL * * *

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

"Agency staff attempted to perform a reactionary inspection the morning of February 6, 2023, to inspect the condition of the five radioactive gauges identified above. This effort confirmed that the registrant did in fact lose accountability of the gauges as it appears they were stolen at some point in the last four months. The last known location was in Sauget, IL in September 2022 when that storage location was involved in a fire. Since that time, the building has reportedly been accessible to looters. Local scrap yards and public safety partners will be notified."

Illinois Incident Number: IL230002

Notified: R3DO (Szwarc) and NMSS Events Notification, ILTAB via email.

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

NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE

The following information was provided by the licensee via telephone:

On February 1, 2023, a clinical dose of radium (Ra-223) dichloride (146 microcuries) was delivered by courier to the hospital hot lab. At approximately 1400 CST on February 2, 2023, a technician identified that the dose was missing while attempting to retrieve it in preparation to administer it to a patient.

The licensee performed a search for the missing dose and suspects that the package with the dose was thrown away during cleanup of the hot lab on the afternoon of February 1, 2023.

The licensee stated that they did not believe that an exposure to a member of the public would result from the dose because Ra-223 is an alpha emitter with a very low gamma yield. In addition, the radioisotope was enclosed in a syringe and external packaging.

The Radiation Safety Officer is still investigating the events of the lost medical isotope.

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

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ACTUATION OF AUXILIARY FEEDWATER PUMP

The following information was provided by the licensee via email:

"This 60-day optional telephone notification is being made in lieu of a Licensee Event Report as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to 10 CFR 50.73(a)(2)(iv)(A) for an invalid system actuation.

"On January 1, 2023, at approximately 0604 EST, static inverter KXA failed causing a loss of power to shared 120-VAC auxiliary control panel board KXA. Operations entered the appropriate procedures to assist in diagnosing and responding to the event. As expected, the solenoid valves in the instrument lines to steam supply valves 1SA-48ABC and 1SA-49AB deenergized, causing 1SA-48ABC and 1SA-49AB to open and admit steam to the unit 1 turbine driven auxiliary feedwater pump (TDAFWP). Operations reduced turbine load to maintain reactor power less than 100 percent. At approximately 0641 EST, power was restored to the KXA panelboard and the TDAFWP was secured. All systems functioned as required.

"Actuation of the TDAFWP was not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system nor was the actuation due to an intentional manual initiation. Therefore, this actuation is considered an invalid actuation. The NRC Resident Inspector has been notified."

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via fax:

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

The NRC Resident Inspector has been notified.

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ACTUATION OF EMERGENCY DIESEL GENERATOR (EDG)

The following information was provided by the licensee via email:

"This 60-day optional telephone notification is being made in lieu of an LER [Licensee Event Report] submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). At approximately 0637 EST on December 25, 2022, the 2B EDG inadvertently started and ran unloaded without a valid undervoltage or safety injection actuation signal. It was determined that this condition was caused by the failure of the emergency start button due to age-related degradation. The button is normally held depressed (closed) by the glass enclosure in standby. To start the EDG using the Emergency Start Button, the button is released (open) when the glass enclosure is broken, which sends a start signal to the EDG. During troubleshooting, the resistance across the button contacts was measured at zero volts DC, indicating the button had failed to an open state causing the EDG to start. The button fell apart when the glass enclosure was removed. The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the emergency diesel generator."

The NRC Resident Inspector has been notified.