Event Notification Report for January 08, 2024

EN Revision Imported Date: 1/8/2024

EN Revision Text: AGREEMENT STATE - LOST TROXLER GAUGE

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

"On November 4, 2023, the Department was notified by the licensee that one of its technicians had lost a Troxler 3430 moisture/density gauge. The gauge contains one 40 millicurie Am-241 source and one 8 millicurie Cs-137 source. The licensee reported that a technician was waiting in their truck to perform a test at a temporary job site when they were told by the job supervisor that the work was done for the day. The technician drove home and when they reached their home, realized they had left the gauge, which was inside its transportation box, sitting on the tailgate of the truck and it was now missing. The licensee did not know if the cesium source rod or transport case was locked. The technician retraced their route twice, but it was already dark, and they did not see the gauge. The technician notified his radiation safety officer that they had lost the gauge. The licensee will notify local law enforcement of the event. The licensee stated they will begin searching for the gauge as soon as it is light out. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10064

Texas NMED Number: TX230050

* * * UPDATE ON 11/5/2023 AT 1052 EST FROM ART TUCKER TO ERNEST WEST * * *

"On November 5, 2023, the Department contacted the licensee and requested the status of the gauge. The licensee stated that they had performed additional searches for the gauge this morning but did not find the gauge. The licensee stated they had contacted the Harris County, Texas, Sheriff's Department. The licensee stated they would offer a reward for the gauges return. The licensee was advised to contact local pawn shops and watch social media platforms like eBay and Craig's List. The licensee was advised to contact local fire departments about the gauge and provide its contact information. The licensee stated the gauge was labeled with its contact information. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Roldan-Otero), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email

* * * UPDATE ON 1/6/2024 AT 1129 EST FROM ART TUCKER TO ERNEST WEST * * *

"On January 4, 2024, the Department was notified by the licensee that a Troxler gauge identical to the one they had lost was on the Facebook Marketplace website. The Department contacted the Federal Bureau of Investigation Special Agent (FBISA) it has worked with previously and shared the information. On January 5, 2024, the FBISA worked with the licensee and was able to set up a meeting with the seller and was able to recover the gauge. [The FBISA confirmed by serial number it was the gauge that was stolen]. The licensee returned the gauge to its secured storage location and will perform radiation and leak test on the gauge. The individual who had the gauge stated they did not know it contained radioactive material. They also stated they never manipulated the source rod. Additional information will be provided as it is received in accordance with SA300."

Notified R4DO (Drake), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via 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 - UNDERDOSE

The following information was provided by the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) via email:

"A medical administration of Y-90 microspheres that took place on 12/29/23. Advocate General Hospital in Park Ridge, IL, failed to deliver nearly 100 percent of the intended dose. There was no patient impact and the treatment will be rescheduled.

"The radiation safety officer (RSO) for Advocate General Hospital, contacted the IEMA-OHS Operations Center on 12/29/23, to report the above described medical underdose. The patient had been prescribed two administrations of Theraspheres Y-90 microspheres. The first administration went without issue. The second administration (from a separate written directive) called for 3.5 GBq to segment 8 of the liver. Post-administration surveys indicated that nearly 100 percent of the microspheres were still contained within the delivery tubing. The patient and referring physician were immediately notified. The RSO and the authorized user (AU) believed that the time between dose preparation and delivery may have been a contributing issue, but the investigation is ongoing. This matter is reportable by the next calendar day. The licensee met reporting requirements. Inspectors will not be dispatched until next week as there is no immediate radiation safety concern. This report will be updated as additional information becomes available."

Illinois Event Number: IL230037

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.

PART 21 - EMD CYLINDER LINER WITH BORE DEFICIENCY

The following is a summary of the information provided by Engine Systems, Inc. (ESI) via fax:

An edge or lip in the bore of an EMD (Brand name: Electro-Motive Diesel) cylinder liner prevented successful installation of the corresponding power assembly on an emergency diesel generator set. The lip is located axially at the bottom of the inlet ports and is present around the circumference of the bore. The EMD model 645E4 is a 2-stroke engine with air inlet ports in the wall of the cylinder liner. As the piston travels below the inlet ports, air box pressure scavenges and replenishes air to the power assembly.

Installation of the power assembly requires lowering the piston through the liner in order to secure the connecting rod to the crankshaft. During this process the piston could not be lowered below the inlet ports due to the piston rings catching on the lip. The power assembly was not installed and therefore there was no safety hazard; however, if the defect had gone undetected there was the potential to damage engine components and possibly reduce load carrying capacity of the engine.

The extent of the condition is this single cylinder liner, P/N 9318833, S/N 20M0938 used in the power assembly at Tennessee Valley Authority (TVA) - Sequoyah Nuclear Plant, Serial Number: 23H1306.

Corrective Actions:
For TVA-Sequoyah:
No action required; the power assembly has been returned to ESI.
For ESI:
To prevent reoccurrence, ESI has revised the dedication package to include verification that bore machining is continuous along the entire length and no edges or lips are present. The revision was implemented on December 6, 2023.

OFFSITE NOTIFICATION

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

"At 1552 [EST] on 01/05/2024, Perry Nuclear Power Plant reported elevated levels of tritium in the underdrain system to the State of Ohio as a non-voluntary reporting of tritium. An investigation is currently ongoing to identify the cause of the elevated tritium levels. The tritium levels in this location do not exceed any NRC regulations or reporting criteria.

"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

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

"The NRC Resident Inspector has been notified."

EMERGENCY VENTILATION SYSTEMS INOPERABLE

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

"At approximately 1111 EST on 01/05/2024, a mechanical penetration room door was discovered unlatched. Based on security badge history, the door was last opened at 1040 EST. The unlatched door resulted in both trains of the station emergency ventilation system being inoperable due to being unable to maintain the shield building negative pressure area. With both trains simultaneously inoperable, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). The door was closed and verified latched upon discovery to restore the systems to an operable status.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."