Event Notification Report for April 05, 2024

EN Revision Imported Date: 4/5/2024

EN Revision Text: UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS

The following is a synopsis of information provided by the licensee via email:

Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.

This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.

This issue has been entered into the licensee's corrective action program as IR-2022-9728.

* * * UPDATE ON 09/13/23 AT 1219 EDT FROM STEPHEN SUBOSITS TO THOMAS HERRITY * * *

The following is a synopsis of information provided by the licensee via email:

On 9/12/2023, while offloading additional barrels of Hematite Ash from the the 2003 shipment, A URRS operator identified that the tag for a drum showed the contents have a higher enrichment than that which is recorded in the Chemical Area Manufacturing and Process System (ChAMPS) and on the original paperwork provided by Hematite Fuel Operations. The unloading activity was stopped, and URRS Management and Nuclear Criticality Safety were notified. The unopened pail was placed back in the drum and the drum was segregated from other items in the area. Environmental Health and Safety requested that the remaining seven drums be opened and the contents tag for each be checked against the information in ChAMPS and the original paperwork from Hematite Fuel Operations. This was done.

This report is conservatively being made as an update to Event Notification 56199 under reporting criterion 10 CFR 70 Appendix A (b)(1) as an event that resulted in the facility being in a state that was not analyzed in the Integrated Safety Analysis, and resulted in a failure to meet the performance requirements of 10 CFR70.61 similar to the 9 drums of Hematite Ash that were discovered in November 2022 due to it being an unanalyzed condition.

Westinghouse believes it is likely that the enrichment listed on the tag of the drum is inaccurate. The issue has been entered into the corrective action program as IR-2023-8953.

Notified R2DO (Endress) and NMSS_EVENTS via email.

* * * RETRACTION ON 04/04/24 AT 1035 EDT FROM STEPHEN SUBOSITS TO JOSUE RAMIREZ * * *

The following information was provided by the licensee via email:

"In response to the discovery of the Hematite Ash material with a U-235 enrichment that was potentially greater than 5 percent U-235, Westinghouse submitted two sequential license amendment requests which were approved by the NRC in May 2023 and October 2023, respectively. The first license amendment permitted possession and storage of the drums containing the ash material in a safe configuration. The second license amendment approved sampling, analysis, and blending, if necessary, of the ash material.

"After receipt of the second license amendment, Uranium Recovery and Recycle Services personnel sampled the drums of suspect ash material, and laboratory personnel performed the analyses of the samples taken to determine U-235 content. Analytical results were less than 4.265 percent U-235 for all of the samples taken. The results confirmed the ash materials were within the license limit for percent U-235, and as a result, blending with lower enrichment materials to meet the license limit was not necessary.

"Westinghouse is retracting Event Notification 56199 based on the sample results of the Hematite Ash material being less than 5 percent U-235 and the resultant conclusion that the facility was not in an unanalyzed condition state. 10 CFR 70.61 performance requirements were met for the Hematite Ash material based on the nuclear criticality safety controls that were documented and in place for material less than 5 percent U-235."

Notified R2DO (Miller) and NMSS_EVENTS via email.

EN Revision Imported Date: 4/5/2024

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)

* * * UPDATE ON 4/4/2024 AT 1322 EDT FROM GARY FORSEE TO TENISHA MEADOWS * * *

The following is a summary of information received from the Illinois Emergency Management Agency (the Agency) via email:

The Agency conducted additional site visits on 3/15, 3/21 and 3/29. The following updated assessment is available:

Contamination and Radioactive Material Accountability: Inspection findings indicate the licensee has used grinders/wire wheels on licensed sources to remove solidified steel both in response to this incident and others. In at least two instances, the grinding has penetrated the stainless-steel capsule and impacted the internal Co-60 wire. This led to contamination in the area referred to as the "mold repair room". Activities giving rise to this contamination and occupational exposures have been identified and ceased. Both can be traced back to inadequate training and a failure to follow operating/emergency procedures. Additional surveys, wipes and air sampling activities performed by the Agency indicate the Co-60 contamination is isolated to the "mold repair room" and is not being re-suspended, distributed throughout the facility or rendered available for inhalation/ingestion. Personnel and vehicle surveys have indicated no contamination. Surveys of locker rooms, bathrooms, elevators, adjacent areas, water circulation and sedimentation systems have all indicated no contamination. The licensee is working with a licensed service provider to perform characterization surveys and mobilize for proper remediation of the area. In the interim, the licensee has implemented appropriate access controls, personal protective equipment (PPE), surveys and additional contamination control measures. Working with the manufacturer, the Agency estimates a combined 328 microCi of Co-60 remains unaccounted for from the two damaged sources. At this point, licensee and Agency surveys limit the likelihood the fragments remain on site on the casting deck, spray down chamber or the resulting collection systems. On 3/29/24, the pathways in which the source fragments could be re-introduced into cast billets was investigated. However, the Agency surveys performed on 3/29/24 of billets representative from heats conducted after the incident date as well as the resulting roll-formed products; all yielded radiation readings consistent with background.

Occupational Exposures and Contamination: Agency inspectors confirmed estimates of exposure which led to an employee exceeding the annual occupational limit for an extremity (114 rem to the hands). The employee has ceased work with radioactive materials for the year. Inadequate training and failure to follow operating procedures are causative for improper handling and damaging sources. In addition, the improper handling of sources is due, in part, to an unauthorized modification of the sealed source, dated shielding assemblies and repeated physical damage/fouling of the threads atop the sealed source.

Based on all information available to the Agency, this is the most likely disposition of the 328 microCi of Co-60. While the sheer volume of the pile, size of the casting remnants and shielding afforded to the 328 microCi of Co-60 is unlikely to yield productive surveys; Agency staff will evaluate on 4/8/24. The Agency will continue to assess contamination control measures and evaluate the licensee's contracted characterization surveys and remediation activities. The Agency will review proposed remediation goals, evaluate the resulting remediation plan, and perform verification surveys once the final status survey is received. Appropriate enforcement action and updating of the license is pending.

Notified R3DO (Edwards), 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

EN Revision Imported Date: 4/5/2024

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO UNPLANNED SITE

The following was received from the Iowa Health and Human Services (HHS) via email:

"On 3/19/2024, MercyOne Des Moines Medical Center reported an equipment failure involving a Best Vascular Inc. A1000 series intravascular brachytherapy device, and a 2.16 Gbq (58.4 mCi) strontium-90 source that occurred on 3/18/2024.

"The initial attempt to send the source train failed to reach the dwell position and stopped short of the treatment area by about 30 millimeters. After the authorized user's (AU) attempts to try and increase pressure to send the sources further to the treatment area failed, the licensee decided to return the source to the device. There was a small delay in the source returning, because there was a slight bend in the catheter, and it seemed that was impeding the water pressure to push the source back. The licensee straightened the catheter a little bit, and when they did the source train returned to the device. At that point, the licensee disconnected and reconnected the catheter to try again and the source train again stopped in the same exact place. The licensee returned the source immediately.

"In total the source was in the incorrect position for approximately 30 seconds. The source was at the same position about 30 millimeters proximal to the treatment area.

"The AU picked up the radiopaque marker set to put back in and see if they could see how far it would go in on fluoroscopic imaging. When the AU picked up the radiopaque marker set, he noticed that there was a very strong kink (almost 90-degree bend) in the radiopaque marker set. Instead of putting the source radiopaque marker set back in, the licensee decided to pull the entire catheter and place a new beta-cath catheter in the patient. While testing the new radiopaque marker set (pulled them out, push them back in) the AU realized that when he did it on the other radiopaque marker set, he had felt a click at some point.

"The licensee's hypothesis is that, when the AU felt the click, the radiopaque marker set bent and there is a potential that when it bent, there was damage to the catheter itself, and it would not allow the source train to go past that position where the kink happened. With the new catheter in place, the AU connected the device and sent the source train out to the treatment position without issue. The licensee continued to treat for the prescribed treatment time.

"Preliminary information: It is estimated that the source train sat for approximately 30 seconds in the wrong location. The dose delivered to that area about 30 millimeter proximal to the treatment site is 0.0632 Gy/s times 30 s equals 1.896 Gy, which is greater than the limits described in 10 CFR 35.3045(a)(1)(iii) reports and notification of a medical event.

"Iowa HHS will do a reactive inspection on 3/20/2024 and will update this event as more details are confirmed."

* * * RETRACTION ON 4/4/24 AT 1301 EDT FROM STUART JORDAN TO TENISHA MEADOWS * * *

The following was received from the Iowa Health and Human Services (HHS) via email:

"Iowa HHS performed a reactive inspection on 3/20/2024 to confirm the facts and dose information. During this inspection, it was determined that the source train stopped in the aorta (30 mm vessel) in which the licensee's initial dose calculations was to a 2 mm vessel. Due to the characteristics of the strontium-90 beta emitter, there is a significant drop off in dose to the tissue with increased distance (3.75 mm goes below the 50 rem threshold). The catheter was not resting against the aorta wall when it had stopped for 20-30 seconds and the actual dose to the tissue was determined to be 5.25 rads [0.0525 Gy], which is approximately 10 percent of the reportable medical event threshold as described in 10 CFR 35.3045. Additionally, the reporting requirements described in 10 CFR 30.50(b)(2) also were not met. Specifically, the day of the incident the licensee used a new catheter and successfully treated without incident so there was redundant equipment available and operable to perform the required safety function.

"The licensee has sent the partially failed catheter to the vendor for an evaluation."

Notified R3DO (Edwards) and NMSS Events Notification via 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.

UNPLANNED CONTAMINATION

The following information was provided by the licensee via telephone:

On March 27, 2024, at 1101 EDT, a sample containing 20.3 mCi of carbon-14 (C-14) in 1,3-Dichloropropene liquid form (348 microliters) was dropped when being removed from a storage container. The authorized user immediately called for assistance and restricted access to the laboratory where the spill occurred. Decontamination efforts began immediately after the incident, and it was confirmed that the contamination was contained to the laboratory where the spill occurred. It was determined on March 28, 2024, at 1025 EDT that restrictions would remain in place greater than 24 hours, and that this incident was reportable under 10 CFR 30.50(b)(1).

Following the spill, a nasal swab was taken of the worker with no detectable activity, however, a urine bioassay taken the following day indicated a potential internal dose of 213 mrem. No other staff were exposed, and there was no risk to public safety or the environment.

The applicable 10 CFR 20 Appendix B annual limit for intake for C-14 is 2000 microcuries.

Decontamination efforts will continue until detectable surface contamination is less than 1000 dpm/100 square centimeters.

ELUATE EXCEEDING PERMISSIBLE CONCENTRATION

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

On March 24, 2024, a generator experienced a breakthrough event. The elution from a Curium technetium-99m (Tc-99m) generator did not meet the concentration requirements of 0.15 microcuries molybdenum-99 (Mo-99)/millicurie Tc-99m per 10 CFR 35.204. The generator is from lot number 914024034. The elution contained 1251.3 millicuries of Tc-99m and 203.1 microcuries of Mo-99, resulting in a ratio of 0.16 microcurie Mo-99/millicurie Tc-99m.

The elution was not used to prepare a radiopharmaceutical kit or for dispensing of patient doses. The elution was set aside immediately for decay and disposal. The generator was eluted multiple times following the breakthrough and none of those elutions exceeded the regulatory limit. Curium, the manufacturer, was notified on 3/29/2024. The generator is being quarantined pending disposal.

NOTIFICATION OF UNUSUAL EVENT DUE TO FIRE ALARM IN THE VITAL AREA

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

On 4/4/2024 at 1618 MST, a Notification of Unusual Event, HU4.2 was declared based on an unverified fire alarm in the containment building greater than 15 minutes. Palo Verde, Unit 3 was operating in Mode 1 at 91 percent power due to end of cycle coast down to a refueling outage. There is no known plant damage at this time. Offsite assistance cannot enter the containment building, therefore, offsite assistance was not requested. The plant is stable in Mode 1.

The licensee notified State and local authorities and the NRC Senior Resident Inspector.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).

* * * UPDATE ON 04/04/24 AT 2313 EDT FROM YOLANDA GOOD TO IAN HOWARD * * *

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

At 2013 MST, Palo Verde Unit 3 terminated the notification of unusual event. The basis for termination was that a containment entry was performed. All levels were inspected, and no fires were found. The NRC Resident Inspector has been notified.

Notified R4DO (Deese), IR-MOC (Crouch), NRR-EO (Felts), DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).