Event Notification Report for May 25, 2021

EN Revision Imported Date: 5/25/2021

EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER STUCK OPEN

The following was received from the Ohio Department of Health via email:

"During removal of the Cs-137 source (20 mCi, Serial # 5450CN) and holder (Ohmart/Vega Model SHLM-B1-P) by the manufacturer (VEGA), it was discovered the shutter would not operate and was stuck open. INEOS is actively working with the manufacturer to develop a suitable path forward for removal of the source. In the meantime, a physical barrier is installed to prevent vessel entry."

Ohio Reference No.: OH 2021-037

EN Revision Imported Date: 5/25/2021

EN Revision Text: MISSING IODINE-125 BRACHYTHERAPY SEEDS

"A brachytherapy treatment was performed at the hospital on 13 May 2021. From a total of 111 Iodine -125 seeds, 88 were implanted into the patient's prostate as planned. The oncology medical physicist mistakenly thought that she had placed the remaining, unused 23 in two lead containers, but did not perform a physical inventory to confirm it. She did not realized that 4 unused seeds were left in a shielded box. Each seed had approximately 0.26 mCi in each. After the procedure, Radiation Safety surveyed the treatment room. All radiation levels were background. The medical physicist returned the unused seeds to Radiation Safety indicating that 23 seeds were in two small lead pigs. The box containing the 4 seeds was put in the medical waste bag and were apparently processed as medical waste. On 14 May 2021, Radiation Safety initiated preparing the unused seeds for shipment to the vendor that provided them. At that point, Radiation Safety realized that only 19 were in the lead containers and 4 were not returned. At that point, Radiation Safety contacted Radiation Oncology. They were not able to locate them at their department. A team consisting of Radiation Safety and Radiation Oncology staff searched for them, unsuccessfully, in the [Operating Room]. The team then searched in the medical waste dumpster bins at the hospital. This search was also unsuccessful locating the missing seeds. It was determined that a dumpster container that likely had the missing seeds was picked up early in the day. The waste management company was contacted, but the company was not able to provide information about what truck or container was involved and its location. The hospital is currently waiting for more information from the waste management company."

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: 5/25/2021

EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED
The following was received from the State of Arkansas via email:

"The Agreement State General Licensed Device licensee reported to the State of Arkansas, Arkansas Department of Health [Department], that a 0.59 mCi (0.022 GBq) Co-60 sealed source (Manufacturer: Berthold Technologies, Model Number: P2608-100, Sealed Source Serial Number: 54-01-05) used in a Berthold Technologies General Licensed Device (Manufacturer: Berthold Technologies, Model Number: LB300L, Serial Number: 15951-1189-10000) was damaged by the conveyor belt rubbing and wearing down the steel housing of the device and into the lead shielding. The damage was discovered by the licensee during a routine inventory and inspection on April 14, 2021. The licensee submitted the required report and photographs to the Agreement State on May 17, 2021 at approximately 1400 [CDT].

"Licensee took immediate corrective actions including stopping the conveyor belt, locked-out gauge, secured area and blocked off area to gauge, performed exposure surveys, and performed wipe tests to confirm no contamination. The damaged gauge will be disposed and will not be replaced according to the licensee. Licensee confirmed no public exposures, no employee exposures, and negative leak tests results.

"Corrective actions by licensee include, but not limited to: (1) storage in place of damaged gauge until the manufacturer removes and disposes the device from its location, (2) installation of a t-roller in front of other similar gauges along with welding it in place to prevent the conveyor belt from contacting a radiation gauge if a troughing idler failure occurs, (3) perform a monthly preventative maintenance inspection of conveyor belts and gauging systems and repair of any damaged or severely worn jointers, (4) perform a monthly inspection of the t-roller in front of the radiation gauges, and (5) perform inspections of the t-roller by the Site Radiation Safety Duty Officer to ensure conveyor belt clearance."

"The Department considers this incident to be closed."

Arkansas Event No.: AR-2021-004

"On 5/24/21 at 0916 EDT, an Automatic Reactor Trip on Unit 1 occurred. All safety systems responded normally and the plant is currently stable in Mode 3 (Hot Standby) at normal operating temperature and pressure. Preliminary indications are that the unit trip was caused by a High Neutron Flux Rate detected by the Power Range Nuclear Instruments. Troubleshooting and investigation are ongoing to determine the initiating cause.

"Unit 2 is not impacted and remains stable in Mode 1 at 100 percent power.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and in accordance with 10 CFR 50.72 (b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system.

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

No relief valves opened. All Rods fully inserted. Decay heat is being removed by Auxiliary Feedwater via the steam dumps. The plant is in a normal post-trip electrical line-up.