Event Notification Report for September 27, 2023

EN Revision Imported Date: 9/27/2023

EN Revision Text: CONTROL ROOM ENVELOPE INOPERABLE

The following information was provided by the licensee via email:

"At 0924 [EDT] on July 25, 2023, it was discovered that both trains of control room air conditioning system were simultaneously inoperable due to an inoperable control room envelope boundary. The boundary was restored at 0925 [EDT] on July 25, 2023. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D).

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

"The NRC Resident Inspector has been notified.

"There has been no impact to Unit 3 which remains at 100% power."

* * * RETRACTION ON 09/26//23 AT 1305 EDT FROM PATRICK SIKORSKY TO JOHN RUSSELL * * *

The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that the access hatch being open did not have an adverse impact upon the control room emergency ventilation system and the control room envelopes boundary's ability to perform their safety function including:

Radiation dose to the occupants did not exceed the licensing basis, design basis accident calculated value.
Protection of control room occupants from hazardous chemicals and smoke.

Therefore, this condition is not reportable and NRC Event EN56637 is being retracted. The basis for this conclusion has been provided to the NRC Resident Inspector.

Notified R1DO (Lally)

AGREEMENT STATE REPORT - UNDERDOSE

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

"After completing a Yttrium-90 TheraSpheres treatment, [medical personnel] were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event."

Colorado Event Report ID: CO 230032

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 - LOST SOURCE

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

"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.

"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.

"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."

Texas Incident Number: 10021
Texas NMED Number: TX230028

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 - LOST THEN FOUND NUCLEAR DENSITY GAUGE

The following information was provided by the Pennsylvania Bureau of Radiation Protection (DEP):

"On September 19, 2023, a licensee vehicle was involved in an automobile accident during which a nuclear density gauge ejected from the vehicle. State Police recovered the device. The licensee reported to the scene and recovered the device. There was no damage to the gauge itself. The only damage incurred was to the transportation box. The side handle was ripped off as a result of the accident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.

"Troxler Model Number: 3440
Serial Number: 35195
Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries"

Pennsylvania Report Number: PA230025

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 EXIT SIGN

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

"On September 6, 2023, the Department was notified of a lost exit sign but did not get detailed information regarding the lost source until September 19, 2023. The licensee reported a tritium exit sign was removed to accommodate a facility renovation, placed in a construction staging area for later disposition, and subsequently was unable to be located on August 15, 2023. The licensee conducted an internal investigation which concluded on September 6, 2023, at which point the Radiation Safety Officer declared that the tritium exit sign was lost. The sign was purchased in 1998 with an initial activity of 25 curies. It is a Betalux, Model SRB S/N 237918. The licensee reported that the integrity of the sign was not compromised and that there is no exposure risk. The Department has requested additional information from the licensee. The investigation into this event is on-going. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10051

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 RADIOACTIVE MATERIAL

The following information was provided by the Maryland Department of the Environment via email:

"On July 12, 2023, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via email from a Tesla employee who reported the loss of a device with NRD model number P-2021 Z705 from a Tesla Body and Paint facility located in Maryland.

"The lost device is manufactured by NRD, LLC with model number P-2021-Z705, serial number A2MF439. The device contains 10 mCi of Polonium-210. No reference date is associated with it, but the device was shipped to Tesla, Inc. on March 16, 2021. These devices are generally-licensed and sold to Tesla by NRD, LLC. Tesla, Inc. Maryland Site, NA-US-MD-Owings Mills-Body is located at 9430 Reisterstown Road, Owings Mills, Maryland 21117.

"On July 14, 2023, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) investigation showed that the Po-210 radioactive material is used for alpha ionizer applications at the Tesla paint and body shop to stop dust from clinging to the body panels prior to painting. As per the company's procedure, when the device is no longer in use, the radioactive 'barrel' cartridges will be returned to NRD (or suitable disposer). The device had the 'gun' separated from the 'barrel' cartridge. The 'barrel' cartridge was returned to NRD as per procedure and the non-radioactive 'gun' part was lost or misplaced. In this process, the Po-210 source was not accounted for by NRD, LLC and reported as lost.

"This information is not conclusive as a lost source and needs to be further confirmed. Information on the current activity is required. MDE/RHP will finalize a reactive investigation."

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 MOISTURE DENSITY GAUGE

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

"On September 20, 2023, the Department received notification of a lost moisture density gauge. The gauge is a Troxler 3430 (serial 39365) with 40 millicuries of americium-241 and 8 millicuries of cesium-137. The gauge was last seen at a job site with the licensee reporting that the handle of the gauge was locked. The gauge was placed inside a transportation case which was also locked. At the job site, the package was placed inside a holding frame in the back of a pickup truck, but the chains were not secured to the case. The tailgate of the truck was also left down. The technician drove about a mile down the road. Someone honking at him alerted him to the fact that the tailgate was down. He pulled over and found the gauge was missing and started searching for it. He alerted his radiation safety officer to the loss and the licensee now has several crews searching for the gauge. The licensee has reported that they believe the gauge might have been picked up by someone and has contacted the state police. This Department has also contacted the State, county, and local city emergency management coordinators. The licensee reported that with the device inside the case they do not expect significant exposure to anyone, but they would expect some exposure in an unrestricted area should someone get near the case. This investigation is ongoing and further information will be provided per SA-300."

* * * UPDATE ON 09/22/23 AT 1912 EDT FROM ART TUCKER TO LAWRENCE CRISCIONE * * *

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

"The Department was contacted by the licensee's radiation safety officer (RSO) who reported the licensee's Regional Director was on-site and had checked with the local pawn shops. The director provided a picture of the device and offered a reward for the return of the gauge. The director did not receive any additional information. RSO stated they had talked to an eyewitness who said they saw the gauge fall out of the truck and then a few minutes later a black pickup truck pulled up and put the gauge in the back of their truck. The RSO stated there is camera footage of the area near where the gauge was dropped (which is at the exit gate to where they were working) and they have viewed the footage for the time they believe the gauge would have been picked up. The gauge did not appear in the video, but the video did help establish an elapsed time of 15 minutes between when the technician left the site until they returned. A second individual stated that there was a contractor working at the same site that had a dark colored truck and had left shortly after the licensee's truck left the site. The licensee has requested additional video footage to see if they can identify that truck."

Notified the R4DO (Groom). Emailed NMSS, ILTAB and Mexico (CNSNS).

Texas Incident Number: 10052

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