Event Notification Report for June 06, 2022

EN Revision Imported Date: 6/6/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST SEALED SOURCES IN TRANSIT

The following report was received via e-mail from the Massachusetts Radiation Control Program [the Agency]:

"The licensee (QSA Global, Inc., License No. 12-8361) reported at 0851 [EDT] on May 27, 2022 that it discovered on the same day (May 27, 2022) at 0750 [CDT] that a package (Yellow-III, T.I. 2.6, Type A) containing 9 sealed sources (Cs-137; 13.89 Ci total) was reported missing by the shipper. The package was shipped in a 924CO Type A with P496 lead shield pot.

"The package was shipped on April 15, 2022. The destination for the shipment is Schlumberger Technology Corp (c/o: NSSI), Houston, TX, 77087, TX License: L02991. QSA Global received email update on May 27, 2022 that the [common carrier] couldn't physically locate the package. The last known location according to the [common carrier] is their facility in Memphis, TN. Schlumberger Technology Corp confirmed that they have not received the package on May 27, 2022.

"The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

* * * UPDATE ON 06/03/2022 AT 1433 EDT FROM BOB LOCKE TO OSSY FONT * * *

The following information was provided by the Agency via email:

"The licensee reported at 1014 EDT on June 2, 2022, that the package had been found at the Houston, TX [common carrier] facility. It was delivered to its intended destination undamaged at 1500 EDT on June 2, 2022."

Notified R1DO (Jackson) and NMSS Events Notification and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - LOST EXIT SIGN

The following report was received via e-mail from the New Jersey Radiation Department and Release Prevention Program [the Department]:

"The Radiation Safety Officer of Rutgers University informed the Department that one H-3 (Tritium) exit sign cannot be found and is considered lost. The exit sign was last inventoried in October 2021 and was noticed to be missing in April 2022. After extensive investigation/searching, the licensee considers the sign lost. The Exit sign in question is an Isolite H-3 Exit sign, model 880-126R10BA, S/N H138883, originally containing 7.59 Ci of H-3. Rutgers will forward a written report within 30 days concerning the loss and their 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

INVALID SYSTEM ACTUATION

The following information was provided by the licensee via email:

"The following event description is based on information currently available. If, through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to describe invalid actuations of the Palo Verde Nuclear Generating Station (PVNGS) Unit 1 B Train Auxiliary Feedwater (AF) system and Essential Spray Pond (ESP) system that occurred while in a refueling outage.

"On April 11, 2022, at approximately 2045 Mountain Standard Time, an automatic start of the Unit 1 B Train AF and ESP systems occurred during restoration from a surveillance test. The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the Engineered Safety Features Actuation Systems to simulated design basis events. The test portion was completed satisfactorily; however, during the restoration portion, the load sequencer inadvertently cycled between Mode 0 and Mode 1 three times in immediate succession.

"At the time of the system actuations, one of the actuation signals associated with this portion of the test had been reset per procedure. Another actuation signal was still in while restoration steps were ongoing, but the sequencer was not expected to cycle between Modes. The system actuations did not occur as a result of actual plant conditions or parameters and are therefore invalid.

"The Unit 1 B Train AF and ESP system actuations were complete and the systems started and functioned successfully. For the systems that did not actuate, the reasons are clearly understood as those systems were in an overridden condition due to test configuration.

"The spurious actuation was not able to be replicated and a direct cause was not identified. There were no adverse impacts to public health and safety nor to plant employees.

"The NRC Resident Inspectors have been informed."

EN Revision Imported Date: 6/7/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOPHARMACEUTICAL PACKAGE

The following was received from the Illinois Emergency Management Agency (the agency) via email:

"The Agency was contacted on 5/5/22, by GE Healthcare to advise that a radiopharmaceutical package was damaged in transit and reported as lost at the carrier's facility. GE Healthcare reports the 6 inch x 6 inch package (UN2915, Type A Package, Yellow II, TI 0.1) was shipped from Arlington Heights, IL to Richland, MS on 5/3/22. The package contained a lead shielded container with 1.956 mCi of In-111 (activity at the time of shipment on 5/3/22). The package reportedly arrived in one piece at the [common carrier's] Memphis hub on 5/3/22. On 5/5/22, the carrier advised the licensee that they had found the damaged package at their Memphis hub with its inner contents missing. Dangerous Goods is currently working with the shipper and conducting a search of the facility. The package now contains approximately 1.2 mCi [of In-111].

"There is no indication of intentional theft or diversion, and the contents would not be useful for illicit intent.

"This matter has a 30-day reporting requirement to the US NRC. Updates will be provided as they become available."

Item Number: IL220015

* * * UPDATE ON 6/6/22 AT 1106 FROM GARY FORSEE TO KERBY SCALES * * *

The following was received from the Illinois Emergency Management Agency (the agency) via email:

"On 6/6/22, the licensee provided the required written report. The carrier has not provided any updates and the package is still lost. At this point, the radioactive material has decayed to less than 0.5 uCi. Pending no additional developments, this matter is considered closed."

Notified R3DO (Szwarc) and R1DO (Grieves), and NMSS Event Notifications and ILTAB 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: 6/2/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST GAUGE LOCATED IN OKLAHOMA

The following information was provided by the Illinois Emergency Management Agency (IEMA, The Agency) via email:

"On 05/17/22, a shipment of scrap metal being hauled from Sallisaw, OK to Rogers, AR tripped a portal monitor at the receiving recycling company. It was returned to Oklahoma under DOT-SP AR-OK-22-007. The load was surveyed once returned to Oklahoma and a Thermo Measure Tech model 5201 fixed gauge containing 50 mCi of Cs-137 (s/n B4473) was identified.

"The gauge has since been isolated in a drum and secured in a shed at the Oklahoma recycling facility. Efforts to identify the owner resulted in a call from Oklahoma Department of Environmental Quality (OK DEQ) to the Illinois program on 5/27/22. IEMA staff were able to identify Mid America Dredging in Good Hope, IL as the owner. Mid America Dredging is registered with the Agency under #9223884 and last reported the gauge as present on 2/15/22.

"Agency staff requested the licensee confirm the gauge was on site and send pictures. Apparently, the `device' the registrant has been exercising control over since 2015 was the outer housing for the gauge which may have a secondary label according to the Sealed Source and Device (SSD) sheet. The licensee suspects the gauge was inadvertently disposed of or abandoned during work in Sallisaw, OK in or around 2015.

"IEMA will address noncompliance with the registrant. This device is generally licensed and registered under 32 Ill. Adm. Code 330.220(a)(4). Due to the activity involved, any loss, theft or diversion is immediately reportable under 32 Ill. Adm. Code 340.1210(a). The registrant did not report, nor was seemingly aware of the loss.

"OK DEQ notified the Headquarters Operations Officer on 5/18/22, and provided an update on 5/27/22. This NMED entry is made to document IEMA actions and track until the gauge is properly returned and/or disposed of. Updates will be provided as they become available."

Reference Event Number 55900 for the initial notification from OK DEQ to the NRC.

AGREEMENT STATE REPORT - DOSE TO EMBRYO/FETUS

The following was received from the Illinois Emergency Management Agency (IEMA) via email:

"The RSO [(Radiation Safety Officer)] for the licensee contacted IEMA to report that on March 2, 2022, a patient was administered a 100 mCi I-131 dose. A pregnancy test was performed in advance of the administration and indicated negative (not pregnant). On April 13, 2022, the RSO received a call notifying him the patient was determined to be 7 days pregnant when the administration occurred. The patient was informed and returned to the hospital to do a whole-body count as a means to estimate biological half-life. The licensee has calculated upwards of 20 microCi of I-131 was retained by week eleven of the pregnancy and 75 percent was taken up by the fetus. Dose prior to eleven weeks was reportedly estimated as that to the maternal uterus (ICRP 88 states this is accurate to 8 weeks). It is unclear if the calculation methodology used was consistent with RG 8.36 (NUREG/CR-5631) or ICRP 88 but will be reviewed when staff investigate.

"The licensee is estimating the dose to the fetus through 12 weeks of development as 266 mGy (26.6 rads)."

Illinois Item Number: IL220018

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health via email:

"On May 31, 2022, the RSO of Alta California Geotechnical, Inc. (Alta), contacted the Brea office of the California Department of Public Health to report a stolen moisture density gauge. The gauge was a CPN model MC-3 S/N M3811862 (10 mCi Cs-137, 50 mCi Am-241:Be). On May 27, at approximately 1700 PDT, the gauge was placed in a locked Mobile Mini (temporary storage) container in a fenced (also locked) area of the construction site in Jurupa Valley, California. The theft occurred sometime between Friday, May 27 and Tuesday, May 31. When Alta personnel arrived at the construction site at approximately 0500 PDT Tuesday morning, they discovered that the storage container lock (a hidden shank/"hockey puck" style) was drilled through and the locked transportation case containing the gauge was removed, along with other equipment. Alta personnel searched the surrounding area until approximately 0630 PDT and then contacted the Riverside County Sheriff to report the theft. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."

5010 Number: 053122

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