Event Notification Report for May 09, 2023

AGREEMENT STATE REPORT - LOST SOURCE

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

"On May 2, 2023, the Agency was notified by the licensee that they were unable to locate a 200 millicurie cobalt - 60 source. The licensee stated that the company had three locations in the United States, one in California, one in Louisiana, and one in Texas. In January of 2023, the company decided to close its offices. The company transferred all its sources to the Texas location. The sources were then sent to a source disposal company in Texas. During the last transfer of sources, the cobalt source could not be found. The licensee searched for the source at the Texas facility but could not find it. The process of locating where the source might be is complicated by the fact that the licensee had laid off most of the employees. The Radiation Safety Officer (RSO) was included in the layoff.

"The individual tasked by the company to dispose of the sources contacted a few of the previous employees and was told that the source was transferred to the location in Louisiana. [The Agency] asked if they had the documents for the transfer. He stated they had given all the documents to the Louisiana location. He did not have a copy of the forms.

"He said the source itself is about half the size of a magic marker. He said it is normally stored in a lead box in a sea van. He said that they would search their paperwork including the sign-out log in Louisiana to see if they can confirm the source was there.
The Agency advised the individual to go to Louisiana and search for the source in and around the storage area. He was also advised to get someone added to their license as RSO.

"Additional information will be provided as it is received in accordance with SA-300"

Texas Incident Number: 10014

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 - STOLEN TROXLER GAUGES

The following report was received from the State of Florida Bureau of Radiation Control [BRC] via email:

"At 1720 [EDT], BRC received a call from [the licensee]. [The licensee] stated two Troxler [soil moisture density] gauges [Model Numbers 3440 and 3430; Serial Numbers 20750 and 77517; and sources 8mCi Cs-137 and 40mCi Am-241/Be] were stolen from their storage facility in Lake Placid, FL. [The] gauges were last signed in to the facility on the 28th of April and sat idle. [The] exact time of loss is not currently known, but [the licensee] went to retrieve the gauges on 5/2/23 at 1700 [EDT]. Law enforcement was notified prior to BRC's contact, however had not yet arrived on the scene at the writing of this report. [The licensee] has been provided department emails to send police reports when they are received."

Florida Incident Number: FL23-064

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 - MEDICAL UNDERDOSE

The following information was provided by the Oregon Health Authority via email:

"Upon completion of [Yttrium] Y-90 Therasphere delivery [to a patient] and completion of post-treatment template measurements, it was noted that the delivery ratio appeared to be below 80%. The technologist who was involved in delivery contacted the authorized user who came and reviewed the information. Both the authorized user and Boston Scientific representative, who was present during delivery, felt that an error had been made in post-treatment measurements, so they were repeated both that day and the following.

"Nuclear medicine staff performed [single photon emission computed tomography with a computed tomography] SPECT/CT imaging of the Nalgene container. This imaging was reviewed on 5/1/23 and it was determined that activity was remaining in the delivery set tubing. Imaging was reviewed with the Assistant [radiation safety officer] RSO, and it was determined that a Medical Event had occurred. Per [the assistant RSO], the Medical Event was reported to the Oregon Health Authority on 5/2/23.

"The Authorized User, communicated the situation with the patient and is confident that no adverse effect has occurred based on calculated treatment thresholds and tumor burden.

"The authorized user reviewed the SPECT/CT imaging and will participate in mitigation."

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.

SHUTDOWN REQUIRED BY TECHNICAL SPECIFICATIONS DUE TO INOPERABLE CORE SPRAY

The following information was provided by the licensee via fax:

"At time 0207 CDT, Cooper Nuclear Station entered Technical Specification [Limiting Condition for Operation] LCO 3.0.3 due to declaring Core Spray Subsystems A and B inoperable. This declaration was based on an issue with relays installed from the same manufacturing batch. The ability of the relays to function correctly to annunciate loss of logic power was called into question and they were declared inoperable. The plant has initiated actions to repair/replace affected relays.

"This event is reportable under 10 CFR50.72(b)(2)(i) as initiation of any nuclear plant shutdown required by Technical Specifications. In addition, this event Is reportable under 10 CFR 50.72(b)(3)(v) as a condition that could have prevented the fulfillment of a safety function for the Core Spray systems.

"NRC Resident Inspector was notified."

* * * UPDATE ON 5/8/2023 AT 1335 EDT FROM ANDREW ASKINS TO BRIAN LIN * * *

The following information was provided by the licensee via email:

"Technical Specification LCO 3.0.3 was exited at 0805 CDT on May 8, 2023. A reasonable expectation of operability was developed for the Core Spray Subsystems A and B. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. Shutdown was initiated and power was reduced approximately 45 percent. Reactor power is currently at 55 percent at the time of notification."

Notified R4DO (Werner) via email.