Event Notification Report for October 24, 2023

AGREEMENT STATE REPORT - LOST SEED SOURCE

The following is a summary of information provided by the Georgia Radioactive Materials Program via email:

On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023.

Georgia NMED Incident Number: 71

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

SURFACE CONTAMINATION ON OUTSIDE OF PACKAGE

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

On 10/17/23 around 1100 CDT, the licensee received two packages each containing technetium-99m. Swipe readings on the packages revealed gross counts of 19158 disintegrations per minute (DPM) for the first package and 6874 DPM for the second package. The licensee's radiation safety officer (RSO) and the supplier, Cardinal Health, were notified. The inside of the package was also wipe tested and was not contaminated. The nuclear medicine department was surveyed, including the hot lab and department hallway and no additional contamination was found. The licensee has placed the two cases in short term storage and intends to send them back to Cardinal Health when they are at background. The licensee also called and left a message with NRC Region 3 personnel.

AVERAGE POWER RANGE MONITORS DECLARED INOPERABLE

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

"On October 21, 2023, at 2048 EDT, reactor recirculation pump (RRP) 12 tripped. The cause for the trip is under investigation.

"Following the RRP trip, the average power range monitors (APRMs) flow bias trips were inoperable due to reverse flow through RRP 12. The APRMs were restored to operable on October 21, 2023, at 2058 EDT, when the RRP 12 discharge blocking valve was closed.

"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(v)(A) which states: "Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition."

"The NRC Resident Inspector has been notified."

SECONDARY CONTAINMENT MOMENTARILY INOPERABLE

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

"On October 22, 2023, at 1149 CDT, with the reactor at 100 percent core thermal power and steady state conditions, the Cooper Nuclear Station secondary containment differential pressure exceeded the Technical Specification (TS) Surveillance Requirement (SR) 3.6.4.1.1 limit of -0.25 inches water gauge. The condition existed for approximately 80 seconds until the reactor building ventilation system responded to restore differential pressure to normal. Investigations identified a hinged duct access hatch found open. The hatch was closed and latched, and ventilation system parameters were returned to normal. There were no radiological releases associated with this event.

"Declaring secondary containment inoperable as a result of not meeting TS SR 3.6.4.1.1 is reportable under 10 CFR 50.72(b)(3)(v)(C) and (D) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material and mitigate the consequences of an accident.

"The NRC Senior Resident Inspector has been informed."

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

At the time the licensee notified the NRC Headquarters Operations Officer, the cause of the hinged access duct being open had not been determined. This event has been added to the licensee's corrective action program.