Event Notification Report for August 02, 2023

AGREEMENT STATE REPORT - DAMAGED ASH/MOISTURE GAUGE

The following information was provided by the Utah Division of Radiation Control (the Division) via email:

"There was a partial roof collapse in a coal mine, resulting in a damaged, beyond repair AshScan coal analyzer. The Division was notified of the incident by voicemail the afternoon of July 24, 2023 (State of Utah Holiday). The Division contacted the licensee's radiation safety officer (RSO) at 0630 [MDT] on July 25, 2023 after listening to the voicemail.

"Received from the licensee (by the Division):

"The device referenced was an AshScan serial number AS16-157, utilizing 300 mCi of Am241 and 5 mCi of Cs137. The roof fall occurred on the morning of July 16, 2023. After notification of the incident, the licensee began the process of developing a plan and getting an approval from the Mine Safety Health Administration (MSHA) to begin the work of removing rubble and uncovering the belt and device. The approval allowed the licensee to work their way through approximately 150 feet of rubble, removing rubble and bolting the roof every 5 to 6 feet according to the roof control plan. The area was pre-shifted twice a day with the pre-shifter using a radiation detector to ensure that there was no errant radiation.

"The RSO was notified on July 19, 2023, that the device was visible but not yet accessible due to the roof not being bolted. That morning, the licensee had a brow collapse in the same area, effectively setting them back to where they started. The process of mucking and bolting the brow took priority until the morning of July 24, 2023 when they were able to safely access the gauge. Once they were able to access the gauge and assess its condition, the licensee determined that the gauge was not repairable and would need to be decommissioned. The licensee moved the gauge with a scoop into Crosscut 38 which is about 100 feet away from the original position of the gauge. It was filled with rock on one end. The licensee taped off the other end and placed radiation warning signs to keep personnel from entering the area. The licensee is arranging for a technician to come and decommission the device and will then forward the appropriate paperwork once that work is completed.

"The Division will investigate this matter and update the record upon completion of the investigation."

Utah Event Report Number: UT23-0006

MEDICAL EVENT - DOSE TO UNINTENDED ORGAN

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

A patient was prescribed Y-90 microsphere implants to the liver. The procedure occurred on 4/20/23 with no abnormal outcomes reported. The patient returned to the hospital on 7/24/23 reporting stomach pain which was diagnosed as an ulcer. A biopsy of the ulcer revealed microspheres. Due to the tissue damage, it was assessed that the dose to the stomach lining exceeded 50 Rem. This event is being reported per 10 CFR 35.3045(a)(3).

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 SEED

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

"A patient at Sisters of Charity Hospital in Buffalo, RAM license 2911, was implanted with a Best Medical International model 2301, serial no. 56305C, I-125 localization seed (108.76 microcurie) on 6/23/23 for a surgical removal scheduled on 6/26/23. The seed was in the breast specimen when it arrived in pathology on 6/26/23 (Activity was 105.08 microcurie) and was supposedly removed, bagged, and stored in the proper storage area. Personnel from nuclear medicine retrieved the seeds from the pathology storage unit on 7/3/23 and filled out the log sheet and the chain of custody paperwork. While bringing the seeds to the nuclear medicine decay closet, a nuclear medical technician (NMT) noticed that one of the bags with seeds in it (they retrieved 4 seeds that day from pathology) had a seed that seemed thicker than the others. Upon further investigation, it was noted that there was a clip and not an I-125 seed in the one bag. NMT staff Immediately went and monitored all areas in pathology (floor, work areas, sharp containers, garbage of the remaining specimen and the patient slides). No activity was noted. Staff contacted the boiler house, and no radioactive waste has been discovered leaving the premises. The licensee believes that the seed possibly went down the drain in the pathology lab. As a precaution, the licensee plans to set up a dedicated area to survey the biohazard bag with the seed in it and the sink drain will be covered during dissection. This seed is considered lost with no reasonable probability of recapture."

New York State Event Report Number: NY-23-06

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 - MISSING STATIC ELIMINATOR

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

"Tesla reported that one of their Polonium-210 static eliminators is missing. The device is a NRD model P-2021-Z705, s/n A2ME848. The device was shipped to Tesla on 2/23/21. The device has been through more than six half-lives so the activity at this point should be below 0.1 millicurie."

New York State Event Report Number: NY-23-07

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 - LOST GAUGE

The following information was provided by the Colorado Department of Health (the Department) via email:

"On July 19, 2023, Geotech Environmental Equipment, Inc. informed the Department that they rented a generally licensed Viken PB200i XRF device (SN: 1015) containing a 5 millicurie, cobalt-57 sealed source to Hi-Tech Environmental located in Brooklyn, New York on July 7, 2021. Geotech Environmental Equipment, Inc. stated that as of October 25, 2022, Hi-Tech Environmental stopped replying to emails, stopped paying their rental balance, and was not providing information for returning the device. Geotech Environmental Equipment also stated that as of June 26, 2023, they made the decision to report the XRF device as a transferred device on their 2023 general radioactive material license registration inventory.

"Based on the description of the event, the device was not transferred and as of July 19, 2023 the Department has determined that Geotech Environmental Equipment, Inc. lost the generally licensed Viken PB200i XRF device (SN: 1015)."

Colorado Event Report ID Number: CO230022

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

PREPLANNED OUTAGE OF A REQUIRED SAFETY MONITORING SYSTEM

The following information was provided by the licensee via email:

"The American Centrifuge Plant (ACP) criticality accident and alarm system (CAAS) is designed to detect a nuclear criticality accident and provide audible and visual alarms that alert personnel to evacuate the immediate area, as required by 10 CFR 70.24, criticality accident requirements.

"The CAAS will be temporarily disabled (declared inoperable in accordance with approved plant procedures) to perform periodic CAAS testing activities. The planned CAAS outage is expected to last for approximately 48 hours, commencing at approximately 0800 EDT, on Wednesday, August 2, 2023. The planned maintenance activities will affect the CAAS in X-3001 North.

"Essential personnel will be present inside the controlled access area during the maintenance activities. Compensatory measures will be implemented in accordance with section 5.4.4 of the license application for the ACP. These measures include the following: evacuation of non-essential personnel from the area of concern and the immediate evacuation zone (IEZ) before removing CAAS equipment from service; limiting access into the area; restricting fissile material movement; and the use of personal alarming dosimeters for personnel that must access the area during the CAAS outage. These measures will be implemented until CAAS coverage is verified to be operational, and the CAAS is declared operable in accordance with approved plant procedures.

"American Centrifuge Operating, LLC will notify the NRC when CAAS coverage is returned to normal operation.

"The licensee has notified the NRC Project Manager."

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

"At 1506 EDT on July 31, 2023, it was determined that a contractor supervisor failed a test specified by the fitness for duty testing program. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."

ACTIVE SEISMIC MONITORING SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"On 08/01/2023 at 0955 EDT, the Fermi 2 active seismic monitoring system provided indication of a potential seismic activity event. Plant abnormal procedures were entered, and compensatory measure were met and remain in place. Neither the [United States Geological Survey] (USGS) nor the next closest nuclear power plant could confirm or validate the readings obtained at Fermi. The seismic monitoring system was declared nonfunctional to validate the calibration of the system. Femi 2 has two active seismic monitors: one on the reactor pressure vessel pedestal and one in the high-pressure core injection (HPCI) room. Only the HPCI room accelerometer was declared inoperable. The HPCI accelerometer is the sole 'trigger' for the seismic recording system, which outputs peak accelerations experienced during a seismic event. This is used in assessment of the magnitude of an earthquake for EAL HU 2.1.

"The loss of the active seismic monitoring system is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).

"No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area.

"The NRC Resident Inspector has been notified."