Event Notification Report for August 08, 2022

LOST IODINE-125 IMPLANT SEED

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

On 7/1/22 a 200 microCurie I-125 implant seed was lost. The seed was discovered to be missing on 7/5/22. Licensee staff verified that the seed had arrived in the pathology lab. A survey of the lab was performed and showed that the seed was not in the lab, in the trash, in the sample, and did not remain in the patient. The licensee believes the seed was most likely washed down a drain.

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

MISSING RADIOACTIVE MATERIAL SHIPMENT

The following summary was provided by the licensee via email and phone:

Two packages were tendered to a common carrier on July 1, 2022. One of two packages was lost during transport and handling. The last known status was at the common carrier's distribution facility in Memphis, TN on July 8, 2022. The lost package contains a liquid salt solution with an activity of 11.844 GBq (0.3201 Curies) of Thallium 201 (Tl-201). A written report shall be completed and submitted to the NRC pursuant to 10 CFR 20.2201(b). A search of the licensee's facility was not successful. An ongoing search is in progress at the Memphis facility.

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 - STOLEN MOISTURE DENSITY GAUGE

The following summary was received from the Tennessee Division of Radiological Health via email:

At 1015 CDT, on 7/31/2022, a truck containing a density gauge was stolen. The gauge was secured and locked in a company work truck near the 4600 Block of Summer Avenue in Memphis, TN. A report has been filed with Memphis Police Department. The gauge is a Instrotek 3500 Xplorer, (SN: 4492) with 40 milliCuries of Am-241 (Source SN: K481/21) and 10 milliCuries of Cs-137 (Source SN: BG1480).

Corrective actions or reports will be updated with a report within 30 days.

TN incident no.: TN-22-056


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: 8/5/2022

EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL SHIPMENT

The following information was received from the Massachusetts Radiation Control Program via email:

"The licensee (QSA Global, Inc., License No. 12-8361) reported at 1359 EDT on August 1, 2022 that it discovered on same day (August 1, 2022) at 1303 EDT that two packages (Yellow-III, Type B(U)) containing 12 sealed sources (Ir-192; 1279.4 Ci total) were reported missing by the shipper, QSA Global.

"Package 1 was shipped on July 19, 2022 in two pieces and one of the pieces containing 4 Ir-192 sources (430.2 Ci) was reported missing. Package 2, also reported as missing, was shipped on July 20, 2022 containing 8 Ir-192 sources (849.2 Ci). Both packages were intended for export to Mexico. Package 1 was most recently scanned at common carrier facility in Memphis, TN on July 28. Package 2 was most recently scanned at the common carrier facility in Memphis on July 22.

"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 four-hour reporting requirement of 105 CMR 120.077(B), missing shipment of Category 2 quantity of radioactive material, also applies.

"The Agency considers this event to be open."

Notified DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk via email.

* * * UPDATE FROM BOB LOCKE TO BILL GOTT AT 1119 EDT ON 08/04/2022 * * *

The following was received from the Massachusetts Radiation Control Program via email:

"The Licensee reported at 1040 EDT on August 4, 2022 that the common carrier has confirmed all packages have been located and have arrived at their intended destination in Mexico.

"The Agency considers this event closed."

Notified internal: R1RDO (Henrion), NMSS DAY (Rivera-Capella), IR MOC (Crouch), and ILTAB (MacDonald), and via email: INES (Smith), NMSS Events Notification, and ILTAB.

Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, CWMD Watch Desk, and CNSNS Mexico.


THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

The following information was provided by the licensee via fax:

PART 21 REPORT - POTENTIAL FAILURE OF SIEMENS CIRCUIT BREAKER

"Pursuant to the requirements of 10 CFR Part 21, this letter is hereby provided as notification to the NRC of a potential Part 21 condition.

"NTS received a notification from Wolf Creek Nuclear Generating Station on June 8th 2022, that a Siemens 5-3AF-GER-350-1200-78 Medium Voltage Circuit Breaker had a failure of its closing spring mounting plate.

"Per Wolf Creek contact 'Failure of a Siemens vacuum breaker's closing spring mounting plate occurred while electrical maintenance personnel were closing the breaker ... The breaker was successfully closed: however, a piece of the closing spring's mounting plate was sheared off during the evolution. Initial investigation also determined the weld associated with the mounting bracket that secures the spring mounting plate was degraded. It appears the closing spring's mounting plate may have been impacting the back of the breaker enclosure during breaker operations ... '

"This specific breaker is non-safety related and installed in a training cubicle. However, it was delivered in a lot containing an additional fourteen safety-related breakers. Even though the failed breaker is non--safety related, NTS has made the decision to be conservative and proceed with this notification.

"Upon consultation with the manufacturer (Siemens) and Wolf Creek Nuclear Generating Station, it was decided to return the breaker to Siemens for evaluation. As of the issuance of this letter, Siemens has not received the failed breaker. This letter is being issued since the evaluation will not be completed within the 60 day period following Wolf Creek notifying NTS.

"Siemens has performed multiple 10,000 cycle endurance tests on 3AF mechanisms. Therefore, it is not believed to be a 'class' problem at this time. We are limiting this notification to the specific breaker lot provided per Wyle TPQ Test Report 43404R002, dated 6/29/2000, and Wolf Creek purchase order 0705394/4 (Rev. 4).

"Wolf Creek conducted extent of condition inspections for installed, safety-related breakers. No other breakers exhibited the same level of degradation. Additional guidance may be issued once Siemens' evaluation is complete.

"Thank you and if you have any questions, please contact NTS' Senior Director of Nuclear Engineering and Test Services, Gary Dennis at (256) 716-4212 or email at gary.dennis@ntslabs.com."


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

The licensee did not provide information regarding the evaluation completion. The Headquarters Operations Center (HOC) called the contact and is awaiting a response.