Event Notification Report for October 21, 2020

EN Revision Imported Date : 10/14/2020

EN Revision Text: AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

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

"On October 12, 2020, the licensee notified the Agency that on October 10, 2020, one of its technicians completed a job at a temporary job site in Dallas, Texas, and drove to another temporary job site in Venus, Texas. Upon arriving, the technician found he did not have the Humboldt 5001 EZ moisture/density gauge in his truck. The gauge contained an 8 milliCurie cesium-137 and a 40 milliCurie americium-241/beryllium source. The technician believed he left the gauge at the Dallas site so he drove back to that site. The gauge was not there. The technician called his supervisor but never made contact. The technician called the company office and left a voicemail about the incident which was retrieved this morning. The licensee is notifying local law enforcement, contacting area pawn shops, and conducting its investigation. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9806

* * * UPDATE ON 10/13/2020 AT 1414 EDT FROM KAREN BLANCHARD TO OSSY FONT * * *

The following update was received from the Agency via email:

"The location where the event occurred is a temporary job site in the 7400 block of Hillcrest Road in Frisco, Texas. The gauge, a Humboldt 5001 EZ, contains 10 milliCuries of cesium-137 (not 8) and 40 milliCuries of americium-241/beryllium. The insertion rod was locked. The licensee has made a report to the Frisco police department. The licensee has thoroughly searched the construction site a second time and will be checking businesses around the site for possible video surveillance that may provide information. The Agency has informed the Frisco fire department/emergency management coordinator. Further information will be provided as it is obtained in accordance with SA-300."

Notified R4DO (Azua) and NMSS Events Notification, ILTAB, and CNSNS (Mexico) via 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

NON-AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

The following is a summary from a phone call with the licensee:

A patient at the Indiana University Health Methodist Hospital was prescribed 46.7 mCi of Y-90 Theraspheres to segments 5 and 8 of the liver, but received 54 percent (25.2 mCi) of the prescribed dose. The remaining 46 percent (21.5 mCi) was trapped in the catheter or the line. The patient and the physician were notified and a follow-up treatment has been scheduled for next week.


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.

MAXIMUM LICENSED POWER LEVEL EXCEEDED

"During the course of operations, a potential error in the power calibration of the PUR-1, License Number R-87, was discovered. This calibration error would result in a special report requirement as specified in [(Technical Specification)] TS 6.7.b.1.c.vi, which is that an observed inadequacy in the implementation of a procedural control such that this inadequacy could have caused the development of an unsafe condition with regards to reactor operations. By extension the miscalibration caused a true reactor power higher than the measured reactor power. As such, this likely resulted in the operation in violation of the limiting condition for operation as established in TS Section 3 Table I and operation with an actual safety system setting for a required system less conservative than the limiting safety system settings specified in the Technical Specifications. These reporting requirements are Part i. and ii. of TS 6.7.b.1.c. The calibration error implicates a violation of the maximum licensed power level of 12 kW. The Safety Limit was not exceeded at any point."

THERMAL EVENT RESULTING IN LOSS OF INTEGRITY OF LICENSED CONTAINER

At 1000 EDT on October 20, 2020, a thermal event occurred inside a hot cell at the Curium facility in Noblesville, Indiana. The thermal event did not result in a chemical or radioactive material release. Prior to the incident, technicians were processing materials containing strontium 82 and 85 (quantities are unknown at this time). The pressure created by the reaction caused the rear door of the hot cell to open approximately eight inches and was immediately shut by the technicians. There is no contamination outside of the hot cell and there were no injured or contaminated personnel. The vessel containing the strontium material was observed to be intact and the resultant fire was extinguished by the hot cell's suppression system. No offsite fire assistance was required. Personnel have not accessed the hot cell due to elevated dose rates. Dose rates outside of the hot cell are within the facility's normal limits and historical averages.

AGREEMENT STATE REPORT - TC-99M EXTERNAL CONTAMINATION

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

"During the afternoon of October 13, 2020, the Agency received a call from the RSO [(Radiation Safety Officer)] at Rush Oak Park Hospital, Inc. (IL-01676-01) to notify the Agency of a potential 24-hr notification requirement from an event which occurred at 0830 CDT, Friday, October 9, 2020. According to the RSO, a Nuclear Medicine Technologist (NMT) was administering a 27 mCi dose of Tc-99m to a patient when the vein "collapsed" which created pressure and sprayed a small quantity of Tc-99m back into the technicians face and eyes. The technician soon thereafter went to the E.R. [(emergency room)] and had her eyes rinsed out. At 1000 the same morning, the RSO met the NMT in the E.R. and took a near contact measurement of her face utilizing a Ludlum model 26 which identified a maximum 6,050 cpm on her forehead. The RSO stated that he could not identify any contamination elsewhere or within the wash water at the E.R. Having no other information, the RSO calculated that in consideration of an approximately 0.23 percent efficiency of the instrument, approximately 1.2 microCi of Tc-99m was on the skin of the NMT. The RSO also stated that he did a few worst case scenario calculations but didn't come close to reportable levels. The Agency concurs with the licensee's determinations. Furthermore, the patient was given most of the dose and still had a normal scan. No contamination was identified on the patient. The used syringe measured 1 mCi remaining following treatment and the accident. The RSO explained that he didn't think it was reportable but following a closer look at 32 IAC 340.1220(c)(3) thought he had better complete his due diligence and give us a call. Inspection and Enforcement supervisor to follow up with the licensee.

"The incident will be entered into NMED [(Nuclear Material Events Database)] and reported to the Headquarters Operations Officer within 24 hours of notification, as required.

"The licensee will be advised of the requirement to submit a written report within 30 days in accordance with 32 IAC 340.1230."

Item Number: IL200019

UPDATE TO ACCEPTANCE CRITERIA FOR ITAAC

"In accordance with 10 CFR 52.99(c)(2) as described in NEI 08-01, Industry Guideline for the ITAAC Closure Process Under 10 CFR Part 52, Vogtle Units 3 and 4 Construction is making this notification to the NRC for determining that Inspections, Tests, Analyses and Acceptance Criteria (ITAAC) 2.3.05.13a.ii (Index No. 344) for Unit 4 requires additional actions to restore the completed status. The ITAAC Closure Notifications for Unit 4 ITAAC 344 was submitted on July 22, 2020 (ML20204B029).

"On October 19, 2020, it was determined that maintenance activities for the Unit 4 Polar Crane auxiliary hoist holding brake used a different approach for Post Work Verification (PWV) than the original test described in the ICN [ITAAC Closure Notification] for ITAAC 344. The alternate PWV used a test method that is standard industry practice and in accordance with ASME B30.2 to demonstrate that the Acceptance Criteria was met.

"An ITAAC Post Closure Notification will be submitted in accordance with 10 CFR 52.99(c)(2) and NEI 08-01.

"The 10 CFR 52.99(c)(4) All lTAAC Complete Notification has not been submitted for VEGP [Vogtle Electric Generating Plant] 4. The NRC Resident Inspector has been notified."