Event Notification Report for May 07, 2024

CONCURRENT REPORT FOR OFFSITE NOTIFICATION

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

"In accordance with 10 CFR 70, Appendix A(c) concurrent reporting, this notification is being made because a plant condition required reporting to the Washington State Department of Health (WDOH). At approximately 1015 PDT on 5/7/2024, three items were found in a storage area.

"Those items were:
1. A metal table that had been used in contaminated areas.
2. A cart that had been used in contaminated areas to transport material, with an additional weight standard stored on it.
3. An out-of-service overpack, designed to transport pellet sintering boats between buildings.

"The items were removed and sent to an outside waste area for gamma spectrometry measurement. The gamma spectrometry results at 1445 PDT on 5/7/2024, indicated that less than 8 grams of uranium were present in the transfer vault. This is more than the annual portion quantity of the building containing the storage area. The limit per stack license for Emission Unit 1511 is 1 gram of uranium.

"The other items were found to not be contaminated. There was no removable contamination on the items as measured by health and safety technicians."

TECHNICAL SPECIFICATION VIOLATION

The following information was provided by the licensee via phone:

Per the licensee's Technical Specifications (TS) 6.1.3.a, "The minimum staffing when the reactor is not secured shall be: . A reactor operator or the senior reactor operator on duty in the control room."

On May 7, 2024, following the reactor shutdown, there was an indication that one control rod was not fully inserted. Both the reactor operator and reactor engineer left the control room to investigate and discovered that one control rod was not fully inserted. The reactor operator leaving the control room violated the minimum control room staffing requirements of TS 6.1.3.a.

On May 8, 2024, the licensee determined that the cause for the control rod not being fully inserted was a dislodged plastic buffer at the bottom of the control rod barrel.

The NRC Project Manager has been notified.

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following is information received from the Washington State Department of Health via email:

"On 05/07/2024, three radiographers started work around 1000 [PDT] and were in the process of completing a second shot about 12-feet off the floor when the collimator attached to the source fell to the ground. This caused a bend/crimp in the guide tube preventing the radiographers from retracting the source back into its shielded position within the exposure device. After several attempts at retracting the source, the radiographers contacted the radiation safety officer (RSO) at 1026 PDT. The boundaries were expanded and the workers guarded the area. No other workers or contractors were present at the time.

"At 1130 PDT, the RSO arrived with additional shielding (lead shot bags) and tools. The RSO made a first approach to the source and observed that the collimator was facing northwest. The RSO, using a long reaching tool to manipulate the collimator, turned it to face the ground. No change in activity was recorded and it was determined that the source was not within the collimator. The RSO placed a 25-pound bag of lead shot on the guide tube just below the collimator. No change in activity was observed. The team then retreated. The technician approached the source and placed a second bag further down the guide tube. Survey meters read a substantial decline in activity. The RSO then returned to the source and placed several more bags on the source location. After the source was shielded, the RSO inspected the guide tube and located a slight pinch in the tube. The RSO then used a tool to partially remove an irregularity from the guide tube and requested the technician to crank the source back into the camera. The source was returned to the camera successfully. The RSO removed the damaged guide tube from service.

"The total exposure to the lead radiographer was 10.75mR. The first assistant radiographer exposure was 3.9mR. The second assistant radiographer exposure was 3.6mR. The RSO had an exposure of 20mR on their arm and 4.3mR on their trunk.

"The camera is a Sentinel model 880 with an Ir-192 source of 38.7 Ci."

Washington Incident No.: WA-24-013

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The radiation safety officer for Endeavor Health Clinical Operations (IL-01248-02) contacted the Agency at 1115 CDT on 5/8/2024 to report a medical underdose. The patient had been prescribed two administrations of Y-90 TheraSpheres. The first administration was completed without incident. The second administration (a separate written directive) resulted in only 14 percent of the dose being delivered (17.1 Gy of 122.14 Gy prescribed). The administering physician reported initial resistance due to a kinked catheter at the distal end. Both the patient and the referring physician were notified. The licensee met the reporting requirements. A reactive inspection is scheduled to be performed on 5/16/2024."

IL Event Number: IL240012

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.

LOST TRITIUM EXIT SIGNS

The following information was provided by the licensee via telephone:

During an inspection in early March 2024, the licensee could not locate ten tritium exit signs. On May 7, 2024, after searching for the signs, the licensee declared the signs lost. The licensee does not know when the signs were lost. The total activity was 118.7 curies.

The licensee notified the NRC Region 4 inspectors.

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