Event Notification Report for May 07, 2021

EN Revision Imported Date: 5/7/2021

EN Revision Text: SAFETY LIMIT EXCEEDED

Based on video surveillance and radiation readings, National Institute of Standards and Technology (NIST) has determined they violated Safety Limit 2.1 - greater than 450 degrees Celsius in a single fuel element. This event notification relates to Event Notification #55094, from 2/3/21.

* * * UPDATE ON 06 MAY 2021 AT 1104 EDT FROM TOM NEWTON TO LLOYD DESOTELL * * *

The following is a summary of an update notification received via telephone:

This notification was made per Technical Specification 6.7.2

The investigation related to the February 3, 2021 NIST event (EN 55094) found administrative and procedural inadequacies including:

The fuel element was unlatched prior to reactor start up.
Inadequate training and proficiencies in latching of fuel.
Limiting Conditions for Operations 3.1.3 and 3.9.2.1 were not met.
Procedural compliance was not enforced.
Inadequate implementation of verification methods for latching fuel.

A written report will be submitted within 14 days.

Notified R1DO (Young), NRR EO (Miller), IR MOC (Gott), NRR PM (Montgomery), NRR PM (Torres), NPR ENC (Takacs), OPA (Burnell).

This material event contains a "Less than Cat 3" level of radioactive material.

EN Revision Imported Date: 5/7/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The State of Colorado reported that a Tritium exit sign at the Centura Health-Saint Francis Health Services, which was not able to be located during a change of ownership in June 2020, has been declared lost. The sign contains 10 Ci of Tritium.

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: 5/7/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE UNABLE TO RETRACT

The following was received via e-mail from the Rhode Island Dept. of Health, Radiation Control Agency:

"A licensee, Electric Boat Corporation, reported the inability to retract a 1.62 TBq (43.8 Ci) Co-60 source (QSA Global, Inc. Model A424-14, S/N 81346G) into the radiography exposure device (QSA Global, Inc. Model Sentry 330, S/N P30106) on March 7, 2021, at Electric Boat's Quonset Point Facility. At approximately 0120 [EDT], the [source] was [extended] without any issue.

"At the completion of the exposure, the radiographer attempted to retract the source into the exposure device, and attempted to re-expose the source to verify that the auto-locking mechanism on the Sentry 330 exposure device had engaged. At this time, the radiographer noted that the auto-lock did not engage and that dose rates indicated by his ND-2000A survey instrument at the reel (remote control) remained at approximately 10 mrem/hr. The radiographer then attempted to expose and retract the source to engage the locking mechanism 2 additional times without success.

"At approximately 0156 [EDT], the RSO [(Radiation Safety Officer)] was notified of the inability to retract a Cobalt-60 source into its exposure device. The RSO was able to observe the set up with an inspection mirror from the opposite side of the large part being inspected and determined that the guide tube had become disconnected from the collimator, exposing 10-12 feet of drive cable on the deck, and the source pigtail had become stuck in the collimator.

"After creating and briefing retrieval and contingency plans, source retrieval evolution began at 0640 [EDT]. The RSO Delegate secured the source pigtail in the collimator with a 6 ft long remote handling tool to prevent the source from leaving the collimator prematurely while the RSO stepped out from behind the lead shield with another 6 ft long remote handling tool to move the guide tube from the deck back up to the collimator. While the RSO was straightening out the guide tube and drive cable, a radiography supervisor was slowly retracting the drive cable at the reel to remove the 10-12 ft of drive cable slack on the deck while the RSO communicated via radio. Once the drive cable slack was removed and the RSO guided the guide tube back up to the collimator and tension on the source pigtail was released, the RSO Delegate released control of the source and it was immediately retracted by the radiography supervisor into the exposure device. The source was confirmed to be secured in its device by survey, and the evolution was declared secure at 0649 [EDT].

"RI Radiation Control Agency has investigated the report by Electric Boat Corporation and has determined that this does not have generic implications for the security of sources in radiography equipment at Electric Boat Corporation. The incident is considered closed by RI Radiation Control Agency."

EN Revision Imported Date: 5/7/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via e-mail from the Texas Department of State Health Services:

"The licensee reported that on April 28, 2021, a medical event involving a High Dose Rate (HDR) afterloader gynocological treatment, using a Varian VariSource iX device, with an iridium-192 sealed source of 6.93 curies, at the time of treatment, had occurred at is facility. The wrong length transfer tube was used which resulted in a dose of 600 centigray, the intended dose fraction, to an area, mostly skin, approximately 12 centimeters from the intended treatment site. The authorized user does not expect any harm to the patient. The patient has been informed. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9843

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: 5/7/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST INDUSTRIAL RADIOGRAPHY CAMERA

The following is a summary from the Illinois Emergency Management Agency via e-mail:

The Emergency Management Agency was contacted at approximately 1416 CDT on April 30, 2021, to report the loss of an industrial radiography camera containing 105 Ci of Ir-192. The device/source is believed to be in the possession of the common carrier and an active investigation is underway. There is no current indication of intentional theft or diversion.

The Licensee called to report that the common carrier had dropped off a package on April 30, 2021, at 1040 CDT which was supposed to contain a Spec 150 camera (S/N 439) with a 105 Ci Ir-192 source (s/n CD2901). The cardboard overpack was damaged and the box was empty. The device/source had been overnighted from Spec Industries in St. Rose, LA to Romeoville, Illinois. The State is reaching out to the common carrier and notifying the Tennessee program officials since it is possible the package was lost at the Memphis hub.

State Item Number: IL210012
Common Carrier Tracking Number: 166975368552

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).

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: 5/7/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK GAUGE SHUTTER

The following information was received from the Alabama Department of Public Health, Office of Radiation Control via email:

"The Radiation Safety Officer for Georgia-Pacific of Pennington, Alabama notified the Alabama Office of Radiation Control that while performing routine six (6) month leak testing and shutter checks, one of their gauges had a shutter stuck in the open position. The manufacturer has been notified and a repair date is pending. Further information involving the gauge is forthcoming in the written report."

Alabama Event No: 21-14

EN Revision Imported Date: 5/7/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS

The following was received via e-mail from the Texas Department of Health Services:

"On April 30, 2021, Biomerics reported the loss of eleven static eliminators (NRD model P-2042-1000) Serial Numbers: A2LD792, A2LD794, A2LD795, A2LD799, A2LD803, A2JQ929, A2KT72, A2EZ959, A2EZ960, A2EZ961 and A2EZ962. Each device contained a 185 MBq (5 mCi) Po-210 source. The devices were received from NRD Advanced Static Control from April 5, 2006 to November 21, 2017. The company was supposed to ship used devices to NRD Advanced Static Control. Biomerics searched the areas where these parts were used and during the course of moving equipment, it is apparent that these devices were thrown away. More information will be provided as it is obtained in accordance with SA-300."

Texas Event Number: 75751

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: 5/7/2021

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

The following was received via e-mail from the California Department of Public Health, Radiological Health Branch (RHB):

"On April 30, 2021, [The] ENGEO [Radiological Safety Officer] RSO contacted RHB to report a stolen moisture density gauge, a Troxler, Model 3440, S/N 26157 containing licensed material 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen from one of their storage locations (Extra Space Storage). The gauge was last in their physical possession on April 22, 2021, and was secured in the facility at approximate 1430 PDT. The facility is secured by a common gate with access granted with an access key code with security cameras that log entering and exiting the facility. The storage unit was secured by a keyed master lock, and the equipment was locked to the inside of the unit with a chain and secured with at least 1 master lock.

"Since April 22, 2021, [the] staff has visited the unit on a couple of occasions, however [the staff] was not concerned at the time when the equipment was not observed in the unit which is common as the equipment is used during the day on a regular basis and also due to the lock to the unit being intact (showing no signs of forced entry). On April 29, 2021, the individual who the equipment is assigned to, returned to pick up the gauge and noticed someone had removed it. It was determined that no one from their company removed the gauge from the storage unit after it was secured on April 22, 2021. [The] licensee was unable to view security footage due to privacy of other customers. [The] licensee was told by the manager that he reviewed all footage of their staff entering and leaving the facility between April 22 and April 29 and he observed the staff return the gauge to the unit on April 22, and leave without the gauge in his vehicle after he secured it in the storage unit. [The] licensee has conducted an internal investigation into the location of the gauge and determined that no one with their organization removed the gauge in question. This appears to be consistent with the reported observations of the facility manager's review of security footage.

"[The] licensee has notified Rohnert Park Police Department of the stolen gauge (police report #21-1838). A cash reward has been offered for the safe return of the gauge.

"RHB will be following up on this investigation."

California Report Number: 043021

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: 5/7/2021

EN Revision Text: FITNESS FOR DUTY REPORT

A non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

MANUAL REACTOR TRIP

"On May 6, 2021 at 1223 [EDT], Unit 1 was manually tripped from 60 percent power due to degrading main condenser vacuum. Unit 1 was in the process of decreasing power due to increased secondary sodium levels identified earlier in the day. The Operations crew entered the reactor trip procedure and stabilized Unit 1 in Mode 3 at normal operating temperature and pressure. All control rods fully inserted into the core following the reactor trip. This reactor protection actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). Auxiliary Feedwater pumps actuated as designed as a result of the reactor trip and provided makeup flow to the steam generators. The automatic start of the Auxiliary Feedwater pumps is reportable per 10 CFR 50,72(b)(3)(iv)(A) for a valid actuation of an ESF [Engineered Safeguards Features] system. Decay heat is being removed by the condenser steam dump system."

The electrical system is in normal lineup for shutdown conditions. There was no effect on Unit 2 operation. The NRC resident inspector has been notified.