Event Notification Report for September 18, 2023

EN Revision Imported Date: 9/18/2023

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF PROCESS AUTOMATION BETA GAUGE

The following information was received from the State of Illinois via email:

"The Plant Manager for WINPAK, Inc., in South Chicago Heights, IL, called to report the loss of an ABB Process Automation Model O-2 beta gauge (SN S-1379-T) containing 70 milliCuries of Sr-90. The recent annual general license self inspection revealed some discrepancies in serial numbers and the licensee could not locate this particular device. They believe it to have likely been removed by a local scrap vendor that was on-site. Another possibility is an equipment vendor that was doing some work on site. Both vendors are being contacted as part of the investigation. lEMA [Illinois Emergency Management Agency] staff are at the scrap yard today investigating as well.

"The licensee is continuing to pursue possible leads on the location of the source. lEMA has contacted the manufacturer and they have no records of return but have contacted NDC [does service work under contract to ABB] to see if they retrieved it under contract work. This item will remain open for the required time until the source is recovered or declared lost."

Illinois Item Number: IL15022

* * * UPDATE ON 9/15/23 AT 1406 EDT FROM GARY FORSEE TO ADAM KOZIOL * * *

"On 9/15/23, the device was located at Gaby Iron and Metal in Chicago Heights, IL. The device was heavily damaged with the source exposed. IEMA-OHS responders fabricated shielding and packaged the device for return to the registrant. The registrant will be responsible for proper disposal through an approved vendor. The Agency verified safe and secure storage and will track this matter until disposal verification paperwork is provided."

Notified R3DO (Szwarc) and NMSS (email)

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 TRITIUM EXIT SIGNS

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

"On August 10, 2023, the Department was notified by the licensee that during the August 9, 2023, inventory of the ExxonMobil (EM) Beaumont Polyethylene Plant (BPEP) Tritium (H-3) exit signs, 9 uninstalled signs previously stored in the [instrumentation and electrical] shop could not be located. After an investigation and questioning of the personnel with access to the signs it was determined the box of tritium exit signs was placed in the trash dumpster during cleanup of the [instrumentation and electrical] shop area. As of August 14, 2023, the signs are considered missing/lost. The general licensee stated there is no evidence the integrity of the signs was compromised during the cleanup and thus there was no radiation exposure to personnel. All other unused exit signs were moved to a secured storage location. The Department has requested additional information from the general licensee. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA-300."

The signs contained a total of 234.9 Ci, H-3 when manufactured in 2016.

Texas Incident Number: 10047

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 GENERALLY LICENSED SOURCE

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

"On July 12, 2023, the Agency received an e-mail from Tesla stating they had lost a generally licensed NRD device model number P-2021 Z705. The device contains a 10 millicurie polonium-210 source. The source is sealed inside an air tool used to blow off dust from cars prior to painting. The company performed searches for the device, but was unable to locate the device. The device was discovered missing when the company was getting ready to return them to the manufacturer. The company stated that due to the remaining activity (purchased on March 30, 2021) and the design of the device, it does not pose an exposure risk to any individual."

Texas Incident Number: 10037

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 GENERALLY LICENSED SOURCE

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

"On July 12, 2023, the Agency received an e-mail from Tesla stating they had lost a generally licensed NRD device model number P-2021 Z705. The device contains a 10 millicurie polonium-210 source. The source is sealed inside an air tool used to blow off dust from cars prior to painting. The company performed searches for the device, but was unable to locate the device. The device was discovered missing when the company was getting ready to return them to the manufacturer. The company stated that due to the remaining activity (purchased on June 8, 2022) and the design of the device, it does not pose an exposure risk to any individual."

Texas Incident Number: 10038

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 - TELETHERAPY UNIT SOURCE STUCK IN UNSHIELDED POSITION

The following report was received via telephone and email by the Texas Department of State Health Services (the Department):

"On September 10, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that while testing a MDS Nordion Model Eldorado 8 teletherapy unit, the 1,000-curie cobalt 60 source became stuck in the unshielded position. The RSO stated that room has been isolated and the dose rates taken outside the room do not create an exposure risk to any individuals. The RSO stated that a request for service has been sent to a service contractor. Access to the room has been posted to prevent inadvertent entry into the room. The licensee will update the Department as soon as the plans for corrective actions have been completed. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10049

Texas NMED Number: TX230040

* * * UPDATE ON 09/12/23 AT 1520 EDT FROM ART TUCKER TO THOMAS HERRITY * * *

"On September 12, 2023, the Department was notified by the licensee that the source had been returned to the fully shielded position by a service provider. The licensee stated the individual retracting the source received less than 10 millirem during the process. The service provider is trying to determine the cause for the failure. Additional information will be provided as it is received IAW SA-300."

Notified R4DO (Warnick) and NMSS_Events via email.

AGREEMENT STATE REPORT - FIRE AT FACILITY CONTAINING RADIOACTIVE GAUGES

The following report was received via telephone and email by the Illinois Emergency Management Agency [the Agency]:

"At approximately 1900 [CDT] on 9/10/23, a fire/explosion was reported at the Archer Daniels Midland facility located at 4666 East Farie Parkway in Decatur, IL. Information available at this time indicates a flammable hexane environment may have contributed to the incident. The Agency contacted the facility at approximately 2100 [CDT] on 9/10/23 to determine the status of the 23 radioactive gauges located within the building. The gauges contain a quantity of radioactive material that if impacted by the fire could present non-life threatening but elevated exposure rates to first responders. At 0945 [CDT] on 9/11/23, the Agency made contact with the Radiation Safety Officer at the facility. He stated the gauges are in an adjacent part of the facility (shared wall) which remains to be determined if impacted. It was noted that the area containing the gauges has an elevated hexane concentration. The Agency is actively coordinating with the facility's radiation safety staff and the Macon County Emergency Management Agency to provide information to first responders and coordinate a site visit to determine the status of the devices. If additional information regarding integrity of the devices is not available by midday, the Agency will coordinate a site visit. Reportedly, site access is still limited and information is still forthcoming to emergency managers.

"The 23 Texas Nuclear Model 5205 gauges range in activity from 50 to 100 mCi of Cs-137. Information available indicates 4 gauges contain 100 mCi of Cs-137 and 19 gauges contain 50 mCi of Cs-137. 8 additional gauges containing up to 500 mCi of Cs-137 are located in other onsite buildings, but are not anticipated to have been impacted. It is unclear if the Texas Nuclear Model 5205 gauges or their containers have been impacted by the fire/explosion at this time. On scene assessment is not immediately possible and may not be within the 24-hour reporting timeframe. The matter is being reported at this time and will be retracted if the gauges are found to be undamaged."

Illinois Incident Number: IL230024

* * * UPDATE ON 9/12/2023 AT 1501 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *

The following is a summary of an update received via email from the Illinois Emergency Management Agency:

The licensee's hazmat response staff was able to enter the building late yesterday (9/11/23) and indicated none of the 23 radioactive gauges appear impacted by the fire. The Illinois Emergency Management Agency (IEMA) nuclear safety staff still plan to perform confirmatory surveys and wipes once the building can be safely accessed. IEMA staff are working with the licensee and county Emergency Management Agency officials to coordinate that site visit. Based on the information available, IEMA staff do not have any radiation exposure or accountability concerns at this time. This incident will be kept open until Agency staff have conducted a site visit and confirmed the integrity of the 23 devices.

Notified the Region 3 duty officer and NMSS events.

TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE

The following information is a summary provided by the licensee via phone and email:

On September 7, 2023, a Senior Reactor Operator (SRO) noted that power indication channel 1 and channel 2 initially responded abnormally during preoperational checks. It was determined that the data acquisition system (DAS) system had been de-energized possibly by a power outage the night before. The DAS was re-energized and channel 1 and channel 2 both returned to normal. Preoperational checks were able to be completed but the reactor start up was not completed due to time.

On September 14, 2023, the licensee was concerned regarding the initial abnormal response of the power indications when the DAS was de-energized, and it was determined that further investigation was needed to fully understand the potential effects on the reactor power channel indications. A plan was developed and approved by the Reactor Administrator to perform applicable steps of OP-1 to perform pre-operational and rod-drop tests with DAS energized and with DAS de-energized. All indications and pre-operational checks were normal with DAS energized.

A rod drop test was performed while de-energizing DAS to determine the effect if any on reactor power and scram functionality. Safety rod 1 and 2 were raised (reactor not critical), data recorded, then the power to DAS was removed. The power readings after DAS was de-energized were as follows: channel 1 - 150 cps (counts per second), channel 2 - off scale high on meter and chart recorder, channel 3 - 33 percent of 10 mW. The SRO noted that reactor did not scram when channel 2 indicated off scale high. The SRO manually scram the reactor, power to DAS was restored, and all indications returned to normal. An attempt to perform the pre-operational checks with DAS de-energized was aborted due to channel 1 and 2 indicating abnormally.

The licensee contacted the NRC Project Manager.