Event Notification Report for December 28, 2021

EN Revision Imported Date: 12/28/2021

EN Revision Text: LOST SURVEY INSTRUMENT

The following information was received from the Radiation Safety Officer (RSO) at the Environmental Protection Agency (EPA), Region 8 via telephone:

On 12/13/21, the RSO received notification reporting a missing shipment containing a Ludlum Model 192 survey instrument. The survey instrument contains a 1 microCi Cs-137 source and was scheduled for calibration at a facility in Sweetwater, TX. The common carrier reported that the incorrect shipping label was placed on the survey instrument's package and sent to an unknown location. The common carrier is conducting an investigation to determine the location of the survey meter. The last location of the survey meter was in Hutchins, TX.

* * * UPDATE ON 12/27/21 AT 1350 EST FROM STEVEN MERRITT TO KERBY SCALES * * *

On 12/22/21, the common carrier recovered the lost survey instrument and delivered it to the calibration facility on 12/23/21. The package was intact and not damaged. The RSO contacted NRC Region 4 personnel.

Notified R4DO (Werner); R4 (Wardrobe), ILTAB, NMSS Events Notification, and Mexico 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: 12/28/2021

EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED WORKER

The following is a synopsis of information received from the New Mexico Radiation Control Bureau (NMRCB):

On October 22, 2019, a worker was manually drilling a container with 1080 millicuries of iridium-192 in ceramic tracer beads. The worker was not wearing eye or face shields and a puff of dust from the drilling struck the worker's face and eyes. Immediately after, the worker repeatedly washed their face and eyes. On the next day, a survey of the worker's face/eye area showed 200 mR/hr. Subsequent surveys over the next 103 days showed steadily decreasing amounts, down to 10 mR/hr at 103 days.

On June 23, 2020, the NMRCB reached out to the NRC seeking assistance in determining the individual's dose. Staff from the Office of Nuclear Material Safety and Safeguards (NMSS) and Region IV Division of Nuclear Materials Safety (DNMS) held a call with NMRCB, providing options on how to proceed, including encouraging the individual submit to a full body count. A whole body radiobioassay was performed on July 17, 2020, 272 days after the exposure. The result on the first run was 4.12 nCi and 4.34 nCi on the second run. NMRCB used RCD Radiation Protection Associates, an NRC contractor, to develop a dose assessment of the exposure event.

In a reported dated November 18, 2021, (ML21354A314) RCD Radiation Protection Associates presented results indicating a committed effective dose equivalent (CEDE) to the worker of 1.48 millirem, a shallow dose equivalent (SDE) estimated to be 663 rem, a lens dose equivalent (LDE) estimated to be 11.5 rem, and an effective dose equivalent (EDE) of 3.6 millirem.

EN Revision Imported Date: 12/28/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY DEVICE SAFETY LATCH FAILURE

The following information was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:

"On 12/17/2021, the licensee notified RHB of an incident in which an INC IR-100 (S/N 7362) radiography exposure device, containing a 54.2 Ci Ir-192 QSA Global source (S/N 55806M), failed to actuate its safety latch plate upon retracting the Ir-192 source to the fully shielded position. The incident occurred on 12/16/2021, at approximately 1900 PST, at the PBF refinery in Martinez, CA. The radiography site was approximately 150 ft. above grade, on temporary staging, and accessed by an adjacent permanent deck. The RSO [(radiation safety officer)] stated that the device was used all day without issue prior to the safety latch plate's actuation failure. The initial personnel during the incident consisted of a radiographer trainer and an assistant radiographer. The radiographer trainer noticed the failure when attempting to 'crank out' after fully retracting the source. After attempting to fully retract the source, the latch plate maintained a visibly depressed position and the source was not fully secured and free to move. The radiography trainer contacted the RSO for further assistance during which an additional radiographer trainer assisted with maintaining security of the barricaded area until the RSO and staff arrived on the site. The RSO stated that he was able to secure the source by flushing the locking mechanism with brake cleaner and that there was no excessive exposure to any personnel involved. RHB will be investigating this incident further."

CA 5010 Number: 121721

EN Revision Imported Date: 12/28/2021

EN Revision Text: AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION

The following was received from the Louisiana Department of Environmental Quality (LDEQ) via e-mail:

"On December 20, 2021, at approximately 1:55 pm, Central Standard Time, [the] Radiation Safety Officer for Rubicon, LLC, notified LDEQ of equipment malfunctions. Three Ohmart Model SH-F1 level/density gauges experienced shutter malfunctions, two installed on a vessel within the MDI-III process unit and one Model SH-F1 gauge installed on a vessel in the MDI-I processing unit. The gauges in the MDI-III unit possess two nominally 20 mCi sealed sources of Cs-137 and the gauge in MDI-I possesses a nominally 70 mCi sealed source of Cs-137. The above gauges were undergoing routine annual shutter tests when the above malfunctions were observed. The first gauge sealed source, 1566CG, installed on October 15, 2001, item 73 on the licensee's source inventory, is mounted on vessel MM-9303 in the MDI-3 unit. The second gauge source, 1567CG, installed on October 15, 2001, item 74 on the licensee's source inventory, is also mounted on vessel MM-9303. The third gauge source, 72930, installed on January 19, 1998, item 38 on the licensee's source inventory, is mounted on the P1 PI scrubber in the MDI-1 unit. [The] Zone Maintenance Coordinator, notified [the RSO] concerning the shearing of screws even with the top of each rotor on the two gauges in the MDI-III unit. [The Zone Maintenance Coordinator] also reported to the RSO that the source holder in the MDI-1 unit experienced a problem with the rotor mechanism not aligning with the shutter handle, which prevented the gauge shutter from closing fully. [The Zone Maintenance Coordinator] learned of the malfunctions during annual inventory work and reported the problem to the RSO on December 16, 2021 at approximately 2:30 pm. The situation with each gauge is under the licensee's control, and there were no exposures to members of the public approaching regulatory limits. Currently, the shutters on gauges, 73, 74, and 38 remain in the open position, as the gauge sources are needed to operate process control equipment. The gauges cannot be locked out in their current state. As a result, no vessel entries will be conducted on either vessel MM-9303 or the P1 PI scrubber vessel until the gauges are repaired by BBP Sales (BBP). Work orders have been written to correct the malfunction of all three devices. The licensee will continue to monitor the gauges and their status of repair. The licensee stated they would keep the LDEQ updated on progress of the repairs."

Louisiana Event Report ID No.: LA 210012

EN Revision Imported Date: 12/28/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOSITURE DENSITY GAUGE

The following information was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:

"On Tuesday, December 21, 2021, Anbessaw Consulting, Inc. RSO [ ] reported the theft of a CPN MC-3 (#M320500859) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi). The theft occurred overnight between Monday and Tuesday 12/20-21/2021 at an authorized gauge user's apartment complex located at 642 Montgomery Circle, Claremont, CA 91711. The AU discovered that his truck was broken into at approximately 0430 PST Tuesday 12/21/21, the truck was parked in a non-covered space in the apartment complex parking area. The AU had returned to his apartment from a jobsite in Glendora at 2100 PST Monday and was scheduled to return to the jobsite early on Tuesday. The CPN nuclear gauge handle was locked to prevent operation, the gauge was locked in its transport case, and the transport case was locked inside the truck cab. Other equipment and personal items were also stolen from the truck. A police report was filed with the Claremont police department (DR# 2103145). The licensee also submitted a reward ad in the local Daily Breeze stolen section which will run from 12/23-29/2021."

CA 5010 Number: 122121

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

LOSS OF SIREN SYSTEM

The following information was provided by the licensee via email:

"On December 27, 2021, at 1014 EST, a system error in the site's Alert and Notification Siren System was identified, indicating a loss of the siren system affecting a greater than 25% of the emergency planning zone population. Review of the system's data logger indicates the system error has been present within the system since December 22, 2021, at 1245 EST.

"The fleet's telecommunications department has been contacted and is aware of the issue. In the event that a radiological emergency should occur at the Shearon Harris Nuclear Power Plant, Primary Route Alerting procedures will be put in use by the local jurisdictions.

"This condition is reportable as a Loss of Emergency Preparedness Capabilities per 10 CFR 50.72(b)(3)(xiii).

"The NRC Resident, state and local agencies have been notified."