Event Notification Report for September 13, 2023

EN Revision Imported Date: 9/13/2023

EN Revision Text: CONTROL ROOM ENVELOPE INOPERABLE

The following information was provided by the licensee via email:

"On July 30, 2023 at 1119 CDT, Waterford Steam Electric Station Unit 3 declared the control room envelope inoperable in accordance with technical specification (TS) 3.7.6.1 due to the control room envelope doors failing a door seal smoke test creating a breach in the control room envelope.

"Operations entered TS 3.7.6.1 Action b.

"Mitigating actions were implemented and tested satisfactorily by 1215 CDT.

"There was no impact on the health and safety of the public or plant personnel.

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident, due to the control room envelope being inoperable.

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 09/12/23 AT 1357 EDT FROM MONICA PEAK TO THOMAS HERRITY * * *

"The original operability determination of inoperable was made based on a conservative evaluation that with presence of smoke in-leakage through Door 261 and 262, the CRE boundary could not perform its safety function. A more detailed engineering evaluation was subsequently performed. No maintenance or intrusive testing was performed on the doors after initial test failure. As documented in version 2 operability determination for condition report WF3-2023-14604, the CRE boundary remained intact for the condition identified and was able to fulfill its safety function."

The licensee has notified the NRC Resident Inspector. Notified R4DO (Warnick).

AGREEMENT STATE REPORT - MISSING PACKAGES

The following information was provided by the Illinois Emergency Management Agency (the Agency) email:

"The Agency was notified after hours on September 1, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of three radiopharmaceutical packages missing in transit. This is in addition to the four previously reported missing shipments [See EN56682, EN56697, and EN56701]. All three were shipped on August 24, 2023, and marked as 'missing' by the common carrier on September 1, 2023. The last known location was the [common carrier] Indianapolis transfer hub on August 24, 2023. Indiana contacted the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) and reported at least two of these packages were located in an Indiana landfill and were recovered by their responders. [One of the two packages recovered from the landfill is for a previous event, See EN56701]. This investigation is ongoing.

"The radiopharmaceutical packages were offered for shipment on August 24, 2023, for delivery to three customers (Nuclear Medicine Associates in Redding, CA; Cardinal Health in Southfield, MI; and RLS USA INC - New Orleans in Harahan, LA). The Nuclear Medicine Associates package contained three 14.3 mCi vials of I-123; the Cardinal Health package contained one 4.1 mCi vial of In-111 and the RLS package contained one 4.1 mCi vial of In-111. Activities are those at time of shipment. Information available at this time indicates the Nuclear Medicine Associates package and at least one other package containing In-111 [see EN56701] were located at a landfill by State of Indiana officials."

NMED report number: IL230023

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 SOURCES

The following report was received via email from the Georgia Radioactive Material Program [the Department]:

"On Thursday, August 31, 2023, the radiation safety officer (RSO) reported two missing solution standard sources of Am-241, 1.0 microcurie each (37 kBq each) to the Department. These two sources were lost during transportation to Nuclear Fuel Services located in Erwin, Tennessee on June 2, 2023. The customer, Nuclear Fuel Services, notified the licensee that they did not receive the shipment package. The RSO contacted the common carrier to trace its whereabouts. On June 26, 2023, the common carrier's records show that the shipment was signed for by an individual at Nuclear Fuel Services. However, Nuclear Fuel Services confirmed that they did not receive this shipment. There is a communication discrepancy between the common carrier and Nuclear Fuel Services. Currently, the licensee is waiting for a detailed response from the customer regarding this shipment."

Georgia Incident Report Number: 69

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 - DAMAGED GAUGE

The following is a summary from a report received via email from the Washington State Department of Health:

A Troxler 3440 portable gauge (two sealed sources containing 9 mCi of Cs-137 and 44mCi of Am/Be-241) was run over by a bulldozer at a construction site. The full report with corrective actions has yet to be issued. No significant releases of radioactivity occurred.

Washington Incident Number: WA-23-015

AGREEMENT STATE REPORT - PATIENT RECEIVED 29 PERCENT OVERDOSE

The following was received from the Colorado Department of Public Health and Environment via email:

"The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023."

Colorado Event Report ID No.: CO230028

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.

SURFACE CONTAMINATION LEVELS OF PACKAGE EXCEEDED LIMIT

The following information was provided by the licensee via telephone:

On September 6, 2023, Adventist Health Castle received an expected package of TC-99M from Cardinal Health. During a wipe test that was conducted at 0737 HST, it was determined that the package had removable surface contamination levels of 17836 disintegrations per minute (dpm) per 300 centimeters squared (cm^2). The radiation safety officer (RSO)'s determination was that this exceeded a limit that he stated was 2400 dpm per 100 cm^2. The RSO notified the Headquarters Operations Officer and the carrier for follow-up. The package was stored in a secure location for the contamination level to decay. Adventist Health Castle plans to return the package to the originator following its decay to a suitable level.