Event Notification Report for June 24, 2022

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the Minnesota Department of Health (MDH) via email:

"We (MDH) received an initial report on 6/15/22 at 1515 CDT of a reportable medical event. The event occurred at the University of Minnesota, license number 1049, in Minneapolis on 6/14/22. The event involved a treatment with Y-90 SirSpheres where 2.2 GBq was ordered but a 5.1 GBq unit dose was delivered and administered. The licensee is working through dose calculations. No additional details are available at this time. Follow up information will be sent when it becomes available."

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.

AGREEMENT STATE REPORT - LOSS OF TWO TRITIUM EXIT SIGNS

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

Upon inventory inspection, Frenchman Valley discovered that two tritium exit signs that had been in their possession had been replaced. The property was then thoroughly searched twice and the signs were not located. The whereabouts of the signs are unknown and no replacement records were found.

The signs were manufactured by Isolite. Both signs were model SLX60. The serial numbers were 12-01067 and 12-01068 with each sign containing 8 Curies of tritium.

Nebraska Item Number: NE220002


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

AGREEMENT STATE REPORT - SOURCE DETACHED FROM PORTABLE GAUGE

The following information was received via E-mail:

"During the morning of 6/16/22, a portable gauge user noticed that the tub and the radioactive source were detached from the gauge cable and stuck approximately 5 ft. underground when the user was trying to retrieve the tub and the source back to the gauge. The portable gauge is a CPN model 503, serial number 50543, containing 50 mCi of americium-241:beryllium. The sealed source is not compromised.

"This event occurred in Kersey, Colorado."

Colorado Event Report ID No.: CO220017

AGREEMENT STATE REPORT - SHIPMENT LOST THEN FOUND

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

"Representatives for Bard Brachytherapy contacted IEMA at close of business on 6/16/22 to report a shipment of I-125 brachytherapy seeds in route from their Carol Stream, IL facility to Tortola in the British Virgin Islands could not be accounted for after a flight change in Miami, FL. The shipment consisted of two overpacks: One containing five boxes with 350 seeds and a cumulative activity of 241 mCi, and one containing four boxes with 385 seeds and a cumulative activity of 265 mCi. The licensee shipped the packages on 6/7/2022 to O'Hare airport where they were received [and] placed on a commercial flight to Miami. After arrival at Miami, the packages missed two different flights scheduled for Tortola. After an inquiry by the licensee, the carrier reported the package could not be immediately accounted for.

"The incident was reported to IEMA shortly before 1600 CDT and then notification was received at 1627 CDT that the packages were located. This matter is considered closed.

"There were no breaches to packages reported and no resulting public exposures. The packages remained incident to transportation and secure.

"Due to the activity involved (A > 1000x the value in Appendix C to 10 CFR Part 20), the loss is immediately reportable under 32 Ill. Adm. Code 340.1210 and 10 CFR 20.2201(a)(1)(i). Unlike missing shipments of lesser activity, a review of SA-300, Appendix A reporting requirements doesn't give the same caveat that the package must still be missing at the time of reporting."

Illinois # IL220020

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: 6/22/2022

EN Revision Text: CONTROL ROOM VENTILATION AND CONTROL AREA CHILLED WATER SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 2240 on 06/21/2022, it was discovered that both required trains of Control Room Ventilation and Control Area Chilled Water System were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(v)(d).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The 'B' train was restored at 2315.

LOSS OF AN ITEM RELIED ON FOR SAFETY

The following information was provided by the licensee via email:

"The plant is in a safe condition.

"On June 21, 2022, while performing a routine management observation, an employee noticed that only a single individual was performing the administrative actions required to implement both [items relied on for safety] IROFS 50b and IROFS 50c. These IROFS are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61. Since only one individual was performing the administrative action, the independence of the IROFS was not being maintained and the performance requirement of 10 CFR 70.61 was not being met. At the time of the event, there were not any heavy vehicles that threatened damage to equipment.

"[Urenco USA] (UUSA) is reporting this event per 10 CFR 70. Appendix A(b)(2).

"All work that requires utilizing person(s) to control the proximity of vehicles to equipment that could release UF6 has been stopped. This issue has been entered in UUSA's corrective action program as EV 152996."

The licensee will notify the NRC Regional inspector.