Event Notification Report for August 24, 2021

EN Revision Imported Date: 8/24/2021

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: 8/24/2021

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: 8/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE-125 SEED

The following information was obtained from the State of North Carolina via email:

"On 25 August 2020, an iodine-125 (I-125) seed was implanted into a perirectal mass in a patient for the purpose of localization and excisional biopsy. Following implantation, the Imaging team surveyed the needle and patient with a Geiger-Mueller detector per standard procedure to confirm proper placement of the seed within the mass. In addition, a post-implantation CT scan confirmed the presence of the seed within the mass. The seed and patient data were entered into the on-line 'Seed Tracker' software by the Imaging team per standard procedure. Excision of the tumor containing the seed was planned for the next day, and the patient was discharged home.

"At the time of surgery on 26 August 2020, the operative team was unable to detect the seed within the mass. Although the absence of the seed was documented in the operative note, the surgical team did not report that unusual occurrence to the Imaging team or the Radiation Safety Division. The specimen, which contained no seed and was not labeled as containing a seed, was sent to Surgical Pathology as a routine specimen and was processed as such. However, the Surgical Pathology team failed to notice that an entry for that patient and seed had been made in the 'Seed Tracker'. The error was not detected until an audit of the information in the 'Seed Tracker' was performed by staff of the Imaging teams and the Radiopharmacy in July 2021. The discrepancy between the 'Seed Tracker' data and the labeling and processing of the specimen as 'non-radioactive' was resolved when the surgical team's operative note was consulted. Because locating the seed would have been unlikely and impractical after 10 months (activity estimated to be 4 microcuries), our efforts were focused on investigating the root causes and identifying corrective actions.

"Probable disposition of lost material: Based upon the confirmation of seed placement in the perirectal mass by survey and CT scan, and its absence upon excision the following day, the seed most likely migrated out the implantation track and was discharged into the sanitary sewer during a bowel movement. Migration of seeds is uncommon but does occur. In this case, it would not have been noticed by the patient."

North Carolina Item Number: NC210013

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: 8/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE-125 SEEDS

The following is a summary of a report received from the state of Washington via email:

On Monday, 7/26/2021, nuclear cardiology personnel identified and reported a loss of Radioactive Seed Localization (RSL) seeds.

Background: RSL seeds are obtained by the Polyclinic as individually loaded implant needles containing one seed, in sterile, one needle use packs. Nuclear cardiology personnel receive the seed shipments, conduct the required surveys and maintain a seed inventory. Needle packs are distributed to mammography personnel on days of RSL seed implant.

On Wednesday, 7/21/2021, the seed was obtained by mammography personnel. The intent was not for RSL implant, but rather to utilize the needle for qualification of new Hologic mammography equipment. The needle pack was provided to the Hologic applications technologist for the qualification. Mammography personnel indicated that the Hologic applications technologist unexpectedly opened the needle pack and ejected the seed within the plastic sterile pack as she needed the needle not the RSL seed. Mammography personnel took the pack, and seed, and stored the pack. At the end of the day, mammography personnel indicated they taped the pack closed and returned the pack to the nuclear cardiology hot lab.

On Thursday, 7/22/2021, mammography personnel again took the needle pack from the hot lab, and utilized the needle for equipment qualification, indicating that the pack, and seed, was returned again to the nuclear cardiology hot lab at the end of the day. Mammography personnel indicate that the seed was visible in the pack at the end of the day.

On Monday, 7/26/2021, nuclear cardiology personnel indicated that the subject pack was visually inspected and no seed was identified. Nuclear cardiology personnel indicated the needle pack was surveyed with an exposure rate calibrated Ludlum 14C w/ 44-9 GM pancake and no evidence of the seed was identified. Nuclear cardiology personnel also indicated the lead foil shielded box was similarly visually inspected and surveyed and no evidence of the seed was identified.

On Tuesday, 7/27/2021, nuclear cardiology personnel surveyed the Nuclear Cardiology hot lab and other areas. Nuclear cardiology personnel indicated that no evidence of the seed presence was identified.

Washington State Incident Number: WA-21-019

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: 8/24/2021

EN Revision Text: MEDICAL TREATMENT WITH CONTAMINATION

"On August 17, 2021, at approximately 0230 [EDT], a Westinghouse employee was washing piping over a container of nitric acid in the Conversion Decontamination Area. The piping fell into the container of nitric acid and employee reached into the container to retrieve the piping and received nitric acid burns to hands and left wrist. Appropriate treatment for exposure to nitric acid was provided by on-site medical response staff. With an abundance of caution, after review with on-site medical, the employee was transported to an off site medical facility [Prisma Hospital]. Per procedure the employee's hands and arm were wrapped in plastic, and the employee was transported to an off site medical facility accompanied by plant health physics personnel for evaluation.

"Contamination was detected on the exposed area of the employee's skin during Health Physics surveys. Direct survey results were 1500 dpm/100 cm squared alpha for the left hand and 900 dpm/100 cm squared alpha for the right hand. All smear results of the exposed area were below clean area limits (<200 dpm/100 cm squared). Contamination surveys were performed in the ambulance and at the hospital and all results were below clean area limits indicating no spread of contamination during care for the employee. All potentially contaminated materials associated with the issue were collected and returned to the [Commercial Fuel Fabrication Facility] CFFF for disposal. Operator was provided with over the counter medication and released.

"The task that the employee was performing required a chemical suit, chemical gloves, fresh air bubble hood, chemical boots, and required taping the gloves to the sleeve of the acid suit jacket with chemical tape. After inspection of employee's personal protective equipment, its was noted that chemical tape was not applied to the gloves which enabled the nitric acid solution to enter the left glove and acid suit sleeve when employee reached into the nitric acid container."

NRC Regional staff was notified.

EN Revision Imported Date: 8/24/2021

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."

OFFSITE NOTIFICATION OF POTENTIAL OIL DISCHARGE

"On August 22, 2021, Columbia Generating Station determined that no more than approximately eight (8) gallons of silicone oil was inadvertently released into a plant service water system due to a failed heat exchanger on a plant installed air compressor. The plant service water system returns water to a water basin that contains at a minimum 300,000 gallons of water. The water basin is connected to the Columbia River via a blowdown line. Although not confirmed, it is suspected that an unknown quantity of silicone oil may have been released to the Columbia River. A visual inspection of the basin did not identify any oil sheen or film, and there are no additional actions needed to mitigate this issue. It does not appear the oil release poses a threat to human health or the environment, however because there could have been a discharge of an unknown quantity of silicone oil into the Columbia River this matter is immediately reportable under RCW 90.56.280 to the US Coast Guard National Response Center and Washington State Department of Ecology.

"This condition is being reported pursuant to 10 CFR 50.72(b)(2)(xi) for news release or notification of other government agencies concerning an event related to the health and safety of the public or protection of the environment. Notifications to off-site agencies were performed at 1825 PDT on 8/23/2021. The NRC resident has been informed."