Event Notification Report for September 14, 2021

EN Revision Imported Date: 9/14/2021

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).

* * * UPDATE ON 9/13/2021 AT 1201 EDT FROM SHINKYU PARK TO BRIAN LIN * * *
The following is a summary of a report by Customs and Border Patrol received via email:
At approximately 0900 EDT on August 12, 2021, the licensee discovered that five sources were stolen out of their truck that was parked at the Element Miami International Airport Hotel. The sources were stored in a shielded pelican case and are low activity sealed sources. There is no significant external radiation exposure risk and the sources are extremely robust reducing the potential for any internal exposure if the capsule were breached. A report was filed with local law enforcement.

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: 9/14/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST AMPULES FROM A TRITIUM EXIT SIGN

The following is a synopsis of information received via E-mail:

This event was originally reported via phone to the New Mexico Radiation Control Bureau on August 6, 2021.

This incident involved a double sided (2 sign faces) tritium exit sign. Specific details of the sign are: Radioactive Material: Tritium (H-3), Quantity: 7.5 Ci per sign face, Chemical and Physical form: Gas, Manufacturer: Sign Tex Inc.

This sign was located outside of the hospital building. The sign was damaged, and was then cleaned up by facilities and placed in a trash receptacle. The staff member who cleaned up the sign was confident that none of the glass ampules were broken and that all pieces were collected. The incident was then reported to the Safety Officer and the sign was removed from the waste bin. The Safety Officer then reported the sign to the RSO [Radiation Safety Officer] for guidance on how to properly dispose of the sign. Upon evaluation of the sign it was discovered that a part of one of the sign faces was missing. This piece includes the ampules which make up the letter "T" and an arrow (3 tubes total) of the sign. In addition, the sign casing was reported as missing. The activity information noted above was received from the sign manufacturer based off of the part number listed on the Order Acknowledgement document. The order date was reported as August 23, 2017. As there is no observable original date for the H-3, no decay correction was made in order to be conservative. It is currently assumed that the casing and the missing piece were disposed of, and due to the radiological properties, the piece was not detected by any waste radiation monitors. All remaining pieces of the sign are intact and were observed to glow, confirming that the ampules are not leaking.





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: 9/14/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDER-DOSING EVENT WITH Y-90 THERASPHERES

The following information was received via E-mail:

"On 8/24/21, a Y-90 TheraSphere treatment was to deliver a planned 13.65 GBq to the patient's anterior right hepatic lobe. The written instructions were followed in the usual fashion and the dose was administered to the patient. The catheter and administration set tubing were placed into the waste container. The patient, personnel, and room were surveyed. No spill was detected. Upon post-calculation measurements, it was found that the patient only received approximately 77 percent of the expected dose of 200 Gray. While the received 154 Gray was medically appropriate given the patient's condition, tumor type and tumor location, this treatment still fell below that intended on the written directive. Further investigation found that this patient was rescheduled multiple times and the dose had decayed further than it was planned to, the patient really should have been treated the day before on a Monday instead of the Tuesday to get the full dose as planned or a new Treatment Window Illustrator to secure a more appropriate Y-90 dose should have been completed. Patient and referring provider were notified. There were no contaminations verified by survey meter measurements. The licensee is currently implementing an Excel spreadsheet program to review accuracy prior to patient scheduling and dose ordered. Reporting Criteria under 10 CFR 35.3045."

Kentucky Event Report ID No.: KY210002

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: 9/14/2021

EN Revision Text: DEGRADED CONDITION IDENTIFIED WHILE UNIT SHUTDOWN

"On September 12, 2021, at 1728 EDT, with Unit 1 in Mode 5 (Cold Shutdown) while performing inspections of the North Anna Power Station Unit 1 reactor vessel head flange area, a weld leak was identified on the reactor vessel flange leak-off line that connects to the flange between the inner and outer head o-rings. Entered TRM 3.4.6 Condition B for ASME Code Class 1,2, and 3 components. With known leakage past the inner head o-ring, this condition is reported since the fault in the tubing is considered pressure boundary [Reactor Coolant System] leakage.

"This event is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(A) for any event or condition that results in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded."

The NRC Resident has been notified.

SPECIFIED SYSTEM ACTUATION

"At 0011 EDT, with Unit 2 in Mode 5 (Cold Shutdown), actuations of the 2B Diesel Generator (DG) and the 2B Motor Driven Auxiliary Feedwater (AFW) Pump occurred during Engineered Safety Features Actuation Periodic Testing while resetting the 2B DG Load Sequencer. The 2B DG was running unloaded following test actuation, and during realignment from the test, a blackout condition was experienced when the breaker opened supplying the 4160 Volt Essential Power System 2ETB from the Standby Auxiliary Power Transformer SATB. Sequencer actuation closed the emergency breaker to 2ETB and loaded the 2B Motor Driven AFW Pump onto the bus. Steam supply valves to the Turbine Driven AFW Pump were open from the previous test configuration.

"This event is being reported in accordance with 10CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 2B DG and the 2B Motor Driven AFW Pump.

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