Event Notification Report for April 14, 2021

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - SEALED SOURCE MISSING IN TRANSIT

The following information was received from the Louisiana Department of Environmental Quality via email:

"A common carrier picked up a black overpack package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 at 1623 CDT on April 1, 2021.

"[The package] left Baton Rouge, LA via common carrier at 2003 CDT and arrived in Memphis, TN at 2319 CDT on April 1, 2021. [The package] was scanned internally at the common carrier's Memphis facility at 0230 CDT on April 2, 2021. That is the last record of this 54 pound package. The [package] destination was Acuren Inspection [located] at 2060 Afton Place in Farmington, NM 87401. (They have not received it.) "

Common Carrier Tracking Number: 9860 8682 9990

LA Incident Tracking Number: LA20210005

Notified: DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).

* * * UPDATE ON 4/7/2021 AT 1612 EDT FROM JAMES PATE TO JEFFREY WHITED * * *

The following is a summary of information received from the Louisiana Department of Environmental Quality via email:

The lost transportation package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 was delivered to its intended licensee this morning.

Notified: R1DO (Werkheiser), IRMOC (Kennedy), NMSS (Rivera-Capella), INES (Milligan), ILTAB (Roundtree), NMSS Event Notifications (email), DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (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

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT SATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE

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

"The Agency was contacted on 4/6/21 by the Radiation Safety Officer (RSO) for Howell Asphalt Company to report a damaged Troxler Gauge. The incident occurred at approximately 1500 CDT at a temporary job site on Locust Street in Centralia, IL.

"The RSO for Howell Asphalt Company called to report that a Troxler 3440 gauge was run over by a vehicle and was stuck under a car. Reportedly, the driver of the vehicle dismissed the barriers and entered the construction zone. Emergency response personnel arrived on site to isolate and assist in moving the vehicle off the gauge. At the time of the accident, the gauge was in use for backscatter measurements and therefore, all sources were in the shielded position. The RSO responded to the site and reported that both the Cs-137 and the Am-241 sources appeared to be shielded and that only the gauge housing was damaged.

"At 1555 CDT, the RSO called to provide an update. The RSO reported that both sources were undamaged and had been retrieved. The RSO has secured the gauge and is returning it to the Effingham office for disposal through Troxler. The gauge will be transported in its Troxler case which was undamaged. Source and gauge serial numbers are pending and the report will be updated once available. Agency staff will continue to track this matter pending receipt of leak tests and confirmation of disposal"

Illinois Incident Number: IL210007

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On April 7, 2021, the licensee reported that a significant amount of Y-90 Theraspheres leaked out of the connection between the tubing and the catheter during a therapeutic procedure in which 24 mCi (a prescribed dose of 200 Gy) was to be delivered to the liver. The liquid was observed dripping out of the connection between the patient catheter and tubing onto the towels and drapings. The dose to skin of patient and worker cleaning up is not known because of the apparently large amount of contaminated towels and such. The [Radiation Safety Officer] RSO will attempt to address this and the cause in the coming days as the activity decreases. The RSO reports that both the patient and patient's physician were notified within 24 hours. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I-9837

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.

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER

The following was received from the New Hampshire Radiological Health Section via email:

"[In January 2017], during routine maintenance of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close by ordinary means. A manual shutter handle within the actuation assembly was used to attempt to close the shutter, but the linkage was binding and causing the shutter to remain open. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure resulted.

"The cause was determined by the service technician as a binding solenoid spool. The spool bushing was reamed out and the shutter linkage was lubricated, which allowed the solenoid spool to resume moving freely as designed."

Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage

The New Hampshire Radiological Health Section considers this event closed.

Report ID #: #NH17-0003

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS

The following was received from the New Hampshire Radiological Health Section via email:

"[In April 2017], a generally-licensed static eliminator was lost during a routine replacement of a series of 30 static eliminators. The devices are leased from NRD Corporation and are affixed to assembly line machines. Annually, they are removed from service and returned to NRD Corporation. The missing device was last in use during a production run on 3/10/17 between 1500 EDT and 2400 EDT. Device exchange occurred during the 2nd shift after the line was shut down. The missing device was noticed during the subsequent 1st shift when supervision performed accountability. A facility search and employee interviews were conducted. Roll-off containers servicing the 'household' and 'recyclables' waste streams were searched without success, likely because the roll-offs contained a significant amount of waste that impeded the search for the relatively small device. The device was still missing after 30 days. The licensee concluded the device was inadvertently disposed in the 'household' waste stream, which is taken to a waste-to-energy incinerator."

Device Details: Polonium-210, 10 mCi (0.37 GBq); NRD Corporation, Model P-2021-8000 static eliminator, s/n A2KN339

The New Hampshire Radiological Health Section considers this event closed.

Report ID #: #NH17-0004

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: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received from the New Hampshire Radiological Health Section via email:

"[In January 2018], during routine semi-annual leak testing of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close completely by ordinary means and the red 'Source ON' status indicator lamp remained continuously lit. A manual shutter handle within the actuation assembly was used to close the shutter. While doing so, a green wire was noted as brushing against the shutter linkage and impeding its operation. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure.

"The cause was determined by the service technician as a wire interfering with the path of the shutter linkage, preventing full closer of the shutter. The wire was moved out of the way, allowing the shutter to move along its full path as designed."

Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage

The New Hampshire Radiological Health Section considers this event closed.

Report ID #: #NH18-0001

EN Revision Imported Date: 4/16/2021

EN Revision Text: AUTOMATIC ACTUATION OF GROUP I CONTAINMENT ISOLATION LOGIC

"At 2323 EST on 02/12/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group I containment isolation logic occurred during fluid flushing of turbine stop valves. The reason for the actuation was due to a maintenance activity resulting in turbine stop valve movement with no condenser vacuum which is a Group I isolation signal. Two Group I isolation valves, 2B31F019 and 2B31F020, reactor water sample valves, automatically isolated as designed when the system actuation signal was received. The other Group I valves had already been removed from service as part of the refueling outage schedule.

"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group I containment isolation system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 4/16/2021

EN Revision Text: AUTOMATIC ACTUATION OF GROUP 2 CONTAINMENT ISOLATION LOGIC

"At 2320 EST on 02/17/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group 2 containment isolation logic occurred on the inboard valves. The reason for the actuation was most likely due to air entrapment in reactor water level sensing lines following maintenance. Group 2 inboard isolation valves in the drywell floor and equipment drain system and the fission product monitor system automatically isolated as designed. As a corrective action, the variable leg and reference leg of the instrumentation were backfilled with water to ensure all air was removed from the line.

"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group 2 containment isolation system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."