Event Notification Report for June 04, 2024

LOST SOURCE

The following information was provided by Agilent Technologies (the licensee) via phone:

A single electron capture device (ECD) containing 15 mCi of Ni-63 was reported to be lost. The ECD was one of ten in a package being transferred by a customer on June 5, 2024. The licensee believes that the ECD was erroneously discarded by a licensee operator. The licensee attempted to recover the ECD without success.

The licensee's root cause analysis determined the event occurred due to the employee not following the established procedure. In addition, employee training was inadequate due to failure to update the training program. Corrective action to update the training program has been undertaken by the licensee.

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

The licensee believes that the ECD was discarded in the facility's normal waste stream.


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

CONCURRENT REPORT FOR DEGRADED HEPA FILTER

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

"This concurrent report is being made because a HEPA filter on a scrap recovery line had degraded below the efficiency that would allow it to remain in service (76.85 percent versus 99.95 percent). This condition is reportable to the Washington Department of Health in accordance with Radioactive Air Emissions License (RAEL) 038. The scrap recovery line has been shut down pending further investigation into the cause of the loss of filter efficiency. Investigation has revealed that no limits were exceeded and no additional reporting is required."

MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 1648 EDT on 06/05/2024, with Unit 4 in Mode 1 at approximately 35 percent power, the reactor was manually tripped due to unexpected response of the turbine run back circuitry following a trip of main feedwater pump `C'. The trip was not complex, with all safety systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam through the steam dumps to the main condenser and main feedwater is supplying the steam generators. Units 1, 2 and 3 are not affected.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

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

EN Revision Imported Date: 8/2/2024

EN Revision Text: PRIMARY CONTAINMENT ISOLATION DUE TO LOSS OF RPS POWER SUPPLY

The following information was provided by the licensee via fax or email:

"On June 4, 2024, at 2141 PDT, with the unit in Mode 1 at 100 percent power, the reactor protection system (RPS) 'B' power supply unexpectedly de-energized which caused containment isolations to occur in reactor water clean up, equipment drains radioactive, floor drains radioactive, reactor recirculation, and traversing in-core probe systems. All actuations occurred as designed upon the partial loss of RPS power.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) as a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates. Emergency assessment capability was restored at 2204."

The NRC Senior Resident has been notified.

* * * UPDATE ON 8/1/24 AT 1925 EDT FROM CHASE WILLIAMS TO ADAM KOZIOL * * *

"A clarification for reactor recirculation valve isolation above - the flow path was administratively isolated prior to the event.

"After further evaluation it has been confirmed that the containment isolations were not caused due to any actual plant conditions or system parameters that satisfied the requirements for isolation. The isolations were a result of loss of power to the RPS 'B' bus and therefore are not considered valid actuations.

"As indicated in 10 CFR 50.73(a)(1), in the case of an invalid actuation reported under 10 CFR 50.73(a)(2)(iv)(A), the licensee may, at its option, provide a telephonic notification to the NRC Operations Center within 60 days of discovery of the event instead of submitting a written licensee event report. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73(a)(2)(iv)(A)."

Notified R4DO (Werner)

EN Revision Imported Date: 6/6/2024

EN Revision Text: MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 1352 EDT, on June 4, 2024 with Unit 2 at 92 percent power, the reactor was manually tripped due to a loss of condenser vacuum resulting from a circulating water pump trip. The trip was uncomplicated with all systems responding normally post trip. Operations stabilized the plant in mode 3. Decay heat is being removed by steam discharge to the main condenser using the turbine bypass valves. St. Lucie Unit 1 was not affected and remains at 100 percent power.

"This event is being reported pursuant to 10 CFR 50.72 (b)(2)(iv)(B).

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - STUCK SOURCE

The following information was provided by the California Department of Public Health (the Department) via email:

"At 1034 PDT on June 6, 2024, the Department received an email from the Mistras Group, notifying the Department of an event at the MRC Martinez Refinery. At 1407 PDT on June 3, 2024, the radiation safety officer (RSO) received a call from a radiography crew at MRC Martinez Refinery regarding a 61 curie Ir-192 source (serial number 475 I) that would not retract back into the industrial nuclear IR-100 radiographic exposure device (serial number 4059). The RSO arrived on the site at 1444 PDT to find that the extension tube female end crimp had dislodged from the tubing and was laying on the deck of the structure that the crew was working on. At 1555 PDT, the RSO was able to manipulate the cable into a position where they were able to retract the source back into the locked and shielded position without incident or overexposure. Five crew members were present during the time the source was in an unshielded position: the RSO, one radiographer trainer, and three assistants. The highest exposure recorded to their instadose [dosimeter] was 40 mR for the radiographer trainer. The RSO will submit a written report within 30 days following an investigation."

California 5010 report number: 060424

AGREEMENT STATE REPORT - LOST I-125 SEED

The following information was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Department) via email:

"On June 24, 2024, the Department was notified that on June 4, 2024, an I-125 seed for breast localization was not recovered during routine tissue processing of the tissue sample at the grossing bench or within the histology lab. The seed was verified in the tissue sample at the time of removal from the patient through both survey of the patient and a radiograph of the tissue sample. The seed was most likely disposed of either in the biohazard waste or in the non-biohazard waste.

"Upon discovery of the lost source, a survey of the lab with a low energy gamma detector was performed in an attempt to locate the source. The source was not found.

"Exposure to the public is expected to be very low or minimal. The low energy X-rays associated with I-125 decay are likely to be attenuated due to overlying waste, minimal time around the waste, and the given low exposure rate associated with the source. The material is encapsulated."

Utah Event Report ID: 240004

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