Event Notification Report for August 04, 2023

AGREEMENT STATE REPORT - FOUND MEDICAL SEED

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

"The Department was notified by the licensee that on 8/4/2023, a person walked into their facility to report a box with a radioactive material label was sitting on top of a trash can outside of their facility with their name on it. The licensee determined that the box contained (1) Isoaid I-125 seed (0.150 mCi) that had been picked up by [Common Carrier] the day before (8/3) at 4:09pm. The licensee inspected the package and determined that the package was still sealed and intact. The Department has requested additional information and continues to investigate the event."

Arizona Event No.: 23-014


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

MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 1320 [EDT] on 08/04/2023, with the Unit 3 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering level in the 3C steam generator. The trip was uncomplicated with all systems responding normally post-trip.

"Decay heat is being removed via the auxiliary feed water system and the atmospheric steam dumps.

"Unit 4 is not affected.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The cause of lowering level in the 3C steam generator was unknown at the time of the notification and will be investigated by the licensee.

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via phone and email:

"At 1746 EDT on 08/04/2023, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to number 2 steam generator low low level. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by using the auxiliary feedwater and steam dump systems. Unit 1 is 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). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight-hour report under 10 CFR 50.72 (b)(3)(iv)(A).

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

"All control rods are fully inserted. The cause of the number 2 steam generator low low level is being investigated."

AGREEMENT STATE - STOLEN MOISTURE-DENSITY GAUGE

The following information was provided by the California Department of Public Health via email:

"On August 4, 2023, the Radiation Safety Officer for Anbessaw Consulting, Inc. contacted Los Angeles County Radiation Management to report a stolen moisture density gauge. After receiving the report, the information was forwarded to the California Department of Public Health. The gauge was a CPN International model MC-3, Serial Number M320500859 [10 mCi Cs-137 (nominal), 50 mCi Am-241:Be (nominal)].

"The gauge was stolen from a 20 foot [long] Container Express (CONEX) box stored at a fenced in and secured construction site with security guards. The gauge was placed in storage around 1700 [PDT] on August 3, 2023, and discovered to be missing around 0600-0615 on August 4, 2023. The lock on the CONEX box had been cut and the transport case containing the gauge was removed from the CONEX box. No other items were stolen from the CONEX box. The transport box was secured with a lock, and a lock was placed on the trigger of the gauge.

"After a search of the area near the CONEX box was conducted without finding the gauge, the Los Angeles Police Department was contacted, and a burglary report was filed. After the report was filed, a further search of the construction site and the area surrounding the site was made without finding the gauge or its transport case. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."



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 - SHIPPING INCIDENT

The following information was provided by the Washington State Department of Health via email:

"A low specific activity (LSA)-2 excepted package arrived at [the licensee's] facility with a wet corner and a minor liquid drip. The package contained resin for Cr-51 with total activity of between 5 to 7 mCi of U-233, U-234, and U-236 isotopes. No contamination [was detected].

"The incident is currently being investigated. The shipper was suspended. The shipper will be required to submit a root cause analysis and corrective actions."

Washington incident number: WMS-DOT-23-05

UNACCOUNTED FOR IODINE-125 SEEDS

The following is a summary of information that was provided by the licensee via phone and follow-up email:

On 8/4/2023 at 1000 CDT, at SSM St. Clare Hospital in Fenton, MO, an oncologist implanted an I-125 prostate seed. After completion of the implant, a radiation oncology physicist went to the hot lab to return the backup seeds that had not been used. The first four unused needles had a single seed, which was expected. The next two had two seeds, which was expected. The last needle, was expected to have three seeds. However, when the physicist pushed the "stylette," the bone wax came out, followed by just one seed. The physicist surveyed the package, but there were no seeds in it. The final needle was still sealed in its sterile package, thus the physicist believed the seed could not have fallen out anywhere but into the sealed package itself. The physicist surveyed the hot packaging with a Geiger-Mller counter and found no radioactivity. The physicist surveyed the entire hot lab, and found no activity. An investigation is ongoing with the vendor. Unaccounted for activity was 0.504 mCi of I-125 on the date of the event.

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