Event Notification Report for November 10, 2021

EN Revision Imported Date: 11/10/2021

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: 11/10/2021

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: 11/10/2021

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

EN Revision Imported Date: 11/12/2021

EN Revision Text: AGREEMENT STATE REPORT - FIRE IN POOL IRRADIATOR FACILITY

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

"The [Illinois Emergency Management] Agency was contacted at approximately 16:00 [CDT] on 11/2/21 by Isomedix Operations, Inc. (d/b/a Steris Applied Sterizliation Technologies, RML IL-01123-02) to advise of a fire in one of their irradiation cells that occurred at approximately 05:00 [CDT] this morning in Libertyville, IL. Sources, irradiator lift mechanisms, and associated safety/security systems were reportedly unaffected. Local fire personnel did respond, but maintenance crew were able to extinguish the fire prior to their arrival. This matter is reportable under 32 Ill. Adm. Code 346.830(a)(2).

"The radiation safety officer for Isomedix Operations, contacted the Agency at 16:00 [CDT] today and informed of a fire in a radiation room at their pool irradiator facility. Reportedly, maintenance crews were performing overhead welding in the source room when hot slag fell on a product tote. The tote was located near the portal entry of irradiator 192. The fire alarm was pulled and the maintenance crew was able to put out the fire using a handheld extinguisher. Local fire arrived, performed an investigation and departed without further concern. The irradiator was removed from service as Isomedix staff spent the duration of the day assessing safety systems. Water purity checks and exposure rates indicate no impacts to sources. Cables, cable shrouds and associated lifting mechanisms were assessed and were not impacted. Having found no additional radiological or safety mechanisms impacted, the facility returned to routine operations at 16:00 [CDT] today.

"IEMA staff are pursuing additional information from the licensee and performing a reactionary inspection on 11/3/21. Additional information will be communicated as it becomes available."

Illinois Report Number : IL210036

EN Revision Imported Date: 11/12/2021

EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MEDICAL EVENT

The following information was received from the Commonwealth of Massachusetts via email:

"On November 2, 2021, 3:00 PM [EDT], licensee reported medical event under license 60-0160 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a Y-90 5 mCi microsphere therapy treatment delivered to patient liver on November 2, 2021 remained in the delivery system causing delivery of approximately 3.67 mCi Y-90 of the prescribed 5 mCi. The error was discovered immediately after treatment. Administered dose to treatment area differed from prescribed dose by approximately 27 percent. Licensee stated the cause, including possible equipment malfunction, has not yet been determined. Prescribing physician, referring physician and patient have been notified. Licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment would be required due to this situation. Licensee stated all Y-90 was accounted for. Licensee stated 5 mCi prescription was unusually small compared to previous procedures (range 9-to-39 mCi with 15 mCi being the most prescribed dose). Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation.

Investigation ongoing. Agency considers this event docket to still be OPEN.

Report by Anthony Carpenito, 11/3/2021.

EN Revision Imported Date: 11/12/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING MOISTURE DENSITY GAUGE

The following information was received from the State of Texas via email:

"On November 3, 2021, a licensee reported a moisture density gauge was discovered missing on August 30, 2021. The licensee's attempts to locate the gauge were unsuccessful. The licensee last had eyes on the gauge during the previous inventory in January of 2021. The gauge is a Humbolt model 5001 serial 7442 containing 10 mCi of Cs-137 with serial 2376CZ and 40 mCi of Am-241 with serial 404-09. The empty transport container with locks on the latches was present at the licensee's storage location. The gauge may not be inside a transport container. The licensee was unsure if a lock was present on the source rod. The incident was reported to the local police department. More information will be provided per SA 300 as it is obtained."

Texas incident no.: 9892

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: 11/10/2021

EN Revision Text: 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.

EN Revision Imported Date: 11/12/2021

EN Revision Text: OFFSITE NOTIFICATION DUE TO VIOLATION OF DISCHARGE PERMIT

"At 1040 hours EST, November 9, 2021, the site reported a violation of the station National Pollutant Discharge Elimination System permit. The 24-hour environmental report addressed an unauthorized discharge of 7,245 gallons of non-radiological water that was pumped into a storm drain to de-water an on-site electrical vault located outside of the protected area. This discharge occurred from 0800 to 1230 hours on November 8, 2021. Sampling and analysis of the vault water is in progress to assess for the presence of pollutants.

"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

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

The licensee notified the U.S. Environmental Protection Agency and the Commonwealth of Massachusetts Department of Environmental Protection.

EN Revision Imported Date: 11/12/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN GUAGE

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

"On May 30, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that a Humboldt model 5001 EZ was stolen from a truck parked overnight at a technician's home. The gauge contains a 40 millicurie americium - 241 source and an 10 millicurie cesium - 137 source. The technician had taken the gauge home on May 29, 2021. The gauge was locked in the truck with two independent chains and locks. The technician went to their truck at 0900 [CDT] on May 30, 2021 and found both were cut and the transport case and the gauge were stolen. The RSO stated the operating arm was locked in the shielded position. The RSO stated the technician drove around in the immediate area in an attempt to find the gauge. The RSO stated local law enforcement had been notified. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9852

* * * UPDATE ON 11/10/21 AT 1727 EST FROM ART TUCKER (VIA EMAIL) TO HOWIE CROUCH * * *

"On November 10, 2021, the Agency was notified by the licensee that they had recovered the missing gauge on November 2, 2021. The licensee confirmed that the gauge cesium operating rod was locked in the shielded position. The licensee agreed to submit a written report to the Agency providing additional information."

Notified R4DO (Gaddy), Mexico CNSNS, ILTAB and NMSS Event Notifications via 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

EN Revision Imported Date: 11/12/2021

EN Revision Text: AGREEMENT STATE REPORT - IMPROPER SOURCE SHIPMENT

The following was received from the Louisiana Department of Environmental Quality (DEQ) via email:

"Louisiana DEQ was notified by Source Production & Equipment (SPEC) Radiation Safety Officer, via the DEQ Radiation Hotline at approximately 1045 CDT on November 5, 2021, concerning an industrial radiography camera shipment from Nigeria. According to the RSO, Dynaquest Energy Limited in Nigeria wanted to exchange three Industrial Radiography Ir-192 sources. When the package was received, two of the drums had the Industrial Radiography cameras (SPEC 150) and the other drum did not have a camera just the unshielded source. The unshielded source was in the type B container without a camera. The source is an Ir-192 with 0.06987 Ci. The reading on the side of the drum was 300 mR/hr and the reading from the top of the drum with the lid off was 40 - 50 mR/hr. SPEC retrieved the source and put it in a shield. The individual that was handling the package and retrieval received 5 mR exposure. The two cameras were a SPEC 150 (s/n 2619) with Ir-192 source s/n AF2815 and SPEC 150 (s/n 2618) with Ir-192 source s/n AF2814 and were locked. SPEC 150 (s/n 2618) did not have a locking cap on it even though the camera was locked. SPEC stated that they will hold on to the devices and terminate their relationship with Dynaquest Energy Limited."

Louisiana Event Report ID Number: LA 202100010

EN Revision Imported Date: 11/12/2021

EN Revision Text: TECHNICAL SPECIFICATION VIOLATION

"This is a required notification per University Of Missouri Research Reactor (MURR) Technical Specification (TS) 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, had occurred. MURR was not in compliance with one Limiting Conditions of Operations (LCO). TS 3.2.f states, 'The reactor shall not be operated unless the following rod run-in functions are operable.' Specifically, the rod run-in function that occurs when water level in the anti-siphon system is greater than or equal to 6 inches above the anti-siphon isolation valves was not operable as required by TS 3.2.f.6.

"On 11/8/21 while the reactor was shut down for maintenance and conducting surveillance testing on the anti-siphon system high level rod run-in instrument channel, the surveillance testing provided measurement that indicated the rod run-in actuation may not have occurred until water level was slightly greater than 6 inches above the anti-siphon isolation valves. Previously on 4/22/2021, the anti-siphon system high level rod run-in instrument channel activated the rod run-in well below the top of the anti-siphon isolation valves.

"Troubleshooting revealed the stainless-steel cable that connects the channel's level controller to its suspended displacer (float) had developed loops in it, effectively shortening the cable. The cable with loops made the rod run-in actuation occur at a higher water level than when the cable has no loops in it. The loops in the cable were removed. The instrument channel was retested and documented to be back in compliance with TS 3.2.f.6.

"On 11/9/21, MURR engineers analyzed the data collected from the 11/8/21 measurement and concluded that prior to removing the loops from the level controller cable, the rod run-in was actuating at a level of approximately 7.3 inches above the anti-siphon isolation valves, which is greater than the maximum of 6 inches above the valves required by TS 3.2.f.6.

"In accordance with TS 6.6.c(4) before it was known if MURR deviated from TS 3.2.f.6, the Acting Reactor Facility Director was briefed and gave permission to restart the reactor prior to the reactor returning to operation later on 11/8/21. Currently, MURR is operating at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3)."

OFFSITE NOTIFICATION DUE TO PCB OIL SPILL

"At 1515 EST on 11/10/21, approximately 89 gallons of PCB oil is unaccounted for from the Substation 'N' Transformer, located in the Owner Controlled Area. Transformer nameplate oil capacity is 569 gallons. Prior to removal of the original Substation 'N' Transformer, approximately 475 gallons of 10-CA-OIL (PCB Oil) was evacuated and stored by HEPACO (a licensee vendor). Approximately 5 gallons of oil is inaccessible to evacuate and remains in the original transformer. Below the transformer was evidence of oil leakage to the ground. The leakage appears to have been occurring over time, not as a result of a catastrophic failure. This condition is reportable to the Virginia Department of Environmental Quality (VA DEQ). The VA DEQ was notified of this condition at 1815 on 11/10/21. Cleanup activities are on-going.

"This event is reportable in accordance with 10CFR50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'"

The licensee will be notifying the Louisa County administrator and has notified the NRC Resident Inspector.