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).