Event Notification Report for June 26, 2024

EN Revision Imported Date: 6/26/2024

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"On June 14, 2024, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge secured in the trunk, was stolen earlier that day. Local police are aware of the incident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided.

"Manufacturer and Model Number: Troxler Electronic Laboratories
"Model Number: 3440
"Serial Number: 35459
"Isotope and Activity: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries."

PA Event Report ID No: PA240012

Surrounding States and the Pennsylvania emergency response team have been notified.

* * * UPDATE ON 6/25/2024 AT 0730 EDT FROM JOHN CHIPPO TO SAMUEL COLVARD * * *

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"On June 24, 2024, the car and gauge were recovered. The gauge was still inside of the vehicle with no damage or evidence of tampering. Survey meter readings of the gauge showed normal levels and it was returned to the licensee. Representatives of the Philadelphia Fire Company accompanied the licensee to retrieve the gauge."

Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (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

EN Revision Imported Date: 6/26/2024

EN Revision Text: TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE

The following information was provided by the licensee via email:

"At approximately 1100 CDT on June 14, 2024, during routine fuel inspections required under Technical Specification 4.1.5, a fuel pin (serial number 11420) did not pass the go/no-go test for transverse bend. This measurement is described in Technical Specification 3.1.5.2.a as part of the fuel inspection conducted under the surveillance described in Technical Specification 4.1.5. Failure of an element to meet any one of the specifications listed in Technical Specification 3.1.5.2 specifies that the fuel element is considered 'damaged' and therefore may not be used in reactor operations.

"Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.

"There have been no indications of cladding failure on routine primary coolant analyses.

"The pin has been removed from service and will be replaced with a spare unused element.

"As required by Technical Specification 4.1.5.2, an inspection of the entire core fuel inventory will be initiated and will be completed prior to resuming routine operations.

"After the identification of the failure, the test rig calibration was confirmed and the pin was checked again, confirming the element failed the transverse bend specification.

"The reactor was not operating at the time of the event."

NRC Project Manager has been notified.

* * * UPDATE ON 6/25/2024 AT 1537 EDT FROM JERE JENKINS TO SAMUEL COLVARD * * *

The following information was provided by the licensee via email:

"During the Technical Specification (TS) 4.1.5.2 required inspection of the entire core resulting from the finding detailed above, an additional element [SN 11391] failed to pass the inspection for transverse bend on Friday, June 21, 2024, requiring that element to be declared as 'damaged' in accordance with TS 3.1.5.2 (same as above). As this meets the definition of a 'reportable occurrence' under the definitions in TS 1.3. In accordance with the requirements of TS 6.6.2 and 6.7.2, we have hereby notified the HOO [Headquarters Operations Officer] by a revision or update of the previous report of damaged fuel, Event Number 57174.

"Additional details:

1. Visual inspection of the pin prior to placement in the test rig did not indicate any obvious degradation that would be exceptional for a pin with seventeen years of burnup history.
2. There have been no indications of cladding failure on routine primary coolant analyses.
3. The pin (SN 11391) has been removed from service and will be replaced with a spare element.
4. We have also informed our project managers.
5. The inspection of the remaining uninspected elements is almost complete, as of this writing no further "damaged" elements have been identified."

Notified NRR PM (Boyle), NPR Event Coordinator (Waugh)

AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

The following information was provided by the Arkansas Department of Health, Radiation Control, Radioactive Materials Program (the Agency) via email:

"The Agency was notified by the Radiation Safety Officer (RSO) for the University of Arkansas for Medical Sciences on Friday afternoon, June 7, 2024, to advise of a possible Y-90 TheraSphere misadministration where the patient did not receive all the prescribed dose. The administration was two doses to segment 5 of the patient's liver. The discovery was made when the tubing and waste from the procedure was surveyed after it was returned to the lab.

"The written report was received on Friday afternoon, June 14, 2024. On June 17, 2024, the Agency reviewed the information provided and determined that this event is a misadministration due to the following:

"The administered doses both differed from their respective prescribed doses by more than 0.5 Sv (50 rem) to an organ. The delivered dose of 95 Gy (9500 rem) was 198 Gy (19800 rem) less than the [prescribed] dose of 293 Gy (29300 rem) for dose number one; the delivered dose of 105 Gy (10500 rem) was 21 Gy (2100 rem) less than the [prescribed] dose of 126 Gy (12600 rem) for dose number two.

"[For] dose number one only, the total dose delivered differs from the prescribed dose by twenty percent or more. Dose number one was outside the treatment prescription range; 68 percent of the prescribed dose was not received. Therefore, [dose] number one is considered to be a misadministration in accordance with current emerging medical technology licensing guidance.

"Dose number two was just inside the treatment prescription range; 17 percent of the prescribed dose was not received.

"The referring physician and [the] patient were notified, and the patient has been scheduled for an additional treatment.

"The investigation is ongoing, and reporting will proceed in accordance with SA-300."

Arkansas Event number: AR-2024-004

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.

AGREEMENT STATE REPORT - DAMAGED GAUGE

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

"Alton Steel Inc. contacted the Agency on June 17, 2024, to advise of an incident in which molten steel impacted and damaged a 2.3 mCi Co-60 sealed source. This incident reportedly occurred on June 14, 2024, and results from the same ongoing conditions (source susceptible to molten steel flowing down the dip tube) identified in the licensee's March 2024 incident (refer to EN 57016). The licensee is still working with the source manufacturer to identify an engineered solution.

"The source and casting mold lid were collectively moved into a restricted area under the oversight of the radiation safety officer. The damaged source was then secured pending a site visit by the source manufacturer's authorized representative on June 18, 2024. The licensee missed the reporting timeline (24 hours). Agency staff will be on site the morning of June 20, 2024, for a reactive inspection. That inspection will assess contamination potential, discuss reporting timelines (reportedly missed due to multiple heat injuries and facility damage), address ongoing susceptibility of sources to damage, review contaminated area remediation timelines, and address proposed corrective actions for the April 19, 2024, Notice of Violation.

"Based on the information available at this time, there does not appear to be any impact to public health and safety. A description of the event indicates licensed material was not dispersed or incorporated into any product. This will collectively be assessed and this report [will be] updated thereafter."

Illinois Item Number: IL240014

THIS MATERIAL EVENT CONTAINS A 'Not Recorded' LEVEL OF RADIOACTIVE MATERIAL

DAMAGED GAUGE

The following is a summary of information that was provided by the licensee via phone:

At 1530 CDT on 6/19/2024, the radiation safety officer (RSO) at Geo Technology, LLC was notified about a water truck that was unable to stop and ran over an InstroTek nuclear gauge. The gauge was a model explorer 3400 (serial number 3379) which contains 370 MBq of Cs-137 and 1.48 GBq of Am-241/Be. The site reported that the source inside the gauge was able to be retracted to the shielded position. The RSO plans to inspect the gauge and perform surveys.

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The following information was received from the Georgia Radioactive Material Program (the Department) via email:

"A report was received from the radiation safety officer (RSO) at Applied Technical Services, LLC. on June 21, 2024, concerning the most recent dosimeter badge report which indicated a whole body dose of over 5,000 mrem for the month of April 2024 for an employee. The RSO has notified their upper management and the employee is suspended from all radiation work as of June 20, 2024, until further investigation. The employee is in the process of writing a detailed statement. The licensee is currently reviewing all utilization logs and will notify the Department once the investigation is complete. Further investigation is ongoing to determine root cause and a follow-up report will be provided within 30 days."

Georgia Incident Number: 85

TECHNICAL SPECIFICATION REPORTABLE OCCURRENCE

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

"In accordance with Technical Specification (TS) 6.7.2.1, a report is required to be made within 24 hours by telephone, confirmed by digital submission or fax to the NRC Operations Center if requested, and followed by a report in writing to the NRC, Document Control Desk, Washington, D.C. within 14 days that describes the circumstances associated with eight different specifications, one of which, (h), is abnormal and significant degradation in reactor fuel, cladding, or coolant boundary.

"At approximately 0900 MDT this morning, abnormal and significant degradation in reactor cladding was observed on fuel element 681E, an aluminum-clad element being inspected for removal from service. The degradation was in the form of an L-shaped hole, approximately 0.25 inches long in the upper section of the fuel element body approximately one inch from the top edge, where the upper aluminum pin and upper graphite section meet internally. It is unknown how long this damage has existed, as there is no visual record of any of this fuel since first inspected in 2003 at the VA Omaha TRIGA reactor before USGS took possession. At that point, it did not have this damage. According to the records, it was dropped during handling in 2003 when it was being unloaded from the shipping cask here at the GSTR [Geological Survey TRIGA Reactor], but no record of further inspection appears to exist. Therefore, this element may have been in the operating core for as long as 18 years in this condition, as USGS was first licensed to use it in 2006."

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

No fission products were detected in the primary, pool, or on an air particulate detector. The damaged element remains in its storage location in the pool with no other mitigating measures planned in the near term.