Event Notification Report for November 01, 2023

EN Revision Imported Date: 11/1/2023

EN Revision Text: PART 21 INTERIM REPORT - DEVIATION IN THE CALIBRATION CERTIFICATES FOR AN ACOUSTIC EMISSION INSTRUMENT

The following is a summary of information provided by the MISTRAS Group via fax:

On June 10, 2021, calibration certificates for an acoustic emission (AE) instrument were found to have been falsified (reference Notice of Violation 99902109/2023-201-02). The AE system was used for testing of lift rigs used for reactor head and internals. A 10 CFR Part 21 evaluation was initiated on June 15, 2021, and is now essentially complete. The final report will be made available by November 1, 2023.

The following reactor plants were affected: DC Cook, Kewaunee, Surry, Millstone, North Anna, Robinson, Oconee, Arkansas Nuclear One, Beaver Valley, Turkey Point, St. Lucie, Seabrook, Shearon Harris, Vogtle, Farley, Sequoyah, Watts Bar, and Prairie Island.

For questions, contact Donald D. Smith, Quality Assurance Director, MISTRAS Group, Inc., (630) 418-7301, donald.d.smith@mistrasgroup.com

***UPDATE ON 10/31/2023 AT 1403 EDT FROM DONALD SMITH TO ERIC SIMPSON***
The following information was provided by the licensee via phone:
The final report will be delayed. The final report will be made by November 10, 2023, instead of the original date of November 1, 2023.

Notified R1DO (Bickett), R2DO (Miller), R3DO (Ruiz), R4DO (Roldan-Otero), and via email: Part 21 Reactors.

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health (CDPH) via email:

"On October 24, 2023, the Radiation Safety Officer (RSO) of Barnett Quality Control Services, contacted the California Department of Public Health (CDPH) regarding a moisture density gauge that was struck by a front loader at a construction site while the Cs-137 source was in the extended position. The gauge was a Troxler Model 3440, serial number 15052 (8 millicuries (nominal) Cs-137, 40 millicuries (nominal) Am:Be-241). The impact with the gauge resulted in the top section of the index rod breaking off. The source rod and the body of the gauge were intact (including the Am:Be-241 source). The RSO was contacted and responded to the scene of the incident. The RSO was able to place the Cs-137 source in the shielded position, but the section of the index rod that allowed the source rod to be locked in the shielded position was missing. The RSO was instructed by a CDPH inspector to secure the source with duct tape on the source handle and at the bottom opening to prevent the source from shifting from the shielded position. The RSO was also instructed to perform a radiation survey of the area of the incident after moving the gauge to ensure that the radioactive sources were not left behind. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."

There were no reports of contamination or exposure to personnel.

California Incident (5010) Number: 102423

AGREEMENT STATE REPORT - LOST AND FOUND RADIOACTIVE SOURCE

The following was received from the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS)) via email:

"IEMA-OHS was contacted the morning of October 25, 2023, by GE Precision Healthcare (a Wisconsin-licensed service provider) to advise of a Ge-68 source that had been improperly shipped to Illinois. Reportedly, a positron emission tomography-computed tomography (PET/CT) unit, still containing the Ge-68 source, was removed from a medical facility in Washington state and shipped to an unlicensed Illinois facility (MAK Healthcare). The parties involved are seeking the proper removal and return of the source to the Washington licensee. It is our understanding that GE Healthcare intends to send a technician to the Illinois facility on Friday, October 27 to remove or retrieve the sources under reciprocity. Thereafter, the source will be packaged and returned to the licensee in Washington state.

"Illinois staff contacted Washington staff and advised them of the available details. In accordance with SA-300, section 5.6.2, this report is being filed with the Nuclear Regulatory Commission as a 'found source'. The matter may also be reportable under the Illinois equivalent of 10 CFR 20.2203(a)(3)(ii). IEMA-OHS staff will monitor the activities in Illinois to verify source integrity and proper return to appropriately licensed individuals.

"This report will be updated as details become available. At this time, the Ge-68 sealed source is estimated to have a maximum activity of 11 mCi and is either an IPL-model number HEGL-0132 or 0019 or 0020."

Illinois report number: IL230031

See NRC Event Notification number 56818 for a parallel report made by Washington.


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

LOST SEALED SOURCES

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

"This is a non-emergency 30-day notification for missing licensed material. This event is reportable in accordance with 10 CFR 20.2201(a)(1)(ii). On September 25, 2023, while performing the required semi-annual source leak check and inventory, radiation protection personnel could not locate seven sealed radioactive sources. Five of the sources exceed the reporting threshold of ten times the activity listed in 10 CFR 20 Appendix C. Of the five sources, four were Ni-63 sources previously utilized in security bomb detection equipment with a current source radioactivity of between 7.1 and 8.7 mCi. The fifth sealed source exceeding the reporting threshold is an Am-241 former lab calibration standard with a source radioactivity of 0.97 microcuries. These sources were last accounted for on July 6, 2022. Pilgrim's accountability process does not require leak checks or physical inventory of sources that are out of service. A search was conducted for the missing sources; however, they could not be located.

"These sealed sources are classified as Category 5 radioactive sources in accordance with the International Atomic Energy Agency (IAEA) Safety Guide No. RS-G-1.9. Sources that are less than Category 3 (Cat 4 and 5 sources) are very unlikely to cause permanent injury to individuals.

"Based on the activity of Ni-63 and Am-241 present in the sources, this 30-day phone notification to NRC is provided pursuant to 10CFR20.2201(a)(1)(ii). The required written report pursuant to 10CFR20.2201(b)(1) will be provided to NRC within 30 days. The Resident Inspector has been notified. The licensee will notify State and local authorities."


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 - POSSIBLE DOSE MISADMINISTRATION

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 10/25/23 by the radiation safety officer (RSO) of University of Kentucky (UK) Broad Scope medical license, of an incident which occurred at the UK Chandler Medical Center on October 23, 2023.

"[The UK] RSO reports, 'During a high dose rate (HDR) treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user (AU) directed that the transfer tubing be replaced and treatment completed. The tubing used to complete the cycle was not the correct length, resulting in approximately 10 seconds of source exposure at the wrong dwell position(s). The source was outside of the body during this exposure period, therefore, there is uncertainty in the dose estimates to patient skin. Likely exposure in the treatment position (legs apart) is likely below the reporting thresholds in 10 CFR 35, while conservative estimates (assuming patient's legs were closed) lead to doses above reporting thresholds. Since the exact positioning is indeterminant, the licensee did not report a dose from this incident at this time. Upper bound worse case estimates place the skin dose below the level where patient harm is expected by the treating oncologist and no changes in plan of care are anticipated from this event. This incident remains under investigation.'

"RHB is following up with the RSO for additional information not included in the initial report."

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

The intended organ to be dosed was the cervix/uterus. Dose estimates were not available at the time the report was received from KY RHB.

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 - STUCK OPEN SHUTTER

The following information was provided by the Tennessee Division of Radiological Health via email:

"During a scheduled 6-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was a normal operating position. A VEGA field technician has been scheduled to arrive onsite on November 7, 2023, to service the gauge.

"Manufacturer: Ohmart/VEGA
"Source holder model: SHLM-CR
"Source serial number: 4259CO
"Isotope: Cs-137, 37 mCi

"Corrective actions or reports as well as additional information will be updated with a NMED report within 30 days."

Tennessee Event Report ID Number: TN-23-079

AGREEMENT STATE - LOST AND FOUND RADIOACTIVE SOURCE

The following information was provided by the Washington State Department of Health via email:

"A positron emission tomography-computed tomography (PET/CT) unit with a Ge-68 sealed source (11 millicurie) was removed improperly from a medical facility in WA (Radia Imaging Center) and shipped to an unlicensed facility (MAK Heathcare in Woodstock, IL). Leak tests are in process to verify no spread of contamination. Currently, the plan is to ship the PET/CT scanner back to source manufacturer, Eckhert & Ziegler, in Burbank, CA on Friday, 10/27/2023."

WA Incident Report Number: WA-23-028

See NRC Event Notification number 56814 for a parallel report made by Illinois.


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

FITNESS-FOR-DUTY REPORT

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

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

The NRC Resident Inspector has been notified.

FALSE NEGATIVE ON BLIND PERFORMANCE SAMPLE

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

"On October 31, 2023, at 0800 CDT, River Bend Station discovered that the results of a blind performance sample provided to an HHS-certified testing facility were inaccurate (false negative). This report is being made in accordance with 10 CFR 26.719(c)(3). The HHS-certified testing facility has been informed of the error."

The licensee notified the NRC resident inspector.