Event Notification Report for March 19, 2024

EN Revision Imported Date: 3/19/2024

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The following information was received from the Illinois Emergency Management Agency (the Agency) via email.

"On Thursday, January 11, 2024, the Agency received written notification from the radiation safety officer (RSO) at a nuclear pharmacy of an elevated dosimetry badge report for a worker in Romeoville, IL. The whole body dose reported would exceed the occupational limits in 32 Ill. Adm. Code 340.210. The information provided indicates the worker received 162,926 mrem during the week of December 11, 2023, which exceeds the annual limit of 5,000 mrem. This is a reportable incident under 32 Ill. Adm. Code 340.1230, and will be reported to NRC and NMED. While an investigation is underway to determine the cause of this overexposure, after speaking with the RSO, it is likely the result of a spill/splash event. If this spill resulted in an occupational exposure in excess of the limits, it is also reportable under 32 Ill. Adm. Code 340.1220(b) and will be reported to the NRC today. In the next week, Agency inspectors will perform a reactionary inspection to inspect the adequacy of the licensee's investigation, compliance with the Agency's regulations, and determine the root cause."

NMED Item Number: IL240002

* * * UPDATE ON 1/24/2024 AT 1557 EST FROM GARY FORSEE TO KAREN COTTON * * *

"A reactive inspection was conducted on 1/19/24. Reportedly on 12/11/2023, the technician noted a pressure issue within an F-18 synthesis cell. While containing approximately 9.9 Ci of F-18, the technician opened the synthesis cell to diagnose the issue. The magnitude of the resulting whole-body exposure is an unknown component of the reported 162 rem. Extremity badges reported only 447 mrem for this wear period. Movement of the synthesis tubing resulted in an undetermined quantity of F-18 contaminating the upper chest, neck and underarm of the technician.

"The technician reports feeling `wetness' as a result of the contamination event. Licensee staff estimated 3-5 minutes passed before decontamination efforts were initiated. Initial survey readings on the technician were 12 mR/hour from the neck and chest after shirt and lab coat were removed. No assessment of uptake/intake was performed, nor were any bioassays performed. No medical assessment was performed for blood changes or impacts to the skin. The corporate Radiation Safety Officer (RSO) was not notified until the dosimetry report was returned nearly 30 days later. At the time of the inspection, no medical conditions had emerged that were indicative of radiation exposure. The technician's badge was not evaluated for contamination, simply assumed to be contaminated and sent for reading. The badge did not show evidence of contamination when received by the dosimetry processor - however, that may have been due to decay.

"The licensee did not cease or limit any work with radioactive materials assigned to the individual. The employee has continued work in 2024, as the elevated exposure was attributed to the 2023 annual limit. Inspectors believe there is some portion of the exposure recorded on the optically stimulated luminescence (OSL) [dosimeter] that was not a true whole-body exposure (resulting from contamination and storage in the bunker). However, the lack of adequate records or timely assessment makes any quantification impossible. While an undetermined fraction of the recorded 162 rem was likely not a whole-body dose to the technician; there are certainly exposure avenues which could have led to at least 5 rem whole body. Until data is presented which indicates otherwise, this matter is being treated as an occupational exposure in excess of the 5 rem limit. While 16 mL containing 9.9 Ci of F-18 was in the synthesis cell, there is no accurate account on the amount of activity deposited on the technician's skin/clothing. (The syringe containing the F-18 was not used and allowed to decay within the cell. No volume or activity assessment performed). The only data allowing an estimate is the initial 12 mR/hour exposure rate, which would be close to 13 microcuries of activity incident to the detector active surface area. I.e., if the badge was surveying 12 mR/hour at one inch, that would equate to approximately 13 microcuries of F-18 incident to the probe. The exposure to the OSL over the mean life of this F-18 is estimated at 20 Rem.

"No data is available to estimate committed dose. While a VARSKIN+ analysis is pending, initial estimates indicate skin dose is likely less than 10 percent of the occupational limit. If the entirety of the 162-rem exposure was suspected to have come from contamination, the initial contamination of the badge would have needed to exceed 100 microcuries. This would have an exposure rate in excess of 100 mR/hour - inconsistent with the recorded exposure rates. Occupational whole body dose year to date, prior to this incident, was recorded at 974 mrem. Average weekly whole-body dose was 19 mrem.

"The area was isolated due to the spill and this incident is likely also reportable under 32 Ill. Adm. Code 340.1220(b), equivalent to 10 CFR 20.2202(b). The investigation is still in process."

Notified R3DO (Orlikowski), NMSS Event Notifications (Email), and NMSS/MSST Division Director (Williams)

* * * UPDATE ON 3/18/2024 AT 1440 TO FROM GARY FORSEE TO SAM COLVARD * * *

"A notice of violation was issued on 2/6/2024. A response was received on 3/6/2024 and included proposed corrective actions and steps to prevent recurrence.

"The licensee contracted a qualified consultant to perform skin dose calculations, and to further evaluate likely whole-body doses. The consultant calculated a skin dose of 89 rem from contamination, and a total whole-body dose of 100 mrem resulting from this incident. The licensee submitted information to indicate a 2023 proposed adjusted [deep-dose equivalent] (DDE) of 1.278 rem and a proposed adjusted [shallow-dose equivalent] (SDE) of 90.2 rem as detailed in the consultant report.

"The Agency has reviewed and concurs with the licensee's calculations for skin dose resulting from this incident. This matter will remain reportable, but on the basis of a skin dose exceeding the regulatory limit. Pending no further developments and appropriate enforcement action, this matter is considered closed."

Notified R3DO (Hills), NMSS Event Notifications (Email), NMSS Regional Coordinator (email) (Rivera-Capella), NMSS/MSST Division Director (Williams), Director, Division of Radiological Safety and Security, R3 (email) (Curtis)

EN Revision Imported Date: 3/19/2024

EN Revision Text: RESIDUAL HEAT REMOVAL DEGRADED DUE TO SERVICE WATER LEAKAGE

The following information was provided by the licensee via email:

"On January 18, 2024, at 0030 PST, diesel generator 2 (DG2) was shut down following a monthly surveillance run. Subsequently, a leak was discovered in the DG2 building. Service water pump '1B' was secured at 0117, effectively stopping the leak. The leak was determined to be service water coming from a diesel generator mixed air cooling coil. Service water system 'B' and DG2 were subsequently declared inoperable at 0135. After discussion with engineering, it was identified that the amount of service water leakage from the cooling coil was assumed to be greater than the leakage allowed by the calculation to assure adequate water in the ultimate heat sink to meet the required mission time of 30 days.

"At 1204, it was determined that entry into Technical Specification 3.7.1 condition D was warranted since the assumed leakage from the cooling coil could exceed the calculated allowed value. At 1238, the control power fuses for service water pump '1B' were removed. DG2 and service water system 'B' were declared unavailable, and the technical specification condition for the inoperable ultimate heat sink was exited. With the control power fuses removed, the pump is kept from auto starting, effectively preventing the leak and ensuring the safety function of the ultimate heat sink is maintained while the cooling coil is repaired or replaced.

"Due to the leakage assumed greater than the calculated allowable value this condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition and per 10 CFR 50.72(b)(3)(v)(B) as an event or condition that could have prevented fulfillment of the safety function of structures or systems that are needed to remove residual heat.

"There was no impact to the health and safety of the public."

The NRC Resident has been notified.


* * * RETRACTION ON 3/18/24 AT 1923 FROM VALERIE LAGEN TO KAREN COTTON * * *

The following information was provided by the licensee via email:

"On January 18, 2024 at 2138 EST, Columbia Generating Station notified the NRC under 10 CFR 50.72(b)(3)(ii)(B) of an unanalyzed condition on the available capacity of the ultimate heat sink (UHS) and under 10 CFR 50.72(b)(3)(v)(B) of an event or condition that could have prevented fulfillment of the safety function of structures or systems needed to remove residual heat.

"On January 18, 2024, following monthly surveillance of the diesel generator DG2, a DG2 room cooler flow alarm was received at 0115. A leak was discovered in the diesel mixed air (DMA) air handler unit. Service Water Pump '1B' was secured and the leakage was stopped at 0117. The service water system 'B' and diesel generator system 'B' were declared inoperable at 0135. The leak was assumed to be greater than that allowed to ensure adequate water in the UHS required to meet the 30-day mission time, and the UHS was declared inoperable at 1204. Control power fuses for the service water pump '1B' were removed to fully eliminate the leakage path from the cooler, and the UHS was declared operable at 1238.

"Following the event, engineering performed an analysis based on the size and location of the leak, and concluded it would have taken 1.4 days to deplete the available excess water in the UHS to below the minimum technical specification required water level of the spray pond. Operations were able to secure the service water subsystem of the UHS prior to exceeding the volumetric margins in the spray ponds to ensure the 30-day mission time was met.

"The condition did not represent a safety significant unanalyzed condition nor a loss of safety function. The NRC Resident Inspector has been notified."

Notified R4DO (Gepford).

EN Revision Imported Date: 3/19/2024

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGES

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"On March 7, 2024, the Agency was notified of equipment damage at Alton Steel in Alton, IL, that exposed two sealed radioactive sources. The licensee reported that molten steel flowed over Berthold Technologies source housings (source housing serial numbers 1197-10-21 and 601-05-12) and, despite trying to cool the steel, it damaged the source housings and exposed the sources. The Berthold Technologies sources are Co-60 and have an activity of 2.3 mCi each (source serial numbers 1200-10-21 and 600-05-12). The sources were removed from the housings by a licensed service provider and placed in secured storage. Leak tests are pending. The licensee determined there were no exposures to any personnel and that the incident does not pose a risk to any members of the public. Licensee surveys indicated no contamination, and radiation levels from these sources were comparable to those from an undamaged source. The Agency plans to conduct a reactionary inspection to verify the lack of contamination/exposure and accountability of licensed materials. This is a reportable event in accordance with 32 Ill. Adm. Code 340.1220(c)(2)."

Illinois Item No.: IL240008

* * * UPDATE ON 3/13/24 AT 1625 EDT FROM GARY FORSEE TO ADAM KOZIOL * * *

"[On 3/8/24], another email update was received in which Alton Steel's licensed contractor advised another portion of the source rod had been located and was actively being cut from the molten steel. A conference call was immediately scheduled and the following information noted: The incident had actually taken place on 2/22/24 with no notification to the Agency. It was stated that the licensee's authorized user removed the damaged sources using pliers and placed them in secured storage but did not follow their approved emergency procedures to cease work and rope off the area at 20 feet. The licensee contacted their consultant (R.M. Wester), and they were on-site the same day. R.M. Wester personnel surveyed the area and assumed there was no contamination because they were getting the expected radiation levels. At that time, the consultant recommended that the licensee contact the manufacturer (Berthold) to come out and further evaluate the sources and devices. The manufacturer was on-site on 3/7/24 and discovered that two source rods were damaged. The manufacturer's rep advised a call to the State was needed. He noted one source rod had been damaged to the point the internal Co-60/nickel wire was exposed. On the afternoon of 3/8/24, Alton Steel's licensed consultant surveyed the mold lid and found what they assumed to be the remaining portion of the source (exposure rate of 50 mR/hour). On 3/8/24, Alton Steel personnel used a torch to cut that portion of the source from the lid of the mold. This piece was also placed in secured storage. The lid was then surveyed by the consultant which he stated evidenced no further radioactive material. The two damaged sources, as well as the source rod fragment, are pending disposal. The Agency has requested that the lid and mold be held for surveys when Agency staff are on-site. Agency staff plan to be on-site 3/13/24 to further investigate. Leak tests from the consultant did not evidence removeable contamination in excess of 0.005 uCi. At this time, there is no indication of risk to workers or the public as all sources are in secured storage. The investigation is ongoing and updates will be provided as available.

"On Monday, 3/11/24, Agency staff conducted interviews with the Berthold service representative which conducted the service call. Information from that call indicated the licensee had cut through a source with a torch. At this point, Agency staff responded that morning to take surveys and interview Alton Steel staff. Survey readings were taken with a microR meter, which lacked the necessary sensitivity and were inconclusive due to [naturally occurring radioactive material] NORM and refractory material. Investigation findings indicate the licensee failed to follow emergency procedures, failed to follow operating procedures, failed to adhere to license conditions, received inadequate and incorrect training, improperly handled and manipulated sealed sources, failed to perform surveys, and failed to make timely notification to the Agency. The licensee's consultant also failed to notify the Agency, lacked sufficient knowledge of the sealed source and performed inadequate surveys. Additionally, it was discovered the licensee had used a 4 inch die grinder on one source, cut through another with an oxygen lance, had a practice of handling unshielded source assemblies and an inadequate radiation safety program.

"Agency staff arrived at the licensee's site again on 3/13/24 to perform additional surveys. Upon arrival, the licensee stated they had found yet another piece of the Co-60 rod source under the spray booth that washes down the cast billets. This was reportedly the area below where the source was first cut with a torch. The Agency confirmed the licensee was aware of the source when using the torch and did not perform surveys or alter operations. The second source which was found to be damaged had also been inadvertently withdrawn from its shielded housing when the molten steel overflowed atop the mold cap. However, the second source immediately fell into two pieces, apparently suffering damage within the housing. That source was reportedly burnt/melt and would not fit into the shield. A licensee gauge user then used a 4 inch angle grinder to smooth out the source so it would fit back into the shield. Agency staff investigated all areas accessible (some areas were inaccessible due to molten steel). A portable germanium spectrometer was employed to discern if elevated count rates were from NORM or Co-60 contamination. Preliminary findings indicate at least two areas adjacent to the vise (where grinding had occurred) had Co-60 contamination. Samples were collected for lab analysis and additional area surveys performed. The [Illinois Emergency Management Agency - Office of Homeland Security] IEMA-OHS lab reported on the afternoon of 3/13/24 that samples did evidence Co-60 contamination. The Agency covered the contaminated area and required it to be posted. Additional surveys will be taken once accessible, to include the wash-down water sedimentation areas. A full survey and remediation plan will be required by the end of the month. Decontamination efforts will be undertaken by a qualified contractor and the Agency will perform verification surveys to support release. Updates will be provided as they become available."

Notified R3DO (Hills), IR MOC (Crouch), NMSS (Williams), NMSS Events (email)
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), Nuclear SSA (email), FEMA NWC (email), CWMD Watch Desk (email)

* * * UPDATE ON 3/18/2024 AT 1440 EDT FROM GARY FORSEE TO SAM COLVARD * * *

"On 3/15/2024, the Agency dispatched seven inspectors to perform comprehensive surveys of the facility, characterize exposures, and determine if additional fragments of the source remained unaccounted for. Inspection findings indicate that there is Co-60 contamination within a single room (mold repair room) at Alton Steel. The licensee has secured the room and implemented contamination control procedures. Updated procedures and training were implemented on Friday, March 15, 2024. Extensive Agency surveys of the facility and personnel performed on 3/15/2024 indicate that the contamination is not being carried offsite; nor was there any indication of public exposures. There is no contamination of water. Contamination of the product (steel) has not been identified; nor is it likely to be a concern resulting from this incident.

"Due to improper handling of sources, it is likely a gauge user received an extremity dose in excess of regulatory limits. Time-motion study will be performed to refine dose estimates and substantiate.

"ONS-RAM is investigating additional, chronic internal exposures to Co-60 which have likely occurred over many years. ONS-RAM will return to the site on 3/20/2024 to evaluate the efficacy of contamination control measures, determine the timeline for remediation activities and perform additional sampling/surveys to better quantify exposures and determine the appropriateness of bioassays. This report will be updated as additional information becomes available."

Notified R3DO (Hills), NMSS (Williams), NMSS Events (email), NMSS Regional Coordinator (Rivera-Capella) (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 - STUCK SHUTTER

The following was received from the Texas Department of State Health Services (the Department) via email:

"On March 11, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that an event at the facility resulted in molten metal being spewed out from the furnace. Some of the molten metal landed on the housing cover of a Berthold LB 300 gauge containing a 2.5 curie (original activity 3 years ago) source. The licensee was able to remove the cover and inspected the gauge. The licensee found that some of the molten metal had leaked on to the shutter operator for the gauge, preventing the shutter from closing. The RSO stated they were able to remove the gauge from the vessel and place in a storage area. The RSO stated the room has been locked and posted to prevent inadvertent entry. The RSO stated they had performed radiation surveys outside the storage room and readings obtained were less than 2 millirem per hour. The RSO stated no individual received any radiation exposure that would have exceeded any limit. The RSO stated they have contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10094

Texas NMED No.: TX240009

AGREEMENT STATE REPORT - MISSING SOURCE

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

"On March 11, 2024, a contracted service provider was on-site to dispose of 6 sources housed in a Kevex Model 6700 Analyst. It is a 2000 Series Spectrometer, Serial Number A011E, Bench Number 5026. The Analyst [device], has been in the possession of the scrap facility for at least a decade but was never utilized. The device was identified in November 2023, as a device which contained radioactive material. At that point the State was notified, and plans were initiated to dispose of the material. The State was unable to determine who previously possessed the device, or to whom it was initially distributed.

"The device should have contained 3 Cd-109 pellets of 7 mCi each, and 3 Am-241 pellets of 7 mCi, each. The source serial number indicated on the labeling is 4047, Model 0202. The assay date was December 1, 1992. When the service provider disassembled the device to reach the source housing, no sources were present within the device. The service provider performed confirmatory surveys to ensure that no sources were present. Apparently, the sources were removed prior to the scrap yard receiving the device.

"Without knowing the provenance of the device, it is unclear whether the sources were ever properly disposed of, therefore, it is being reported as missing material."

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 MISADMINISTRATION

The following summary of information was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email:

On March 1, 2024, the Department was notified of a medical misadministration that occurred on February 28, 2024. The misadministration was that of Ga-68 Dotatate (5.24 millicuries) being administered instead of F-18 FDG (Fludeoxyglucose). The licensee proceeded with the scan having an incomplete scan description on an outside physician's order. The signed order received only asked for "PET-CT Scan (Base of Skull to Thigh)." An unsigned order/history form, clearly designating a Ga-68 Dotatate scan, was filled out by the outside clinic's medical staff and included with the physician's order. The licensee proceeded with scan as directed using the elaboration of the unsigned order/history form as designation of the specific scan ordered.

The patient was notified of the incident and will receive the appropriate scan the following week. Investigation in to how this situation can be avoided in the future has been conducted by the licensee.

WA Event Number: WA-24-0007

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 3/14/24 AT 1538 EDT FROM BORIS TSENOV TO ADAM KOZIOL * * *

The following was provided by the Washington State Department of Health Office Radiation Protection (the Department) via email:

The licensee provided a written report to the Department identifying root causes and corrective actions. The report also calculated an effective dose estimate of 498 mrem and the highest expected effective organ dose to the spleen of 5.47 rem.

Notified R4DO (Werner) and NMSS Events (email)

NON-AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

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

During an inventory which began the week of March 4, 2024, the licensee discovered one lost tritium exit sign (Isolite SLX-60, 4.4 Ci). The sign was at a location undergoing renovation. All other tritium exit signs that were on site have been accounted for. An investigation ensued to attempt to determine the disposition of the missing sign. This sign was declared lost on March 12, 2024.

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

MANUAL REACTOR TRIP DUE TO MAIN FEEDWATER PUMP TRIP

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

"On March 17, 2024, at 1515 CDT, the Comanche Peak Unit 2 reactor was manually tripped due to an anticipated automatic trip due to lo-lo steam generator (SG) water levels. Prior to the trip, main feedwater pump '2B' tripped and an auto runback to 700 MW (60 percent power) was in progress. Both motor driven auxiliary feedwater pumps and the turbine driven auxiliary feedwater pump started due to lo-lo level in all SGs.

"Unit 2 is being maintained in hot standby (Mode 3) in accordance with integrated plant operating procedures IPO-007B. The emergency response guideline network has been exited. Decay heat is being rejected to the main condenser via the steam dump valves."

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

The cause of the '2B' main feed pump trip was due to loss of primary and redundant power to the servo control valve. The loss of power to the servo control valve is under investigation.

PART 21 - FAILURE TO COMPLY WITH TESTING REQUIREMENTS

The following is a summary of the information provided by Alpha -Omega Services (AOS) via email:

During shipment of an Alpha Omega Services (AOS)-100A-0003 cask, a metallic seal was used instead of an elastomeric seal. The failure to comply, discovered February 16, 2024, is that the testing requirements for the metallic seal were not properly followed. The shipment arrived without incident.
The storage location of the active unit is Merritt Island, FL. The failure to comply is an isolated incident affecting one AOS-100A package which is certified and is currently in service. The remaining units are not in service.
AOS has initiated a corrective action plan that will identify the issue, begin the internal investigation process to determine the cause, and identify any additional corrective actions. This investigation is currently in progress.