Event Notification Report for August 23, 2022

AGREEMENT STATE REPORT - LOST RADIOACTIVE PORTABLE GAUGE

The following information was received via email:

"The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to [Environmental Protection Division] (EPD) at [1530 EDT]. The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. [The driver was unable to locate the gauge]. We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss."

The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance:
The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241).

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 - BROKEN SHUTTER

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

"On August 24, 2022 the Agency received a report of an equipment failure from a general license acknowledgement (GLA) licensee. A lead plate on the shutter was found to no longer be attached to the shutter. An initial possible cause is that vibrations allowed the lead to go through the screws and become detached. The shutter was removed from service and placed into storage. A lead blanket is covering the gauge and a survey found no elevated readings. The device is approximately 8.5 years old and contains a 200 milli-Curie Cs-137 source. Nobody was believed to have received a significant dose from this issue. The licensee is taking pictures and will try to better determine the cause. The device will be repaired by a service company on August 26, 2022. An investigation is ongoing and further information will be provided per SA-300."

Texas Reference Number: 9951

AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE

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

"On August 23, 2022, the licensee notified the Agency that a string of well logging tools containing a 1.5 curie cesium-137 source and a 15 curie americium-241 source was lodged downhole in a well in Starr County, Texas. The sources are at 8,772 foot depth. Efforts to remove approximately 1,800 feet of wireline cable from above the tool were unsuccessful. The abandonment plan has been submitted to the Agency and to the Texas Railroad Commission for review. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9950

SAFETY EQUIPMENT FAILED TO FUNCTION - CRITICALITY ACCIDENT ALARM SYSTEM LOSS OF POWER
The following information was provided by Westinghouse via email:

"At approximately 1430 [EDT] on 8/23/2022, a ground fault caused a circuit breaker to trip, causing a loss of power to the Criticality Accident Alarm System (CAAS) Stations 18 and 19 at the Columbia Fuel Fabrication Facility (CFFF). This removed all power to the stations, as the circuit breaker is between the UPS (ultimate power source) and the detectors. Upon the loss of power, a signal was received at the manned guard station, as designed, providing both visual indication and an audible alarm that Stations 18 and 19 were disabled. Notifications and actions were performed in accordance with internal response procedures. It was determined that the area of lost coverage was limited to part of the outdoor UF6 cylinder storage pad. Special Nuclear Material (SNM) movements at the UF6 cylinder storage pad were immediately suspended. No personnel were in the affected area at the time. Power was restored to the circuit at approximately 1540 and CAAS detectors 18 and 19 were placed back in operation at approximately 1600. Operations were cleared to resume at that time. A reportability evaluation was performed and determined there was redundant equipment available and operable to perform the safety function of the out of service detectors and, therefore, was not reportable.

"On 8/25/2022, site electrical engineering staff completed their causal analysis and extent of condition review of the incident on 8/23/2022. The understanding of the condition during the event was that two breakers on the sub-panel tripped, one which removed power from Criticality Stations 18 and 19.

"In fact, the ground fault caused the breaker to the sub-panel to trip and the extent of condition review on 08/25/2022 at 0919 determined that a CAAS horn loop consisting of 7 horns and one strobe light were also disabled. If the CAAS is out-of-service, CFFF is required within one hour to suspend movement and processing of SNM in the coverage area until the process is brought to a safe shutdown condition. In the unlikely event of a criticality anywhere in the plant, the emergency response is to evacuate the entire plant. Therefore, since a portion of the horn system was unavailable all SNM movements should have been suspended in the plant within an hour. It was not recognized until completion of the extent of condition review that the horn loop was out of service for approximately 90 minutes due to this incident. The fire alarm speaker system was operable at the time and the station guard would have made an announcement in the event of a criticality. The fire alarm system does not meet all the requirements in ANSI/ANS-8.3 (1997) for CAAS response.

"The condition is being reported in accordance with 10 CFR 70.50(b)(2). Specifically, the equipment required by 70.24, was inoperable for approximately 30 minutes outside the window allowed by the license, without a cessation of movement and processing of SNM, and with no redundant equipment available and operable that met all the requirements of ANSI/ANS-8.3."

The NRC Region was notified.

AGREEMENT STATE REPORT - LOSS OF I-125 BRACHYTHERAPY SEED

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

"The Agency received a phone and email report from Bard Brachytherapy [licensee] on September 2, 2022 indicating the loss of a single I-125 brachytherapy seed, accounting for a maximum estimated activity of 0.75 millicurie. The licensee's investigation leads them to believe the seed remains within their Illinois facility and the loss of accountability is a function of either operator or documentation error. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. Agency inspectors are conducting a reactionary inspection the week of September 12, 2022 for this incident and the loss reported September 1, 2022. While not representing a significant public safety concern, the quantity requires reporting to the US NRC HOO [Nuclear Regulatory Commission Headquarters Operations Officer] within 30 days.

"DETAILS: On August 23, 2022, staff at Brad Brachytherapy in Carol Stream, IL notified their manager of a missing brachytherapy seed. An investigation was opened and the counts compared against orders processed from this lot. Surveys were conducted of the workstations, the lab and the dumpster; yielding no identification of the seed. Reviews of paperwork, inventory records and orders also failed to indicate the location of the source. No customers have reported the receipt of an extra source. While the licensee believes the loss can be attributed to operator or documentation error; no root cause or corrective action was provided. An IEMA inspection team will seek this information in the reactionary inspection."

Illinois Incident Number: IL220032.

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