Event Notification Report for August 14, 2023

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

The licensee reported three lost exit signs, each containing 9.21 Ci of tritium.

Colorado Event Report ID Number: CO230025

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 - REMOTE SHUTTER INDICATION FAILURE

The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:

"On August 2, 2023, Nylon Corporation of America (NYCOA) reported that a specifically-licensed fixed level gauge (Berthold, Serial No. 175-02-07) installed on the `Capro Recovery Unit' apparently failed a semi-annual detector test. The detector provides a remote indication of tank level and shutter position. In the absence of remote indication, shutter position can be noted visually. The gauge shutter is manually operated and performs as designed. Additional testing performed on August 3, 2023, verified the detector failure. NYCOA formally reported their findings to the NHRHS via email on August 3, 2023 at 1316 [EDT].

"The fixed gauge (Berthold Model LB-300L) houses a 32.9 MBq (0.89 mCi) Co-60 source assayed on January 1, 2006. The current activity is calculated as 3.3 MBq (0.088 mCi). The gauge is affixed to a tank that is suspended about 9 feet above the process room floor. The location cannot be accessed without a ladder. The surrounding area contains process piping and is not normally occupied.

"On August 4, 2023, at 0930, NHRHS inspectors arrived to perform a reactive inspection. As found, the level gauge shutter was closed and appropriately locked-out/tagged-out of service. The highest measured exposure rate was 0.327 mR/hour in contact with the gauge housing (shutter closed). At head height, below the gauge, the exposure rate was 0.010 mR/hr, which approximates normal background. A Ludlum 9DP ion chamber was utilized for these measurements.

"There is no indication of personnel overexposure.

"NYCOA stated that the Capro Recovery Unit has been offline for about five years and there are no near-term plans to bring it back online. NYCOA will investigate removal and disposal of the level gauge rather than repair the detector."

NMED Report Number: NH-23-0001

AGREEMENT STATE - STOLEN MOISTURE-DENSITY GAUGE

The following information was provided by the California Department of Public Health via email:

"On August 4, 2023, the Radiation Safety Officer for Anbessaw Consulting, Inc. contacted Los Angeles County Radiation Management to report a stolen moisture density gauge. After receiving the report, the information was forwarded to the California Department of Public Health. The gauge was a CPN International model MC-3, Serial Number M320500859 [10 mCi Cs-137 (nominal), 50 mCi Am-241:Be (nominal)].

"The gauge was stolen from a 20 foot [long] Container Express (CONEX) box stored at a fenced in and secured construction site with security guards. The gauge was placed in storage around 1700 [PDT] on August 3, 2023, and discovered to be missing around 0600-0615 on August 4, 2023. The lock on the CONEX box had been cut and the transport case containing the gauge was removed from the CONEX box. No other items were stolen from the CONEX box. The transport box was secured with a lock, and a lock was placed on the trigger of the gauge.

"After a search of the area near the CONEX box was conducted without finding the gauge, the Los Angeles Police Department was contacted, and a burglary report was filed. After the report was filed, a further search of the construction site and the area surrounding the site was made without finding the gauge or its transport case. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."



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 - MEDICAL UNDERDOSE

The following information was provided by the PA Bureau of Radiation Protection (the Department) via email:

"On August 4, 2023, the licensee, University of Pennsylvania, informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. The event is reportable per 10 CFR 35.3045(a)(1).

"On August 3, 2023, it was determined that 71.0 percent of the prescribed dose to the target tissue was delivered for the above treatment. The only information relayed to the Department so far was that there were no spills or leaks in the system. The DEP [Department of Environmental Protection] is currently in contact with the licensee and will update this event as soon as more information is provided.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

Event Report ID No: PA230021

* * * UPDATE ON 08/07/2023 AT 1207 EDT FROM JOHN CHIPPO TO ERNEST WEST * * *

"An administration of Y-90 TheraSpheres occurred with no apparent difficulties. No leaks or spills were identified, as corroborated by post administration monitoring which identified no contamination. However, when the waste was measured it was determined that less than 80 percent (72.6 percent) of the prescribed activity was administered. It is estimated that 21.18 mCi of the 29.18 mCi prescribed dose was administered. The patient and prescribing physician have been informed. No adverse effects to the patient are present nor are any anticipated."

Notified R1DO (Dimitriadis) and NMSS (Email).


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.

AGREEMENT STATE REPORT - FOUND MEDICAL SEED

The following information was provided by the Arizona Department of Health Services (The Department) via email:

"The Department was notified by the licensee that on 8/4/2023, a person walked into their facility to report a box with a radioactive material label was sitting on top of a trash can outside of their facility with their name on it. The licensee determined that the box contained (1) Isoaid I-125 seed (0.150 mCi) that had been picked up by [Common Carrier] the day before (8/3) at 4:09pm. The licensee inspected the package and determined that the package was still sealed and intact. The Department has requested additional information and continues to investigate the event."

Arizona Event No.: 23-014


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 SOURCE

The following is a synopsis of information was provided by Helmuth, LLC via phone call:

During a relocation of Helmuth to a new facility in November 2022, the static removing air nozzle was mistakenly disposed of in the municipal trash. The mistake was not noticed until a new unit was delivered to the new location.

Manufacturer: AMSTAT Industries
Model : P-2021-8101
Serial Number: A2MR173

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Activity of the nozzle is 10 mCi ( 370 MBq) of Po-210.

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 - EXTERNALLY CONTAMINATED PACKAGE

The following information was provided by the Defense Health Agency via email:

The licensee made a 10 CFR 20.1906 report of receipt of a shipment of Tc-99m with external contamination present on the "high-tech solution bag." The licensee reported this event due to contamination levels potentially exceeding regulatory limits prior to receipt during transit.

At approximately 0900 (CDT) IonSouth delivered a package to the licensee's facility at Keesler Air Force Base Medical Center's hotlab. The licensee identified that the bag had external contamination present. The licensee performed 300 square centimeter wipes at approximately 1130 (CDT) resulting in 50544 disintegrations per minute (dpm) inside the package and 5920 dpm outside the package. The Radiation Safety Officer (RSO) projected that the contamination level outside the bag was 7917.5 dpm at time of delivery. The package was placed in a plastic bag and secured for decay.

The licensee notified IonSouth to inform them of the contaminated package. The RSO is awaiting additional information from the vendor.

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 0039 [EDT] on 8/10/23, with Unit 1 in Mode 1 at 100 percent power, the reactor automatically tripped during a reactor protection system (RPS) bus shift. All systems responding normally post-trip. There was no equipment inoperable at the time of the trip. Operations responded and stabilized the plant. Reactor water level being maintained via feedwater. Decay heat is being removed by cycling safety relief valves.

"An actuation of high-pressure core spray, division 3 diesel generator, and reactor core isolation cooling occurred during the scram and main steam line isolation closure. The reason for the auto-start was reaching Level 2 (130 inches in the reactor pressure vessel) during the transient. The systems automatically started as designed and injected to the reactor vessel when the Level 2 signal was received.

"The RPS actuation is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The emergency core cooling system (ECCS) injection is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A). The ECCS actuation is being reported as a eight-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A).

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

AUTOMATIC REACTOR SCRAM

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

"At 0329 [CDT] on August 11, 2023, with Unit 2 in Mode 1 at 90 percent power, the reactor automatically tripped due to a turbine trip. The trip was uncomplicated with all systems responding normally post-trip. The cause and details of the event are under investigation. Containment isolation valves actuated closed in multiple systems on a valid Group II signal.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B), and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group II isolation.

"Operations responded using the emergency operating procedure and stabilized the plant in Mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 is not affected.

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