Event Notification Report for July 24, 2023

EN Revision Imported Date: 7/24/2023

EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE

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

"The South Carolina Department of Health and Environmental Control was notified via telephone at 1515 EDT on 06/22/23, that during the commissioning of a new device [at their Gaston S.C. facility] the strip source of the fixed gauging device was stuck between the source housing and dip-tube. The licensee is reporting that the fixed gauge is a Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device, housing a Cs-137 Berthold Technologies USA, LLC., sealed source Model BT-MPLM. The licensee is reporting that no immediate health and safety concerns have been identified. The licensee is reporting that a consultant has been contacted to perform the repair. A department inspector will be dispatched to the facility to conduct an on-site investigation. This event is still under investigation by the Department."

* * * UPDATE ON 7/21/2023 at 1058 EDT FROM KORINA KOCI TO SAMUEL COLVARD * * *

"A Department inspector was dispatched to the facility on June 23, 2023. The licensee submitted their 30-day written report on July 14, 2023. The licensee is reporting that the serial number of the Berthold Technologies USA, LLC., LB 300 IRL Type III Series gauging device is 40876-01-10009. The licensee also reports that the serial number of the sealed source containing 0.74 GBq (20 mCi) of Cs-137, (Model BT-MPLM) is G0990_22. The device was removed from service by a licensed contractor and will remain in the site's radiation storage room until the licensee and manufacturer determine the best option moving forward. The licensee reports that no regulatory exposure limits were exceeded as a result of this event, and that the sealed source remained housed for the duration of this incident. This event is still under investigation by the Department."

Notified internal: R1DO (Carfang) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information is a summary of information received from the California Department of Public Health, Radiologic Health Branch via email:

On July 12, 2023, Kaiser Medical Center of Southern California (the licensee) discovered that nine tritium exit signs were missing (Make: Shield, Model: SLX-60, Original activity: 10 Ci, tritium). The missing signs were exit signs at the licensee's parking garage. It has not been determined how the signs went missing after an engineering and security review.

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 - RADIOGRAPHY SOURCE DISCONNECTION

The following report was received by the Texas Department of State Health Services [the Department] via email:

"On July 16, 2023, the Department was notified of an industrial radiography source that was discovered to be not connected on July 15, 2023. The licensee reported that the camera was a QSA Delta 880 with serial number D11651 which contained a 31.5 curie Ir-192 source with serial number 72211M. The radiography crew had completed their first exposure and tried to crank the source back in, but it would not lock. After several more tries, they reported the incident to their site radiation safety officer (RSO). The RSO instructed them to expand the barrier and maintain constant surveillance. When the RSO arrived, he checked the dosimetry of the two radiographers and found they were both around 1 mR. He tried cranking the source back in and found that it would not lock. He also found that the survey meter readings were not changing so he concluded the source was not connected. Using 6 foot tongs, he was able to manipulate the guide tube and get the source to drop out. He then covered the source with about 150 pounds of lead such that the exposure rate was down to 30 mR/hr. He then connected the source to the drive cable and cranked it back into the locked position.

"The RSO received about 14 mR to both hands and whole body. Another worker who assisted with the lead received about 10 mR to the whole body. Badges have been sent in for processing.

"Further information will be provided per SA-300."

Texas Incident Number: 10040
Texas NMED Number: TX230031

AGREEMENT STATE REPORT - LOST PACKAGE

The following information was provided by the Arkansas Department of Health, Radiation Control Section (the Department) via email:

"The Arkansas Department of Health, Radiation Control Section, was notified on July 7, 2023, via a phone call received from 3D Imaging Drug Design Development (3DI) in Little Rock, Arkansas, of a radioactive material package not ever reaching its intended destination (Canada). The package, when offered to the common carrier, contained 48.5 mCi of Zr-89 oxalate solution. Considering the half-life of 78.4 hours, the package contains approximately 2.5 mCi at the time of this report (July 17, 2023). The single, 3 mL glass vial was shipped within a 4-5 inch tall lead, cylindrical pig inside of a DOT Type A package, 1 cubic foot, 30 pounds, Yellow III.

"A second package of 12.9 mCi Zr-89 oxalate, was offered at the same time (July 3, 2023) to the same carrier but with a different destination (Maryland - also licensed for this type and quantity of material). The 3DI customer intended to receive the 48.5 mCi package instead received the second package with lesser activity. The 48.5 mCi package has not been located.

"3DI and the Department have been in communication with the carrier. The Department also contacted its NRC Regional State Agreement Officer who informed NRC Region I concerning the Maryland licensee and the NRC liaison for Canada concerning the Canadian licensee. The investigation is ongoing, and reporting will proceed in accordance with SA-300."

Arkansas Event #: AR-2023-005
Reporting requirement: RH-1501.a.1.B. of the ASBH Rules for Control of Sources of Ionizing Radiation [10 CFR 20.2201(a)(1)(ii)]

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
The following information was provided by the licensee via email:

"At 1148 EDT on 07/21/2023, with Unit 3 in Mode 1 at 32 percent power, the reactor automatically tripped on low reactor coolant pump (RCP) speed due to decaying RCP motor voltage during power ascension testing. The trip was not complex, with all safety-related systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam via steam generator power operated relief valves to the atmosphere, and startup feedwater is supplying the steam generators. Units 1, 2, and 4 are not affected.

"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).

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