Event Notification Report for November 09, 2021

EN Revision Imported Date: 11/9/2021

EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE

During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.

On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).

The licensee will notify the NRC Region 2.

* * * UPDATE ON 11/8/21 AT 1502 FROM BLAKE BIXEMAN TO KERBY SCALES * * *
During the Apparent Cause Evaluation related to Event Notification 55480, an extent of condition was performed. This extent of condition revealed three historical examples of inaudible CAAS alarms that were not reported under 10 CFR 70.50(b)(2) as required by regulation.
These conditions occurred on April 12th, 2014, August 15th, 2014, and August 20th, 2015.

Corrective actions were implemented for these deficiencies during the approximate time period in which they were identified. The affected systems are currently compliant with 10 CFR 70.24 regulations. Details of this extent of condition are documented in UUSA's Corrective Action Program, EV 148663.

The licensee notified NRC Region 2 personnel.

Notified R2DO (Miller) and NMSS Event Notifications via email.

EN Revision Imported Date: 11/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED

The following information was received from the Arizona Department of Health Services (the Department) via email:

"On November 2, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, two IsoAid Advantage I-125 breast localization seeds were removed by surgery on October 29, 2021 and were verified to be included in the specimen. The specimen with the seeds was delivered to pathology on the afternoon of October 29, 2021. The seeds were not removed from the specimen until November 1, 2021 by pathology. At this time, pathology was only able to locate one of the I-125 seeds. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the one missing I-125 seed. [The missing I-125 seed was between 0.3 and 0.4 microcuries.] The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona Incident No: 21-008

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: 11/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED

The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:

"The Agency was notified at 12:46 CDT on November 2, 2021 by the University of Illinois at Chicago to advise of a lost/missing 2.5 mCi I-125 eye plaque brachytherapy seed. The amount and form of radioactivity contained in the seed would not be useful for illicit intent and there is no indication of intentional theft or diversion. The quantity, however, is reportable and will be transmitted to the US NRC electronically today.

"The Radiation Safety Officer, RSO, for the University of Illinois at Chicago (UIC) contacted the Agency to advise that a shipment of 21 eye plaque brachytherapy seeds from Theragenics Corporation received on September 27, 2021 was found to contain only 20 seeds upon opening of the package. The RSO reported that no damage to the package was observed and that the container holding the seeds was appropriately sealed. Surveys were performed of packing materials and the package receipt area to locate the potentially lost 2.5 mCi I-125 brachytherapy seed. The licensee's surveys and investigation did not result in locating the seed. Theragenics was notified on September 27, 2021 and initiated an investigation. A letter received by UIC from Theragenics on November 1, 2021 stated that no discrepancies were identified and the manufacturer/shipper maintained 21 seeds were shipped as ordered. An additional seed was ordered and received on September 28, 2021 from Theragenics and the patient treatment was successfully completed on September 30, 2021 to October 4, 2021.

"The incident is immediately reportable per 32 Ill. Adm. Code 340.1210(a). The matter was not reported timely by the licensee, which the Agency will address under separate correspondence. Additional information is being sought from the licensee at this time."

Illinois Item Number: IL210035

EN Revision Imported Date: 11/9/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"The licensee was at a temporary jobsite and stepped away from their vehicle. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case. The licensee notified the police and has begun actions to recover the gauge. The Division is waiting for additional information from the licensee. "

Utah Event Report ID Number: UT 210006

* * * UPDATE FROM SPENCER WICKHAM TO THOMAS KENDZIA AT 1259 EDT ON 11/4/21 * * *
The following information was received via e-mail:

"At the time of this notification (UT 210006) we did not have information pertaining to the gauge. Please see the following gauge information.
Model: Instrotek 3500, Serial Number: 3823, Cs-137: 11 mCi, Am-241: 44 mCi.

"The licensee has recovered the stolen gauge. The gauge was still locked and chained in the transport vehicle in it's transport package and had not been tampered with. The Division will update and send the NMED report once the event is closed."

Notified R4DO (KOZAL), NMSS Events Notification group (email), and ILTAB (email).

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

OFFSITE NOTIFICATION

"At 1015 CST, a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-10, Auxiliary Boiler Fuel Oil Storage Tank. The tank was removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to historical information from a similar tank removal earlier this year (June 2021). The soil contamination levels are from the historic use of the tank. The contamination levels [of Volatile Organic Compounds] are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. There was no contamination noted in the groundwater samples. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40 CFR280.10(c)(4).

"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."

The licensee will notify NRC Region 4 personnel.