Event Notification Report for April 19, 2024

EN Revision Imported Date: 4/19/2024

EN Revision Text: STUCK IRRADIATOR SOURCE

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

At 1000 MST on 3/5/24, a 10,000 Ci Co-60 source (Model 7810) became stuck in the unshielded position during operator training. The irradiator is a J.L. Shepherd, Model SDF-34-M1, panoramic dry-source storage type. Upon determining that the source was stuck, the operator attempted to manipulate the source back into the shielded position using the emergency cable, but it came loose. Site staff have secured the irradiator facility.

No personnel exposure occurred, and there are no elevated dose rates outside of the irradiator enclosure. The site has requested manufacturer support to resolve the issue.

The NRC Project Manager (O'Keefe) has been notified.

* * * UPDATE ON 4/18/24 AT 1508 EST FROM MAJ RYAN EISWERTH TO ADAM KOZIOL * * *

On 3/18/24, authorized users were able to return the source to a shielded position. A post-event inspection was scheduled during the week starting 4/22/24 with the vendor to verify operability of the irradiator.

At approximately 1000 MST on 4/18/24, while an authorized user was conducting a performance functional check in preparation for the scheduled inspection, the irradiator source again became stuck in an unshielded position.

The irradiator had not been used since the initial report on 3/5/24. No personnel exposure occurred, and there are no elevated dose rates outside of the irradiator enclosure. The site has requested manufacturer support to resolve the issue.

Notified R4DO (Young), IRMOC (Crouch), and NMSS Events (email).

EN Revision Imported Date: 4/19/2024

EN Revision Text: ITEM RELIED ON FOR SAFETY (IROFS) INOPERABLE

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

"At approximately 2345 MDT, on 4/1/2024, it was observed that the physical boundary of IROFS10 had been opened while this boundary was being relied upon to perform its safety function. This initial report is being made as a 1-hour notification under Appendix A to 10 CFR70 (a)(4). The boundary (an isolation valve) was partially opened inadvertently by contact with adjacent equipment while performing operation of 1003 liquid sampling autoclave. The partially opened valve has been shut, restoring the IROFS10 boundary, and the autoclave has been placed in cooling mode. Out of conservatism, until an extent of condition can be performed, the 1004 autoclave which has a similar design has been taken out of service and placed in cooling mode as well.

"There has been no indication of leakage from any operating liquid sampling autoclave to the environment. The system and plant are in a stable condition."

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

The isolation valve was open less than 30 seconds and there was no exposures to personnel. The licensee will notify the NRC Region.


* * * RETRACTION ON 4/18/2024 AT 1029 EDT FROM JIM RICKMAN TO BILL GOTT * * *

"The potential leakage through the open boundary has been determined. The valve, if fully open, would not result in exceeding the 10 CFR 70.61 performance requirements. Thus, the 10 CFR 70 (a)(4) reporting requirement was not met, and this event notification is retracted."

Notified R2DO (Miller) and NMSS Events Notification (email).

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following is a summary of information received from the Alabama Office of Radiation Control via email:

On April 11, 2024, at 1500 CST, a device (Ohmart/Vega, SH-F1, Model A-2102, Source SN 9254GK, 100 mCi Cs-137) was discovered to have a stuck open shutter during routine shutter checks. The device is in place and operational. The area around the vessel on which the device is mounted has been barricaded and marked for no entry. The licensee's plan is to replace the source holder with a new one. The licensee is getting a quote for replacement and installation with an estimated repair date of May 10, 2024.

AGREEMENT STATE - MEDICAL UNDERDOSE

The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."


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 - LOST EXIT SIGNS

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

Two SRB Technologies exit signs, model number: BX10GY, containing 10 curies each, of tritium (20 curies total) were determined to be lost by the licensee.

Colorado event number CO240010


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

INITIAL PART 21 REPORT - POTENTIAL DEFECT WITH CIRCUIT BREAKER

The following information was provided by the licensee via email:

"Pursuant to 10CFR 21.21 (a)(2), Paragon Energy Solutions, LLC is providing this interim notification of ongoing analysis for Part 21 reportability of a potential defect with a Schneider Electric Medium Voltage VR Type Circuit Breaker Part Number V5D4133Y000.

"On February 15, 2024, Paragon completed initial documentation of a potential defect with the subject circuit breaker in which Duke-Oconee had identified failure to close on demand or delayed operation to close with extended application of the remote closing signal. Since the primary safety function of the circuit breaker is to close and maintain continuity of power to downstream loads, failure to close could potentially contribute to a substantial safety hazard.

"This is the first reported instance of this failure mode, and Paragon suspects the issue to be related to aging of the circuit breaker's lubrication. Paragon requires more time to complete testing and analysis to confirm the failure mode and determine reportability.

"Date when evaluation is expected to be complete: 5/03/2024."

Affected licensee: Oconee. Paragon is currently evaluating the extent of condition as it pertains to other plants and equipment that may utilize the same or similar circuit breakers.