Event Notification Report for July 21, 2021

EN Revision Imported Date: 7/21/2021

EN Revision Text: UNPLANNED CONTAMINATION TO AN INDIVIDUAL

The following synopsis was received via phone call from the licensee's Radiation Safety Officer (RSO):

At 1800 EDT on June 24, 2021 at the licensee facility, an employee left the work site unaware that he was contaminated on his skin and his clothing. The only places the individual traveled to were his car and his home before being called back to work at 1924 EDT to investigate the contamination event. When the individual came back to the facility, contamination was found on his hand including Sr-82, Sr-85, Rb-83, and Rb-84. The activity was 600,000 counts or 0.18 micro curies. Dose calculations have not been performed, however, the RSO does not believe the dose will be near any federal limits. The work area has been decontaminated and the individual's car has been surveyed and no contamination was found. The licensee plans to survey the individual's home as well as contact the NRC Region 3 materials inspector. The licensee is reporting the event under both 30.50(a) and 30.50(b)(1) as a precaution as more data is being collected.

* * * Update from Matthew Trusner to Donald Norwood at 1914 EDT on 6/25/2021 * * *

The following information was received via E-mail:

"On June 24, 2021, at approximately 1800 EDT, Curium-Noblesville RSO became aware of a radioactive spill in a restricted (production) area. The spill occurred behind the production hot cells. The affected area is designated as a triple shoe cover area and cordoned to limit access.

"The RSO directed a Radiation Safety Technician to respond to and initiate the investigation and data collection. The Radiation Safety Technician performed contamination surveys and found a maximum count rate of 800,000 cpm. The Radiation Safety Technician subsequently remediated the spill to 70,000 cpm (below the administrative level of 100,000 cpm) within minutes of completing the survey.

"The spill initiated when a Chemist tried to manually un-crimp a vial containing approximately 695 mCi of Sr-82 and 703 mCi of Sr-85. As the the Chemist tried to un-crimp the vial, the glass below the crimp broke leading to a few drops to fall on the concrete floor behind the hot cells. During the initial investigation surveys, the RSO discovered that the production batch record was contaminated. This prompted the RSO to find the Chemist to ensure he was free of contamination. The RSO discovered that the Chemist had already left the site.

"The RSO immediately contacted the Director of Health Physics for assistance. They made the decision to bring the Chemist onsite for a survey. The RSO discovered that the Chemist's work clothes presented spots reading approximately 600,000 cpm on contact with the pants and 200,000 with the shirt. The RSO also found contamination on the right hand reading approximately 34,000 cpm. Because the Chemist had left the site, the RSO surveyed the Chemist's car and did not identify contamination above background levels. The RSO communicated the findings to the Director of Health Physics and initiated the decontamination activities for the Chemist.

"Prior to decontaminating the Chemist's hand, the RSO obtained a gamma spectrum to identify the radioactive contaminants. He found a mixture of Sr-82, Sr-85, Rb-83 and Rb-84. The Director of Health Physics reviewed the notification requirements prescribed in Part 20 and Part 30 and escalated the event to Curium management and legal teams. Curium made the decision to proactively report the event to the NRC Operations Center under 10 CFR 30.50(a) given that the notification was required within 4 hours of discovery and Curium had not acquired enough data to verify if any regulatory limit was exceeded or not. After the notification, the RSO stopped the decontamination activities after no further contamination was being removed. The RSO measured a residual contamination of 4,200 cpm on the hand. He then followed the Chemist to his home and performed a contamination survey of the areas in which the Chemist indicated that he had been present after leaving the work site that day. The RSO found no contamination above background levels.

"The Director of Health Physics performed an initial dose estimate on June 25, 2021. The RSO used Rb-84 as the most restrictive nuclide that yielded the highest dose in the mixture. The estimates indicated that the Chemist received approximately 1,203 mrem to the maximally exposed shallow dose equivalent (extremity), 636 mrem shallow dose equivalent (whole body) and 13 mrem deep dose equivalent. The RSO performed 24-hour urinalysis and did not find the presence of the radionuclides. All license material was accounted for.

"Curium personnel discussed the incident with NRC Region-III on June 25, 2021. Curium is in the process of completing formal root cause analysis."

Notified R3DO (Stone) and the NMSS Events Notification E-mail group.

* * * RETRACTION ON 07/20/21 AT 1506 EDT FROM MATTHEW TRUSNER TO SOLOMON SAHLE * * *

The following retraction is a summary received from the licensee via phone:

As part of an internal investigation, the licensee determined that neither the employee nor any member of the public received any exposure exceeding regulatory limits.

The licensee will notify the NRC Region 3.

Notified R3DO (Pelke) and NMSS Events Notification via email.

EN Revision Imported Date: 7/21/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING DEVICE

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

"On July 14, 2021, the licensee notified the Agency that in the process of terminating their license for radioactive materials, the Agency discovered that its records indicated the licensee had at one time a Thermo Niton XL3p-800 device, containing 30 millicuries of americium- 241, which was not on the licensee's current inventory of devices and they learned it had not been on their inventory for years. The licensee stated to the best of their knowledge the analyzer was loaned to a former associated company several years ago and this company was then sold or dissolved. It appears the analyzer was not returned to the licensee. The individuals who were, or may have been involved, are no longer employed by the licensee so further information is not available at this time. An investigation is ongoing. More information will be provided as it is obtained in accordance with SA-300.

"Texas Incident No.: I-9868"

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: 7/21/2021

EN Revision Text: MEDICAL EVENT - UNDER DOSE

The following was received from the licensee via email:

"Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, which holds Permit Number 13-00694-03 under the VA master materials license, reported discovery of a medical event to NHPP [VA National Health Physics Program] at approximately 1045 EDT, July 14, 2021. A Y-90 microsphere therapy administration for liver cancer was performed on July 14, 2021. The dosage was intended for two segments of the left lobe of the liver. Post implant surveys of the administration set found an elevated amount of Y-90 present. Measurements and calculations indicated the patient had received about 63 percent of the prescribed activity. The patient has been notified. There is no expectation at this time of harm to the patient.

"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified our NRC Region III Project Manager, Bryan Parker."

This event is reportable pursuant to 10 CFR 35.3045.

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: 7/21/2021

EN Revision Text: REACTOR OPERATED AT GREATER THAN 100 PERCENT TECHNICAL SPECIFICATION POWER LIMIT

"On February 28, 2021, [at approximately 1500 EST], following recalibration of the reactor power in accordance with PUR-1 Technical Specifications, the reactor operator operated the reactor at 8.5 kW (85% of nominal power) and noticed that the rate of temperature change of the coolant was greater than expected. Noting that this presents the possibility of the power being in excess of expectations, PUR-1 was shut down and has remained shut down to date. PUR-1 staff immediately notified the Committee on Reactor Operations (CORO) and developed a plan to perform an in-depth investigation.

"Since then, multiple independent assessments on the reactor power have been performed, which include: Hand calculations, Monte Carlo N-Particle code (MCNP) simulations, analysis on activity measurements of irradiated materials, a thermal-hydraulic analysis using a Computational Fluid Dynamic (CFD) model of PUR-1, and a more physical assessment using resistance heaters as heat sources to determine the coolant temperature change rate as a function of power and pool temperature, which has just been completed.

"These five independent evaluation methods performed to determine the core power during the experiment on February 28, 2021, suggest that the reactor may have been operated for about 4 hours at a power in the range between 118.3 percent to 129.2 percent of our 12 kW maximum allowable power (per TS 2.2). While the reactor was not operated outside the bounds of the Safety Analysis Report (SAR), this represents a potential need for reporting under TS 6.7.b.1.c.vi, 'An observed inadequacy in the implementation of procedural controls...'.

"Staff are currently evaluating several potential corrective actions including adjustment of the current power calibration constant, which relates the activity of the gold foil to the core power, by the most conservative factor suggested by these five analyses. There was no impact to the safety of the public or PUR-1 staff and the Safety Limit was not exceeded at any point. A formal report will be subsequently issued."

EN Revision Imported Date: 7/21/2021

EN Revision Text: ONSITE MEDICAL EMERGENCY

On July 19, 2021 at 1316 EDT, an individual experienced a non-work related medical emergency. The onsite fire brigade and emergency medical technicians administered first aid, but the individual was unresponsive. The individual was transported to the local hospital. At 1458 EDT, the local hospital notified the station that the individual was deceased. The individual was outside of the radiological controlled area and was not contaminated.

OFFSITE NOTIFICATION

"At approximately 1310 EDT on July 19, 2021, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system encompassing the Fuel Manufacturing Operation (FMO) was impaired. The electric fire pump was without power as the result of a failure of an electrical feed from Duke Energy. The backup diesel fire pump remained fully operational and available to perform its safety function. Power was restored at approximately 1400 EDT on July 19, and the Deputy Fire Marshall was notified of system restoration. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will notify the North Carolina Radiation Protection Branch and NRC Region II.

FITNESS FOR DUTY REPORT

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

The NRC Resident Inspector has been notified.