Event Notification Report for August 23, 2021

EN Revision Imported Date: 8/23/2021

EN Revision Text: STOLEN SOURCE REPORT

The following is a summary of a report by Customs and Border Patrol received via telephone:

Five sources were stolen from the back of a truck while it was parked in a hotel lot in the Miami area, after the lock on the truck was broken. The sources were being transported to calibrate Radiation Portal Monitors at Customs and Border Patrol offices in the Miami area.

The theft was reported to the US NRC Region 1 Office and the Miami-Dade Police Department (report number: PD210812-254442).

Source details: Cf-252, 5.16 microCuries (S/N: N7-402); Co-57, 75.44 microCuries (S/N: 2187-53-6); Co-60, 9.3 microCuries (S/N: 2185-40-6); Ba-133, 6.7 microCuries (S/N: 1794-56-5); and Cs-137, 6.79 microCuries (S/N: 1288-76-5).

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: 8/23/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:

"Loyola University Medical Center contacted the Agency this afternoon to report a medical underdose of Lu-177 that occurred today, August 13, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.

"[The] Radiation Safety Officer for the licensee contacted the Agency at approximately 1500 CDT on August 13, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 14 percent of the dose prescribed (28 mCi) in the written directive. The underdosing was intentionally aborted by the authorized user after the patient advised they had received the planned chemotherapy injection the day before, rather than after the radiopharmaceutical administration per procedure. The licensee is investigating root cause. The licensee is calculating organ dose to the kidney, but preliminary estimates are 67 rad. If the dose falls beneath 50 rad, the incident may be retracted. Notification to the patient and the referring physician has been completed. Agency inspectors are awaiting additional information but plan a reactive inspection within 10 days. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated as additional information becomes available."

Illinois NMED Report No.: IL210024

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: 8/23/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following information was obtained from the Arkansas Department of Health (the Department) via email:

"The Agreement State Radioactive Materials Licensee immediately reported to the State of Arkansas, Arkansas Department of Health, at 0930 CDT on August 16, 2021, that a Troxler 3430 (Device SN: 22686; Cs-137 SN: 75-4448; Am-241/Be SN: 47-18528) portable gauge fell off a truck in Maumelle, Arkansas, and the gauge was lost. At 0955 CDT hours on August 16, 2021, a Member of the Public notified the Agreement State Radioactive Materials Program that the Troxler 3430 gauge was found on the road and is being held in the bed of pick-up truck at a local gas station. The Agreement State Radioactive Materials Program personnel and Agreement State Radioactive Materials Licensee met with said Member of the Public for exchange to licensee. The found Troxler 3430 had minor damage by screws being exposed on bottom of the gauge. The sealed sources and gauge appear to remain intact during the Department's inspection. Exposure surveys were performed by the Department with the surface of portable gauge reading 2.5 mR/hr maximum. Leak tests were performed by the Radiation Safety Officer during the Department's event response and inspection.

"Pending outcome of the leak tests by the licensee, it is not expected that the Member of the Public will exceed the dose limits for Individual Members of the Public. The Member of the Public stated he/she only picked-up the gauge to place into the bed of truck."

Arkansas State Event Report ID Number: AR-2021-006

EN Revision Imported Date: 8/23/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN XRF LEAD PAINT ANALYZER

The following was received from the Maryland Department of Environment Radiological Health Program via email:

"On August 11, 2021, at approximately 1630 EDT, the Radiological Safety Officer (RSO) who is the authorized user put down the locked [Lead-Paint Analyzer] (LPA) (XRF case, with the XRF device inside) on the sidewalk next to his vehicle that was parked on the corner of Pennsylvania Avenue and Laurens Street in Baltimore City, Maryland after testing the exterior of a property nearby on Pennsylvania Avenue. The RSO was moving a few items around the trunk of his car to better place a ladder and went to grab the XRF case, it was gone. The RSO made the effort to check for the LPA around the block and asked individuals in the area, but the attempt was unsuccessful.

"On August 12, 2021, at about 1415 EDT the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone by the RSO of 100 percent Lead Inspections that a portable Lead-Paint Analyzer (LPA) was missing from 100 percent Lead Inspections, LLC (license number MD-05-244-01). The Lead-Paint Analyzer was identified as Viken Detection (formerly known as Heuresis), model pb200i XRF, device serial number 2861 with nominal activities of 6 milliCi of Co-57 source (on 11/15/2020), and source model A3901-02 and source serial number T3-296.

"The event has been later reported to the Baltimore City Police Department, in Baltimore; the Incident Number 1-210803237.

"MDE/RHP will conduct a reactive investigation."



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: 8/23/2021

EN Revision Text: PERSONNEL VIOLATED FFD POLICY

A covered employee had a confirmed positive during a for-cause fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

EN Revision Imported Date: 8/23/2021

EN Revision Text: FITNESS FOR DUTY REPORT

A licensed operator failed a pre-access authorization test specified by the FFD testing program test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

EN Revision Imported Date: 8/23/2021

EN Revision Text: AUXILIARY BUILDING GAS TREATMENT SYSTEMS INOPERABLE

"At 0905 EDT, it was discovered both trains of Auxiliary Building Gas Treatment System (ABGTS) were simultaneously INOPERABLE due to the auxiliary building secondary containment enclosure (ABSCE) being inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v).

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

ABSCE and ABGTS were returned to operable.

EN Revision Imported Date: 8/23/2021

EN Revision Text: HPCI DECLARED INOPERABLE

"At 0529 EDT on August 22, 2021, HPCI [(High Pressure Coolant Injection System)] was declared inoperable due to receiving the HPCI Inverter Circuit Failure annunciator. The cause of the annunciator was a fuse failure. The cause of the fuse failure is unknown at this time and is under investigation. Concurrent with the HPCI fuse failure was a similar fuse failure within the Division 2 EDG [(emergency diesel generators)] Load Sequencer which renders the Division 2 EDGs inoperable. Relation to the HPCI issue is unknown and is part of the investigation.

"The RCIC [(Reactor Core Isolation Cooling System)] was verified operable per Tech Spec 3.5.1 E.1. In addition, offsite circuits were verified operable per Tech Spec 3.8.1.B. Division 1 EDGs remain operable.

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"There was no impact on the health and safety of the public or plant personnel.

"The Senior NRC Resident Inspector has been notified."