Event Notification Report for April 28, 2019

SAFETY EQUIPMENT FAILURE - RADIOGRAPHY SOURCE FAILED TO RETRACT

"This report is intended to serve the requirements of written notification of an inability to retract a radionuclide source assembly to its fully shielded position, per 10 CFR 34.101(a)(2). The incident occurred at NIPSCO Michigan City Generating Station [in] Michigan City, IN at 0545 CDT, on 28 April, 2019. The event consisted of a temporary inability of the radiography crew to immediately return a radionuclide source assembly of Cobalt-60 (76 Ci) to its fully shielded position.

"The cause of the incident is presumed to be a source guide [tube] positioned with too tight of a radius, through which the sealed source could not be fully retracted. The equipment involved was manufactured by Source Production and Equipment Co., and was a model SPEC-300 projector (SN: 0080) and model G-70 source assembly (SN: C60-100).

"The actions taken to return the source assembly to the projector consisted retracting the source as far as possible, the RSO [Radiation Safety Officer] approaching from behind the projector, using the intrinsic shielding of the exposure device as shielding, straightening the guide tube with the use of 7 ft. remote-handling tongs, allowing the source to clear the bend in the source guide tube, then retracting the source, as normal, using the control cables.

"The incident occurred at approximately 0545 CDT, and upon discovering that the inability to fully retract the source, radiographer called [the] RSO at 0552 [CDT], while [the] assistant radiographer extended barricades to emergency distance. [The] RSO left his home promptly to gather the retrieval kit from IRISNDT's Hammond, IN office. RSO arrived on site at approximately 0715 [CDT]. After performing an assessment, the source retrieval took approximately fifteen (15) minutes to complete, and the source was returned to the shielded position by 0745 [CDT].

"All retrieval operations were conducted by individuals who have been trained to perform such tasks. All associated remote-handling equipment was subsequently removed from service for inspection. No involved equipment was found to be damaged or defective.

"No members of the public received any dose. The lead radiographer, received a dose of 8.8 mrem from the start of his shift until the retrieval was complete, the assistant radiographer, received a dose of 0.2 mrem from the start of his shift until the retrieval was complete, and the RSO performing the retrieval, received a total dose of 4.3 mrem.

"Radiographic personnel responded appropriately in identifying that the source had not returned to the shielded position, reposting and monitoring emergency barricades, contacting the Radiation Safety Officer, maintaining the restricted area while awaiting the RSO's arrival to site, and assisting with the retrieval as instructed, and following all procedures and O&E instructions."

AGREEMENT STATE REPORT - THEFT OF CAT 2 MATERIAL

The following was received from the state of Arizona via e-mail:

"The [Arizona Department of Health Services] received notification that an individual stole [three] industrial radiography cameras and threatened to use them. It is believed that the individual is a current or former worker at the licensee. The isotope is Iridium-192 for all three cameras and the approximate activity amounts are 30 Curies, 49 Curies, and 80 Curies. As of approximately 1120 [MDT], the individual was located, the material was secured, and the [Radiation Safety Office] is waiting to bring the material back to the storage location. The Department has requested additional information and continues to investigate the event.

Arizona Incident No.: 19-009

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and Domestic Nuclear Detection Office Joint Analysis Center (email).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

* * * UPDATE ON 4/28/19 AT 1920 EDT FROM BRIAN GORETZKI TO JOANNA BRIDGE * * *

The following is a summary of a telephone call:

The sources were safely recovered. They were found in the radiography cameras. It is widely believed that the suspect never removed the sources from the shielded cameras. The cameras have been returned to the storage facility.

Notified R4RDO (Young), NMSS Events Notification (email), NMSS (Moore), ILTAB (e-mail), CNSNS Mexico (email), IR MOC (Kennedy), ILTAB (Smith), NMSS INES Coordinator (email), INES National Officer (email).

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and Domestic Nuclear Detection Office Joint Analysis Center (email).

CONTROL BLADE INOPERABLE

"On April 28, 2019, at 0633 CDT, with the University of Missouri-Columbia Research Reactor (MURR) operating at 10 MW in the automatic control mode, the Lead Senior Reactor Operator (LSRO) was conducting surveillance Technical Specification (TS) 4.2.a, which states, 'All control blades, including the regulating blade, shall be verified operable within a shift.' During this verification of control blade operability, shim control blades 'A,' 'B,' 'C,' and the regulating blade were verified operable. However, shim control blade 'D' would not move in the inward direction. The LSRO then immediately shut down the reactor by initiating a manual scram by placing Master Control Switch 1S1 to the 'TEST' position. The LSRO completed all immediate and applicable subsequent actions of reactor emergency procedure REP-8, 'Control Rod Drive Mechanism Failure or Stuck Rod,' and verified all shim control blades were fully inserted.

"This email is a required notification per TS 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by TS 1.1.b, has occurred. MURR was not in compliance with all of the Limiting Conditions for Operations (LCOs) as established in TS Section 3.0. The failure of the control rod drive mechanism to insert shim control blade 'D' is a deviation from TS 3.2.a, which states, 'All control blades, including the regulating blade, shall be operable during reactor operation.' In addition, shim control blade 'D' would not have inserted during the activation of any rod run-in function listed in TS 3.2.f - shim control blades 'A,' 'B,' and 'C' would have inserted. All reactor safety system scram functions were unaffected and remained operable during this event.

"Troubleshooting revealed a broken wire to the inward motor winding of shim blade 'D' control rod drive mechanism. The wire was repaired, and the shim control blade 'D's operability was tested satisfactorily. Permission from the Reactor Facility Director was obtained prior to reactor startup per TS 6.6.c(4), and the reactor returned to 10 MW operation at 1319 CDT on April 28. A detailed event report will follow within 14 days as required by TS 6.6.c(3)."

TECHNICAL SUPPORT CENTER VENTILATION SYSTEM OUT OF SERVICE DUE TO DISCOVERED CONDITION

"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability.

"A condition impacting functionality due to a loss of cooling of the Technical Support Center (TSC) ventilation system occurred on 4/28/19. Filtration capability was not impacted by this condition. Maintenance subsequently repaired the condition and the TSC ventilation system was returned to service on 5/1/19. This condition did not affect the health and safety of the public or station employees.

"The NRC Resident Inspector has been notified.

"This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) as the discovered condition affected the functionality of an emergency response facility."