Event Notification Report for September 13, 2022

EN Revision Imported Date: 9/13/2022

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.

* * * UPDATE ON 09/12/2022 AT 1313 EDT FROM ROBERT LOCKE TO ERNEST WEST * * *

The following information was provided by the Agency via email:

"Source/Radioactive Material Information:
"Model Number: CDC.700

"Device/Associated Equipment Information:
"Manufacturer: QSA Global, Inc.
"Model Number: 924CO Type A
"Serial Number: 242

"Corrective Actions Information: No corrective action taken"

The State considers this event closed.

NMED reference number: 220254

Massachusetts event number: 17-5028

Notified R1DO (Young), 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

EN Revision Imported Date: 9/13/2022

EN Revision Text: PART 21 REPORT - POTENTIAL PREMATURE FAILURES OF VALCOR COIL SHELL ASSEMBLIES

The following is a synopsis of information received via facsimile:

Valcor Engineering Corporation (VEC) was notified via a letter dated 5/19/2022 that Catawba Nuclear Station (CNS) discovered two failed Coil Shell Assemblies, part number V52653-6040-7, which were removed from V70900-39-3-1 Solenoid Valves and returned to VEC for evaluation. VEC has not concluded this is a reportable condition in accordance with 10 CFR 21.22(d) and requires additional time to complete testing and evaluation.

VEC is submitting this 60-day Interim Report Notification per 10 CFR 21.21(a)(2).

VEC will complete the evaluation and provide a determination of reportability in accordance with Part 21 no later than 09/12/2022.

Currently, Catawba Nuclear Station is the only affected facility.

For additional information, please contact Mike Swirad, Valcor Engineering Quality Assurance Director (973-467-8400 x 7223)


* * * UPDATE ON 9/12/2022 at 1438 EDT FROM MICHAEL SWIRAD TO ERNEST WEST * * *

The following is a synopsis of information received via facsimile:

VEC is providing final notification with regard to defects in coil shell assemblies (part number V52653-6040-7) per 10CFR Part 21.21(d)(4).

The root cause of failure of this part was determined to be an internal short in the coil shell assembly.

In addition to Catawba, licensees affected are: Brunswick, Callaway Energy Center, Oconee, Braidwood, and Fitzpatrick.

Root cause of the failed component is inconsistency in the coil assembly manufacturing process.

VEC initiated internal and supplier corrective actions and all coil shell assemblies have been quarantined and VEC supplier was notified. All existing coil assemblies in stock will be reworked to conform to VEC drawings. Completion of rework expected within 60 days.

VEC is in the process of notifying all affected customers. Defect can not be visually or electrically identified. All coil assemblies that perform safety related function must be returned to VEC for evaluation/replacement.

For additional information, please contact Mike Swirad, Valcor Engineering Quality Assurance Director (973-467-8400 x 7223)

Notified R1DO (Young), R2DO (Miller), R3DO (Hanna), R4DO (Drake) and via email: Part 21 Reactors.

EN Revision Imported Date: 9/13/2022

EN Revision Text: AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

The following information was received from the South Carolina Department of Health and Environmental Control [the Department] via email:

"At 0905 [EDT] on August 12, 2022, the Department received a call from a representative of the Lowcountry Medical Group to report a contamination event. At about 0830 that same day, the certified nuclear medicine technician (CNMT) prepared to administer a dose to a patient on a treadmill to perform a stress test. While inserting the dose into the IV [intravenous], the cap loosened and the dose was sprayed onto the CNMT. Drops were released onto the treadmill handrails, track, and side. The CNMT decided to complete the treatment rather than to stop the treatment and perform radiation cleanup procedures as listed for the office. The CNMT, while still contaminated, left the room, went down the hall, and grabbed a replacement dose for the patient. This contaminated a hallway that was otherwise an unrestricted area. The CNMT successfully injected the patient with the second dose and completed the test then put the patient on a table to measure his shoes. The CNMT put booties on the patient and released them to go home. The CNMT changed clothes, went home, showered, and returned to the office afterward. The other CNMT remained at the office and cancelled the remaining patients.

"Inspectors from the Department arrived at the location at approximately 1215 to investigate the situation. At the time the inspectors arrived, no cleanup had begun and the contaminated hallway had not been blocked off. The inspectors surveyed the hallway and instructed the CNMTs to block the hallway and begin cleanup procedures. They reviewed the procedures with the staff and made sure that they had the right equipment to perform the cleanup.

"The radioactive material used was Tc-99m [technetium-99m]. The amount of material was 30.7 mCi. The treatment being performed was a nuclear stress test. The office reported that both CNMTs were 0.03 mR/hr (background) after the event. The results of the surveys pre-cleanup were as follows: Treadmill: 20 mR/hr, Floor: 20 mR/hr, Floor behind treadmill: 20 mR/hr."

* * * UPDATE ON 9/12/2022 AT 1736 EDT FROM LELAND CAVE TO ERNEST WEST * * *

"The individuals did not perform any cleanup on [August 12, 2022], preferring to allow the contents to decay over the weekend. They documented post cleanup numbers on Monday, [August 15, 2022], as follows: Treadmill: 0.03 mR/hr, Floor: 0.03 mR/hr, Floor behind treadmill: 0.03 mR/hr."

Notified R1DO (Young) and NMSS Events Notification 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

AGREEMENT STATE REPORT - STUCK SHUTTER RESULTS IN UNINTENDED EXPOSURE

The following event was received via e-mail from the Mississippi State Department of Radiological Health:

"On August 22, 2022, the [Radiation Safety Officer] RSO reported to the Mississippi Director of Radiological Health that a shutter was found stuck open during six month surveys. [The gauge is an Ohmart/Vega Model SH-F2-45, Serial Number 2933 CN, with a 100 mCi Cesium 137 source]. On August 31, 2022, source lock out procedures were implemented to allow a crew in the tank to inspect the tank. The gauge was locked out in the unshielded position. A confined entry crew of four workers were exposed for seventy-seven minutes and three workers were exposed for twenty-two minutes. On September 2, 2022 at approximately 1830 [CDT], the licensee RSO contacted the Radioactive Material Director regarding the exposures. On September 6, 2022 at 1247 [CDT], the inspector was notified of the incident, contacted the licensee, and will arrive on site on September 7, 2022. Findings and updates will be reported to the NRC after onsite investigation."

Mississippi Event Number: MS-220003