Event Notification Report for May 19, 2021

EN Revision Imported Date: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE

The following report was received from the state of Ohio via email:

"A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified."

Ohio Event Number: OH210003

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: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - DISCOVERED DENSITY GAUGE

The following was received from the California Radiation Control Program via email:

"On 05/11/21 the California Office of Emergency Services (Cal OES) contacted [the Radiologic Health Branch] RHB to report a moisture density gauge that was discovered by [the California Highway Patrol] CHP in Santa Cruz, CA. The message stated that while CHP and [California Department of Transportation] CALTRANS were removing a transient encampment, a Soil Density Gauge (Troxler Model 3430, S/N #38287, containing 9 mCi of Cs-137 and 44 mCi of Am-241) was discovered at the site and the device does not appear to be damaged.

"CHP contacted the gauge vendor, Troxler, and was able to locate the licensee (Dees and Associates, Inc) and inform them of the stolen gauge. CHP took possession of the gauge and [the Radiation Safety Officer] RSO had already picked up the gauge from the CHP facility. According to the RSO, they have noticed a gauge stolen from their storage on 4/15/21. She had immediately notified Santa Cruz Police Department (Case # 21S-02156) and Troxler of the theft at the time of the incident. RHB was unaware of the theft until the Cal OES notification on 5/11/21."

California 5010 Number: 051121

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: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - DEVICE NOT LOCATED DURING INSPECTION

The following was received from the Alabama Office of Radiation Control (the Agency) via email:

"An Agency inspector performed an inspection of Wallace State Community College, registrant 554 GL [Generic License], in Hanceville, AL on 4/27/2021. The registrant's GL device was not located during the inspection. The registrant stated the device was moved/disposed in 2019. The registrant was unable to provide documentation of disposal. The inspector followed up with Perkin Elmer (manufacturer); the Perkin Elmer representative stated that no documentation of receipt/disposal of this device was/is present. No further information is available at this time.

"Device description: Perkin Elmer model N610-0063 s/n 3345, source model N610-0063, s/n 3345, with 15 milliCuries of nickel-63 as of 9/1/2000."

Alabama Incident 21-16

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: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - EQUIPMENT FAILED IN SHIELDED POSITION

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

"On May 12, 2021, the [Division of Nuclear Safety - Radioactive Material] DNS-RAM section was verbally notified that a reportable equipment failure had occurred on the Agency's JL Shepherd Model 81-12T irradiator the previous day. The equipment failed in the shielded position and no public/staff exposures were reported as a result of the failure. The unit has been taken out of service pending repair by the manufacturer. All security systems required under 32 [Illinois Admin] Code 337 remain unaffected.

"This equipment and associated calibration activities are operated under a self-issued materials license, IL-01030-01. Additional details on the equipment failure are forthcoming. Initial notification was made within the 24 hour reporting requirement. A written report containing the information in 32 [Illinois Admin] Code 340.1230 is required within 30 days. This report will be updated as information becomes available."

Illinois Item Number: IL210016

EN Revision Imported Date: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The following is a synopsis of an email received from the Colorado Department of Health:

The licensee could not find an exit sign (H-3; 6.22 Ci) during a routine inventory inspection on 6/24/20.

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: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The following is a synopsis of an email received from the Colorado Department of Health:

The licensee could not find an exit sign (H-3; 11.47 Ci) during a routine inventory inspection on 6/9/20.

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: 5/19/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On May 12, 2021, the Agency was notified by the licensee that a medical event had occurred on May 10, 2021. The event involved a prostate seed treatment using cesium - 131 seeds. The licensee reported that after the implant procedure they discovered that a large portion of the seeds had been implanted in the wrong location. The licensee stated the seeds that were misplaced ended up in mostly fatty tissue and they do not believe any adverse effects will be experienced by the patient. The licensee could not provide specific information on what percent of the prescribe dose had been received by the targeted tissue. The event and its cause is currently under investigation by the licensee. The prescribing physician has been made aware of the event and is notifying the patient. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9848

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: 5/19/2021

EN Revision Text: UNUSUAL EVENT DUE TO A FIRE ALARM INSIDE THE DRYWELL

[Peach Bottom Atomic Power Station declared an unusual event due to a] "receipt of a single fire alarm in the Unit 2 drywell and the existence of the fire not verified in less than 30 minutes of alarm receipt."

The NRC Resident Inspector and State and Local Authorities were notified.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 5/17/21 AT 1423 EDT FROM BRETT HENRY TO HOWIE CROUCH * * *
At 1355 EDT, the licensee terminated the notification of unusual event. The basis for termination was that the smoke has dissipated and there were no signs of fire.

The licensee notified State and Local Authorities and the NRC Resident Inspector.

Notified R1DO (Grieves), NRR EO (Miller), and IRD MOC (Grant). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), FEMA NRCC THD (email) and FEMA NRCC SASC (email).

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID DIESEL GENERATOR INITIATION

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid specific system actuation. On March 23, 2021, during the performance of the Division 1 ECCS [(Emergency Core Cooling System)] Integrated Test, the Division 1 Diesel Generator (DG) unexpectedly started. While performing the local lockout testing, per the procedure, a step was performed that initiated the unexpected DG start. The following step was to verify the diesel did NOT start. It was later determined that this was a procedural deficiency. The DG started and ran as designed. The DG did not tie to the safety bus as no undervoltage condition was detected.

"This event is considered an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A). The actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. Therefore, this notification is provided via a 60-day optional phone call in accordance with 10 CFR 50.73(a)(1) instead of submitting a written Licensee Event Report.

"All affected systems functioned as expected in response to the actuation. The DG was shut down in accordance with plant procedures and the testing procedure corrected. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."