Event Notification Report for December 27, 2023

AGREEMENT STATE REPORT - LOST SOURCE

The following summary of events was received via phone call and email from the New Mexico Environment Department, Radiation Control Bureau (the Bureau):

The licensee reported a lost source to the Bureau on December 7th, 2023. The source was described as a mixed gamma button source S/N 64820-570, 25.4 mm diameter, 1/8 inch thickness, containing multiple isotopes of low activity. The isotope with the highest present day activity was Am-241 with an activity of 0.253 microcuries. All of the other isotopes had a negligible activity by the Bureau's reporting criteria. The source was shipped by the licensee and considered lost on December 7th after receiving an email from the common carrier that they were not able to locate the shipment. There is no evidence that any individual was potentially overexposed as a result of the lost source.

New Mexico Incident #: N/A

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 - LEAKING SEALED SOURCE

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

The licensee, Medical Center of Aurora, discovered a leaking sealed source on December 18, 2023, during a routine semi-annual inventory and leak test. The sealed source is an Eckert and Ziegler (Serial Number 1360-6-20) Cs-137 vial with estimated current activity of 0.136 millicuries. The plastic vial had been stored in a lead box since the last inspection, but it was discovered that the plastic was cracked. Wipe test showed 0.052 microcuries of removable activity inside the storage box. No contamination was found outside of the box. The source vial will be wrapped in several layers of plastic to stabilize it and limit contamination inside the box. The licensee has contacted the manufacturer to return the source.

Colorado Event Number: CO230044

AGREEMENT STATE REPORT - SOURCE UNABLE TO RETRACT

The following report was received via phone and email by the Texas Department of State Health Services [the Department]:

"On December 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that on December 19, 2023, they were unable to retract a 52 curie iridium-192 source into a QSA 880D exposure device. The RSO stated its radiographers were performing radiography on a pipe. The pipe fell and struck the guide tube, crimping it far enough to prevent them from retracting the source. The radiographers isolated the area and contacted the RSO. A retrieval team arrived at the location and was able to retract the source. The RSO stated no individual exceeded any exposure limits. Additional information will be provided as it is receive it accordance with SA-300."

Texas Incident Number: 10074
Texas NMED Number: TX230058

AGREEMENT STATE REPORT - SHUTTER STUCK IN OPEN POSITION

The following report was received via email from the Tennessee Division of Radiological Health:

"During a scheduled 3-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was in a normal operating position. A vendor field technician has been contacted about the gauge which is an Ohmart/Vega gauge, model SHLG-1, with an isotope of cesium-137, 300 millicuries. Corrective actions as well as additional information will be updated with a NMED report within 30 days."

Tennessee Event Report Number: TN-23-089

EN Revision Imported Date: 12/27/2023

EN Revision Text: PART 21 REPORT - DEFECT IN VALCOR SOLENOID VALVES

The following is a synopsis of information received via facsimile:

Valcor Engineering Corporation (VEC) identified a defect with Valcor solenoid valves with part number V52600-5890-1 on October 23, 2023. The defect identified is that stroke matching of internal components was not performed in accordance with internal procedures causing valve flow coefficient (Cv) to be only approximately 50 percent of the minimum required Cv of 2. Substantial safety hazard could be created if the flow rate through the solenoid valve exceeded a certain threshold.

VEC has identified two of these solenoid valves at LaSalle County Nuclear Generating Station (LaSalle) with serial numbers 33 and 34.

For corrective actions, VEC repaired and returned the valve with serial number 34 to LaSalle. To prevent recurrence, VEC intends to improve the training program for production personnel and, if needed, review and revise the stroke matching procedure including enhancing quality assurance oversight of that process. VEC estimates it will take 30 days to complete corrective actions.

Currently, LaSalle is the only known affected facility. Valcor is in the process of identifying and notifying affected customers.

For additional information, please contact Mike Swirad, Valcor Engineering Quality Assurance Director (973-467-8400 x 7223), email: mikeswirad@valcor.com