Event Notification Report for November 01, 2022

AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received via email by the Iowa Department of Public Health:

"A fixed nuclear gauge was determined to have a stuck shutter on 10/24/2022 and reported to the Iowa Department of Health & Human Services (Iowa - HHS) on the evening that same day. The C-frame (IMS model 5221-02) profile thickness device contains five, 5-curie Americium-241 sources with each having its own shutter [total device activity is nominally 25 curie of Am-241]. One of the five shutters (source holder number 2) was not working correctly. After troubleshooting (i.e., rebooting the gauge and failed standardizations) did not fix the computer error, the gauge was removed from the mill line and securely placed in the gauge house. Initial reported radiological surveys were 1.0 mR/hr directly under the shutter number 2 source holder and 11 inches above the receiver, and background around the perimeter of the secured gauge house. No personnel were overexposed from this incident, and Iowa HHS will gather additional information on what caused this equipment failure once it has been determined. The licensee's service provider was notified and is expected to be onsite for repairs on 10/25/2022."

Iowa Event Number: IA220006

AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE

The following information was provided by the Georgia Radioactive Material Program via email:

"On 10/18/2022 at 0630 EDT, a Cs-137 vial source was being used to measure dose calibrator constancy. The nuclear medicine [NM] technologist noticed a crack in the bottom of the sealed source vial and possible contamination surrounding the vial.

"The sealed source was placed in a leak proof container, the Radiation Safety Officer (RSO) was notified, and decontamination protocol was followed. A leak test of the vial confirmed there was more than 0.005 microcuries of removable Cs-137 contamination.

"Post-decontamination surveys and wipe tests of the staff and department indicated that there was no contamination in the department, but there was detectable contamination on the hands of one staff member. The staff member is the individual who was handling the sealed source and discovered the crack in the source. He repeatedly scrubbed his hands - first with lukewarm soap and water, then with Bind-It brand radioactive decontamination hand soap until there was no improvement in the surveys of his hands.

"A final survey of the individuals hands hands showed there was no detectable contamination on his left hand. A small area on his right-hand thumb still measured 1000 [Counts Per Minute] CPM above background, and another small area on his right-hand index finger measured 700 CPM above background using a GM probe. Measurements of the contamination on his fingers using the on-site well counter indicated it was Cs-137 contamination.

"Both the Radiation Safety Officer and Medical Director were notified of the incident. The RSO came on-site to supervise decontamination efforts and to secure the leaking source and decontamination waste.

"Dose calibrator measurements of the source by the RSO indicated the source had leaked approximately 6 microcuries total. Since 6 microcuries of Cs-137 is less than 10 percent of the annual limits on intake (ALI) for Cs-137 (100 microcuries ALI for oral ingestion as defined in Appendix B of 10 CFR 20), [the Program's] understanding is no individual bioassay monitoring is required for the individual.

"The sealed source has been placed back within its shielded container, sealed with tape, and marked as leaking and out-of-service. The waste generated during the decontamination process was placed in a leakproof plastic bottle and marked as containing Cs-137. Both items are currently stored in [a secure area]. We are contacting waste disposal companies to arrange disposal of both the leaking sealed source and decontamination waste. The NM staff was re-educated on the requirement to wear disposable gloves at all times while handling radioactive materials, which includes sealed radioactive sources, per the Model Rules for Safe Use of Radiopharmaceuticals."

Georgia Incident Number: 60

AGREEMENT STATE REPORT - LOST SHIPMENTS

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

"The Agency received a phone call from the Radiation Safety Officer at Bard Brachytherapy (IL-02062-01) on 10/25/2022 indicating the loss of three packages containing Iodine-125 brachytherapy seeds. The information for each package is as follows:
"1) Ninety (90) I-125 brachytherapy seeds, accounting for a total activity of 40.23 mCi (0.447 mCi per source) at shipment.
"2) Ninety (90) I-125 brachytherapy seeds, accounting for a total activity of 43.65 mCi (0.485 mCi per source) at shipment.
"3) Seventy-five (75) I-125 brachytherapy seeds, accounting for a total activity of 50.4 mCi (0.672 mCi per source) at shipment.

"The packages appear to have been lost at a [common carrier facility] in Memphis, TN. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion.

"DETAILS: On 10/20/2022, Bard Brachytherapy shipped three packages to Gwinnett Hospital in Lawrenceville, GA. The anticipated delivery date for all packages was 10/24/2022. Bard Brachytherapy was notified by [the common carrier] via email on the morning of 10/25/2022 that all three packages were lost.

"The common carrier is continuing its search. Additional information will be provided as it becomes available."

Illinois Item Number: IL220040

* * * UPDATE FROM ZACH MENGEL TO GEROND GEORGE AT 1123 EDT ON 10/26/2022 * * *
The following information was received via email:

"The following updated information is being provided regarding Event Number 56181:
"All three packages identified in the notification were located at the [common carrier facility] in Memphis, TN the evening of October 25, 2022. All three packages are expected to be delivered to their final destination on October 26, 2022."

Notified R1DO (Dentel), R3DO (Feliz-Adorno), ILTAB and NMSS Events Notification email group.

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

AUTOMATIC REACTOR TRIP AND AUXILIARY FEEDWATER SYSTEM ACTUATION

The following information was provided by the licensee via email:
"At 0653 Eastern Daylight Time (EDT), with Unit 1 in Mode 1, at 16 percent power, an automatic reactor trip occurred due to an under-voltage condition on the 'A' reactor coolant pump (RCP) and the 'C' RCP. Power was lost from the 'A' auxiliary bus while performing an operating procedure to transfer power from the 'A' start-up transformer to the 'A' unit auxiliary transformer.

"Operations responded and stabilized the plant. Decay heat is being removed by the main steam system to the atmosphere using the steam generator power-operated relief valves. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the auxiliary feedwater system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

SPECIFIED SYSTEM ACTUATION - AUXILIARY FEEDWATER SYSTEM ACTUATION

The following information was provided by the licensee via email:

"At 2057 Eastern Daylight Time (EDT), with Unit 1 in Mode 3 at 0 percent power, an actuation of the Auxiliary Feedwater (AFW) System occurred during an attempt to start the 'B' Main Feed Pump. The reason for the AFW system auto-start was due to the 'A' electrical bus being under clearance and the 'B' Main Feed Pump not starting, resulting in a valid actuation signal for loss of both Main Feedwater pumps. The 'A' and 'B' motor-driven AFW (MDAFW) pumps were running prior to the attempted start of the B Main Feedwater pump and continued to run. The MDAFW Flow Control Valves (FCVs) went full open automatically as designed when the MDAFW actuation signal was received.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW System.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

PART 21 - OUTER CONTAINMENT PERSONNEL AIRLOCK LEAKAGE

The following information was provided by the licensee via email:

"On February 22, 2021 while in Mode 1 and at 100 percent power, Grand Gulf Nuclear Station (GGNS) identified through surveillance testing that the 208 foot elevation outer containment personnel airlock door failed its technical specification leakage test. Analysis indicated that the airlock equalizing valves were leaking due to lack of lubrication during installation.

"Subsequent analysis determined that the lubrication was to have been performed during a vendor's qualification / dedication process. GGNS completed a substantial safety hazard Evaluation and determined that the failure to lubricate the valve components constituted a substantial safety hazard.

"The NRC Resident [Inspector] has been notified.

"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i).

"A written notification will be provided within 30 days."

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

This condition has been corrected. This report is submitted to meet 10 CFR Part 21 reporting requirements.