Event Notification Report for December 09, 2022

EN Revision Imported Date: 12/9/2022

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was provided by the New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH BERP) via fax:

"On November 3, 2022, at approximately 1430 EDT, an authorized user for the licensee had finished conducting soils testing at a temporary job site located in Manhasset, NY and locked the moisture density device in the carrying case within the trunk of their vehicle. The authorized user was conducting concrete work while the gauge was locked in the trunk and returned to their vehicle later to find that the vehicle was stolen, with the gauge locked in the trunk. The authorized user contacted the Radiation Safety Officer (RSO) and Nassau Police immediately and the case was initiated by Nassau [Police] to track this vehicle. The RSO contacted NYSDOH BERP the following morning to report the missing device.

"The following information is available on this device: Make/Model: Troxler 3430 Source 1: Cs-137 (10 millicurie); Source 2: Americium-241:Be (40 millicurie); Device S/N: 20136.

"New York State Department of Health is reaching out to the manufacturer and neighboring regulators to inform them of this event. NYSDOH will continue to monitor this event and provide updates as necessary.

"NY Event Report ID: NYDOH-22-07"

* * * UPDATE ON 11/21/2022 AT 1549 EST FROM DANIEL SAMSON TO IAN HOWARD * * *
The following information was provided by the NYSDOH BERP via fax:

"On November 21, 2022, the licensee notified the NYSDOH BERP that the above mentioned vehicle and device were located by local law enforcement agencies and returned to the licensee. The licensee confirmed that there was no apparent tampering of the device and carrying case, however, the licensee is performing a leak test to confirm sources have not been breached during this incident prior to recommissioning this device into service.

"The licensee is providing a written description of this event including a failure analysis and proposed corrective actions. As a result, NYSDOH will continue to monitor this event and provide updates as necessary. This event is still open as of 11/21/2022."

Notified R1DO (Carfang) and NMSS Events Notification, ILTAB, and CNSC email groups.

* * * UPDATE ON 12/08/2022 AT 1613 EST FROM DANIEL SAMSON TO LLOYD DESOTELL * * *
The following information was provided by the NYSDOH BERP via fax:

"The licensee provided a written report [to NYSDOH] in accordance with 10 CFR 20.2201(b). This report further confirmed the events as previously described, and provided a copy of the police report filed by Nassau County Police Department. In discussion with the licensee, it was proposed that staff are re-trained in security and notification procedures as a preventative measure. The Radiation Safety Officer has purchased Apple AirTags for installation into the device case as an additional tool to rapidly track and locate any missing/stolen gauges in the future as a supplemental mitigation action.

"New York State Department of Health has independently evaluated the investigation, failure analysis, and corrective actions provided by the licensee and has deemed the response and subsequent actions sufficient. NYSDOH has closed this event."

Notified R1DO (Bickett) and NMSS Events Notification, ILTAB, and CNSC email groups.

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 INADVERTENTLY SHIPPED

The following information was provided by the Ohio Department of Health via email:

"[The] licensee (NDC Technologies, Inc.) inadvertently shipped a 150 mCi Am-241 source to a customer in Germany. Only the electronic portion of the gauge should have been shipped to that customer. The source was [intended] to be shipped separately to a separate licensed facility in Germany. The source was not handled at the facility in Germany and was immediately sent back. The source has arrived at the NDC facility in Dayton."

Ohio Reference Number: OH220012

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 - DAMAGED GAUGE

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:

"On December 1, 2022, at approximately 1400 [EST], the Department was notified by the licensee that its contracted vendor used to replace sources, damaged the threads while attempting to exchange sources on June 27th, 2022. The source is a Berthold Model SSC-100 containing 20 millicuries of Cobalt 60, source serial number 1359/10/21. The source is designed to be mounted onto a dip tube via the use of threads. The source remains in the shielded position on the vessel and the area is roped off. This incident is still under investigation."

South Carolina Event Number: To be announced.

NON-AGREEMENT STATE REPORT - LOST AND RECOVERED RADIOACTIVE SOURCE

The following information is a summary of the information provided by the licensee via telephone and email:

While in transport from Grand Rapids, MI to Franklin, WI, a Troxler moisture density gauge fell off the trailer and into a median of I-94 near Coloma, MI. The gauge was discovered and secured by another company knowledgeable with gauge use until the licensee was able to retrieve it. The licensee has secured and transported the gauge to their office until a service provider can retrieve it. There is no indication that the gauge has leaked. The date the gauge fell off the trailer is unclear at this time. The gauge was in the control of a transportation service beginning 11/30/2022. The Michigan Department of Transportation and Michigan State Police have been notified of the event (complaint number 53-4067-22).

Gauge information:
Manufacturer: Troxler
Model: 3430
SN: 31413
Source Info:
Am241: serial number 47-1397 [nominal 40 mCi]
Cs137: serial number 750-6146 [nominal 8 mCi]

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the North Carolina Division of Radiation Protection via email:

"The state of North Carolina Radioactive Materials Branch received a report at 1050 EST on December 2, 2022, from Duke University Medical Center (license number: 032-0247-4) of a possible medical event involving a patient receiving Yttrium-90 therapy for treatment of a liver tumor. The treatment had an intended dosage of 91.6 mCi with a delivered dosage of 54.6 mCi resulting in a 40 percent under dosing that did not appear to involve stasis. The patient and the patient's representative were notified at the time of the treatment and the referring physician was notified the morning of December 2, 2022. The licensee is currently investigating the root cause but initially believes it to be caused by equipment failure. The State is currently investigating and will provide more information as it becomes available."

NC Incident No.: NC220015

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 - LOST GAUGE

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

"[The] gauge was placed on the tailgate of a truck by a technician at the Eastman Airport and not secured in the box. It fell out within 4 miles of last use in the city limits of Eastman, Dodge County. The licensee will be contacted for more detailed information. The Georgia Radioactive Material Program will update this report as more information comes in. "

Georgia Incident No.: 62


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: 12/9/2022

EN Revision Text: UNUSUAL EVENT DUE TO EXCESSIVE REACTOR COOLANT SYSTEM LEAKAGE

At 1402 EST Turkey Point Unit 3, while operating at 100 percent, declared an Unusual Event due to unidentified leakage greater than 10 gallons per minute for more than 15 minutes. The abnormal procedure for Reactor Coolant System leakage was entered. The plant remains at 100 percent power. The cause of the leakage is under investigation.

At 1446 EST it was verified that the leak had been isolated. The plant remains at 100 percent power.

Unit 4 was unaffected.

State and local authorities were notified by the licensee.

The NRC Resident Inspector has been notified.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).


* * * UPDATE ON 12/08/22 AT 1621 (EST) FROM SZEMEI CHOI TO THOMAS HERRITY * * *

Turkey Point Unit 3 has isolated the leak. The Unusual Event was terminated at 1558 EST.

The NRC Resident Inspector has been notified.

Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Crouch). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).

EN Revision Imported Date: 12/12/2022

EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 0400 EST on November 28, 2022, during the performance of Division 2 Residual Heat Removal (RHR) cooling tower fan operability and RHR Service Water valve lineup verification, it was reported that the Mechanical Draft Cooling Tower (MDCT) Fan 'B' was making a loud metallic noise. The cause of the metallic noise is unknown at this time. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on inoperable cooling water to the HPCI room cooler, per LCO 3.0.6.

"Investigation into the Division 2 MDCT Fan 'B' abnormal noise is in progress.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"The NRC Resident Inspector has been notified."

* * * RETRACTION FROM JEFF MYERS TO LLOYD DESOTELL AT 1615 EST ON 12/09/2022 * * *

The following information was provided by the licensee via email:

"The purpose of this notification is to retract a previous Event Notification 56241 reported on 11/28/2022. On 11/28/22, an event notification to the NRC was made when mechanical draft cooling tower (MDCT) Fan B was declared inoperable and issued Limited Condition of Operation (LCO) 2022-0428 for Division 2 MDCT Fan B abnormal noise. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS) (Technical Specification [TS] 3.7.2). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system (TS 3.7.2), which cools various safety related components, including the High-Pressure Coolant Injection (HPCI) system room cooler (TS LCO 3.0.6).

"Subsequent inspection and evaluation determined that the brake noise is expected while fans are running at low speeds. This is supported by plant technical procedure, 24.205.10 `Div. 2 RHR Cooling Tower Fan Operability and RHRSW Valve Line-up Verification' (line item 2.2 in Precautions and Limitations) which states `Chatter from the brakes of the MDCT Fans is expected and no cause for discontinuing the test.' The equipment vendor stated that brake chatter is possible and common given that the internal components are free to move along the splined connections. Internal Operating Experience from experienced station operators and maintenance technicians confirmed that the condition is normal and expected. Both Division 2 MDCTs exhibited the same behavior at low speed and passed surveillance testing satisfactorily.

"No other concerns were noted during fan operation. Therefore, HPCI remained operable and there was no loss of safety function. The event did not involve a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident under 10 CFR 50.72(b)(3)(v)(D).

"EN 56241 is retracted and no Licensee Event Report under 10 CFR 50.73(a)(2)(v)(D) is required to be submitted."

The NRC Resident Inspector has been notified.

Notified R3DO (Stoedter).

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following information was provided by the Texas Department of State Health Services via email:

"On December 5, 2022, the licensee reported that an equipment malfunction occurred with a Source Production & Equipment Company, Inc. (SPEC) 150 Radiography Camera, serial number 1524, containing 66 curies of Iridium-192. They were testing the camera in the office because the technician reported it started to hang up several times when retrieving the source and disconnecting the crank cables. The camera was tested and the source was retrieved but they were unable to disconnect the crank cables. They had to cut the locking device, remove the cables, and install a plug. The camera and cables are being transported to a service company for inspection and repair. No additional radiation exposure occurred from the incident. SPEC source serial number DI2710. Additional information will be provided in accordance with SA 300."

Texas Incident No.: I - 9969

OFFSITE AGENCY NOTIFICATION DUE TO CHEMICAL LEAK

The following information was provided by the licensee via email:

"On 12/8/2022, Prairie Island Nuclear Generating Plant initiated a notification to the State of Minnesota due to a HVAC coolant leak reaching waters of the state. The estimated quantity is 5 gallons of NALCO LCS-60. The leak was due to a failed heat exchanger coil and has been isolated. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

TECHNICAL SPECIFICATION VIOLATION

The following information was provided by the licensee via email:

"On December 6th, 2022, University of Utah Training Reactor (UUTR) was in the process of performing a research sample irradiation. The sample was known to have a negative reactivity worth and was therefore placed in the reactor prior to reactor startup. Upon commencing reactor startup procedures, the reactor operator subsequently terminated the startup attempt after noting that the sample appeared to demonstrate a larger negative reactivity worth than what was initially anticipated. After investigating, we identified that there was an inconsistency/miscommunication regarding the sample materials specifications, and the actual negative sample reactivity worth was a larger negative value than that of the original estimate. Immediately afterwards, we performed an updated materials assessment of the sample, which, following reactor calculations, revealed that the sample indeed demonstrated a larger negativity reactivity worth than was originally predicted. As a result, this report is being submitted in accordance with UUTR Technical Specification (TS) 6.7.2 due to 'observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy could have caused the existence or development of an unsafe condition with regard to reactor operation.'

"In accordance with UUTR TS, the reactor was secured, and Utah Nuclear Engineering Program Director notified, and operations shall not resume unless authorized by the Director."

The NRC Project manager was notified.