Event Notification Report for July 22, 2021

EN Revision Imported Date: 7/22/2021

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: 7/22/2021

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: 7/22/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED VARIED BY MORE THAN 25 PERCENT

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

"A patient whose thyroid had been removed was to receive treatment for the remaining nodules. The WD [(written directive)] prescribed 30 mCi I-131 NaI. However the licensee ordered and administered 100 mCi. The expected whole body dose is 26.64 rem and dose to the bladder wall is 225.7 rad."

Item Number: OH210006

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: 7/22/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

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

"On July 13, 2021, the licensee discovered a stuck shutter in the open position during a 6 month shutter test. This is the normal operating position and there is not expected to be any additional dose outside of normal operations to workers or public."
"The device was a Vega SH-F2B density/level gauge (serial number 3578CR), with a 200 mCi CS-137 source (serial number 3578CR)."
Texas incident number: I-9869

EN Revision Imported Date: 7/22/2021

EN Revision Text: STOLEN TROXLER GAUGE

On July 14, 2021, a technician left a job site unknowingly leaving a Troxler gauge on the tailgate, which subsequently fell off. The project supervisor was informed of the incident at approximately 1445 EDT. A local business has still images of an individual in a truck picking up the gauge on the side of the road and driving off. Local law enforcement was called, and an investigation is underway. The Troxler gauge, model number 35/40, 25423, contained 8 mCi of Cs-137 (serial number 75-8257) and 40 mCi of Am-241:BE (serial number 47-21754). The Transport Index is 0.6.

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: 7/22/2021

EN Revision Text: 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.

EN Revision Imported Date: 7/22/2021

EN Revision Text: 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.

AUTOMATIC REACTOR SCRAM

"At 1826 EDT on July 21, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed due to a trip of the Main Turbine.

"Unit 1 reactor was operating at 100 percent reactor power with no evolutions in progress. The Control Room received indication of a Main Turbine trip with both divisions of RPS [Reactor Protection System] actuated and all control rods inserted. The Reactor Recirculation Pumps tripped on EOC-RPT [end of cycle recirculation pump trip]. Reactor water level lowered to +8 inches causing Level 3 (+13 inches) isolations. No ECCS [Emergency Core Cooling Systems] or RCIC [Reactor Core Isolation Cooling system] actuations occurred. The Operations crew subsequently maintained reactor water level at the normal operating band using Reactor Feed Water.

"The reactor is currently stable in Mode 3 with main condenser available. Investigation into the trip of the Main Turbine is in progress.

"The NRC Resident Inspector was notified. A voluntary notification to PEMA will be made.

"This event requires a 4 hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B)."