Event Notification Report for July 19, 2023

AGREEMENT STATE REPORT - LOST AND FOUND RADIOACTIVE MATERIAL

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"The licensee (QSA Global, Inc., License No. 12-8361) reported at 1015 [EDT] today (July 11, 2023), that it discovered yesterday (July 10, 2023) at 1553 that one of two packages destined for delivery to AMCOL Ingenieria LTDA of Bogota, Columbia was missing. Each of the two packages was a single QSA Global, Inc. model 650L source changer containing an iridium-192 sealed source(s) shipped on June 26, 2023. One of the two packages was received by AMCOL Ingenieria LTDA of Bogota, Columbia on July 10, 2023.

"The missing package was a QSA Global, Inc. Model 650L source changer, serial number 120 containing two sealed sources of iridium-192, 104.2 curies (3.86 TBq) and 104.3 curies (3.86 TBq), respectively. The licensee reported that the missing package was last known to be at the carrier's sorting facility in Memphis, TN, on July 1, 2023. The carrier package tracking number was provided by the licensee.

"The licensee then reported at approximately 1300 on July 11, 2023, that the missing package was found by the carrier at the carrier's Memphis, TN facility, and that the package will likely be moved forward by the carrier to the Bogota, Columbia destination.

"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 and of 105 CMR 120.077(B).

"The Agency considers this event to be open."

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - STOLEN AND RECOVERED RADIOACTIVE MATERIAL

The following information was provided by the Florida Department of Health, Bureau of Radiation Control (BRC) via email:

"The BRC received a call on Monday, 7/10/2023, at 1335 [EDT], from Miami-Dade Police reporting they found two Troxler gauges in an empty lot next to the incident location address. One gauge belonged to the licensee (Sacyr Construction), the other gauge belonged to another company (see FL23-104) [NRC EN 56617]. Miami-Dade Police on the scene said they had contacted the owner of the gauge and someone was en route to retrieve it. Miami-Dade Police sent pictures of the gauge, and the gauge appeared to be intact. The RSO [Radiation Safety Officer] was contacted on 7/11/2023, and he said one of his employees called him yesterday morning [and stated] that their construction site was broken into over the weekend, and several pieces of equipment were stolen. The RSO stated that the gauge was found before he was able to report it stolen, the gauge is back in their possession, and that there is no damage to the gauge.

"The BRC Inspector is to conduct a more thorough investigation with each licensee."

Florida Incident Number: FL23-103

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 AND RECOVERED RADIOACTIVE MATERIAL

The following information was provided by the Florida Department of Health, Bureau of Radiation Control (BRC) via email:

"The BRC received a call on Monday 7/10/2023 at 1335 [EDT] from Miami-Dade Police reporting they found two Troxler gauges in an empty lot next to the incident location address. One gauge belonged to the licensee (CTI Construction Testing and Inspection, Inc.), the other gauge belonged to another company (see FL23-103) [NRC EN 56616]. Miami-Dade Police on the scene said they had contacted the owner of the gauge and someone was en route to retrieve it. Miami-Dade Police sent pictures of the gauge, and the gauge appeared to be intact. An attempt was made to contact the [company] RSO on 7/11/2023, and a voice mail was left to return the call. Another company RSO (on license #3298-1) was contacted, who said the gauge is back in their possession with no damage.

"The BRC Inspector is to conduct a more thorough investigation with each licensee."

Florida Incident Number: FL23-104

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

MEDICAL EVENT - DOSE MISADMINISTRATION

The following information was provided by the licensee via phone:

On July 11, 2023, at 1700 EDT, an intravascular brachytherapy treatment was delivered to the wrong treatment site. The original dose of 23 Gy was intended for a different part of the vasculature system. The brachytherapy device made by Best Vascular is a Beta-Catch (model # 5ICW-2) containing 3.62 GBq of Sr/Y-90. Physicians expect that there will be no permanent damage to any of the patient's organs.

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 - STUCK OPEN SHUTTER

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

"On July 12, 2023, the Agency was notified by the licensee's service company that during routine shutter checks, the shutter on a Vega Americas model SH-F2 [gauge] could not be shut. The gauge contains a 200 millicurie (original activity) Cs-137 source. Open is the normal operating position for the shutter. The licensee has made plans to repair the gauge in the next seven days. The service company stated there is no risk of radiation exposure to members of the general public or radiation workers due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10036

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID ACTUATION OF AN EMERGENCY AC ELECTRICAL POWER SYSTEM

The following information was provided by the licensee email:

"At 0339 CDT on May 17, 2023, diesel generator 3 (DG3) had an auto-start during a surveillance test of excess flow check valves in containment atmosphere instrument sensing lines. During the surveillance, workers failed to recognize residual pressure in the system from the test. Per procedure, MS-PS-47C (main steam pressure switch) was placed back in service, resulting in initiation logic for both the high pressure core spray (HPCS) system and DG3 auto-start. Because the HPCS system was tagged out of service for maintenance it did not actuate.

"The auto-start of DG3 was an expected response to the high drywell pressure indication. The signals cleared, and DG3 was shutdown per procedure.

"As indicated in 10 CFR 50.73(a)(1), in the case of an invalid actuation reported under 10 CFR 50.73(a)(2)(iv)(A), the licensee may, at its option, provide a telephonic notification to the NRC Operations Center within 60 days of discovery of the event instead of submitting a written licensee event report. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73 (a)(2)(iv)(A).

"This actuation was invalid since it was caused by programmatic issues in quality of procedural guidance and not the result of actual plant conditions warranting auto-start of DG3. The actuations were not initiated in response to actual plant conditions, this was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation. Therefore, this event has been determined to be an invalid actuation.

"Diesel generator 3 system responded as designed to the actuation signal. The HPCS system did not actuate since it was tagged out of service. There was no impact on the health and safety of the public or plant personnel.

"The following information is provided as specified in NUREG-1022:
(a) The diesel generator 3 was actuated.
(b) The actuation of DG3 was complete.
(c) The DG3 train was started and functioned successfully.

"The NRC Resident Inspector has been notified."

FITNESS FOR DUTY - PROHIBITED SUBSTANCE FOUND INSIDE THE PROTECTED AREA

The following information was provided by the licensee via email:

"This report is being made pursuant to 10 CFR 26.719(b)(1).

"At 1111 (PDT) on 7/17/23, a knowledgeable individual received test results from a lab which identified a prohibited substance that was found in the protected area during the recent refueling outage. This prohibited item was found on 5/21/23 in an infrequently accessed area, the condenser bay, and removed from the protected area. The item was old and is surmised to be from construction. Residual ash on the prohibited item tested positive for a prohibited substance.

"The licensee notified the NRC Resident Inspector."