Event Notification Report for July 05, 2024

EN Revision Imported Date: 7/5/2024

EN Revision Text: 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.

* * * UPDATE ON 07/03/2024 AT 0927 EDT FROM JONATHAN WALLICK TO JORDAN WINGATE * * *

The following is a summary of information provided by the licensee via phone and email:

After continued fuel inspections, four additional damaged fuel elements were identified (Fuel Element 3007, Fuel Element 5952, Fuel Follower Control Rod 5767, and Fuel Follower Control Rod 5768). The damaged elements will be moved to dry storage and will not be considered for further use.

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

Inspections are approximately one third complete.

Notified NRR PM (Boyle), NPR Event Coordinator (Waugh), and USGS PM (Sutherland).

REMOVABLE CONTAMINATION LIMITS EXCEEDED

The following information was provided by the Veterans Health Administration (VHA) National Health Physics Program via phone and email:

"Per 10 CFR 20.1906(d), VHA National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits.

"The package was received Wednesday, June 26, 2024, at about 0650 EDT, at the Carl Vinson VA Medical Center, 1826 Veterans Blvd, Dublin, Georgia. This facility operates under VHA permit number 10-09569-01 issued in accordance with master materials license number 03-23853-01VA.

"The package was checked in and surveyed upon receipt around 0650 EDT. A wipe performed on the external surface of the package indicated a removable contamination level that exceeded the regulatory limit of 240 dpm/cm^2 for beta-gamma emitters. The measured contamination was 26,679 dpm/100cm^2. After adjusting for a 10 percent wipe efficiency and converting units, this equals 2668 dpm/cm^2 or about 10 times the reporting limit. The contamination was isolated primarily to the package handle.

"The package contained four dosages of Tc-99m with a total activity of about 90 mCi (nominal). Analysis of the wipe test confirmed a gamma peak consistent with Tc-99m. Wipe tests of the interior of the delivery package resulted in levels below the exterior level of around 2800 dpm. The dosages themselves appeared to be unimpacted and able to be used. The container was isolated and is being stored in a designated, shielded area for decay.

"The facility Nuclear Medicine Technologist (NMT) notified the delivery carrier by phone about the contaminated package at around 0910 EDT. VHA National Health Physics Program, who manages the master materials license, was alerted to the incident around 0710 CT (0810 ET)."

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

HOO follow up calls with the licensee and the radiopharmaceutical delivery company confirmed no spread of contamination. The receipt area at the licensee indicated no spread of contamination. The delivery driver clothes and hands were surveyed clean. There is no indication of spread of contamination to the public.

AGREEMENT STATE REPORT - BROKEN BRACHYTHERAPY SEED

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

"The Agency was contacted on 6/25/24 by Bard Brachytherapy in Carol Stream, IL to advise that they received a package which contained an applicator device with a broken brachytherapy seed. The applicator device was found to be contaminated and was placed in the licensee's hood for decontamination, recovery, and proper disposal. The licensee indicated there was no staff or area contamination as a result. The South Carolina licensee, having shipped the seed, similarly reported no contamination or adverse impacts. Due to the condition of the damaged seed, the radionuclide (Pd-103 or I-125) as well as the model and lot number are still pending. The activity remaining is likely beneath 0.5 mCi. This matter is reportable under 32 Ill. Adm. Code 340.1220(c)(1) and was transmitted to the NRC. Updates will be provided as they become available.

"Bard Brachytherapy is a manufacturer and distributor of brachytherapy seeds (IL-02062-01). Their client, West Hospital in Charleston, SC, returned the damaged seed in proper packaging. There is no indication of a public health or contamination concern."

Illinois Report #: IL240015

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 - LOST ELECTRON CAPTURE DETECTOR SOURCE

The following summary of information was provided by Colorado Department of Public Health and Environment, Radioactive Materials Unit (the Department) via phone and email:

On June 27, 2024, the Department was notified by the licensee (IEH-WAL Laboratories) of a missing source from an electron capture detector for gas chromatography (ECD-GC) (Agilent Technologies, ECD, Model: 1923369576, 15 mCi Ni-63). The discovery of the lost source was through an inventory check earlier in the day. The last record of the device was on February 21, 2024, at a location in Littleton, CO, where similar units were repaired or dispositioned. Searches at both the Greeley and Littleton locations were performed. This notification is being made to the NRC in accordance with Colorado Regulations Section 4.51.1.1.

Colorado Event Report ID: CO240015

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 - Y-90 UNDERDOSE

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"On 06/28/24 at 1430 EDT, the licensee reported a medical event under license 60-0096 for BWXT Medical Ltd. TheraSpheres Model TheraSphere Y-90 Glass Microsphere System (Sealed Source and Device Registry: NR-0220-D-131-S) for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more.

"The medical event was reported to the radiation safety officer (RSO) at 1430 EDT on 6/27/2024. The prescribed dose to the patient was 106.4 mCi over two fractions. The dose received by the patient was 68.5 mCi (60.4 mCi on the first fraction, and 8.1 mCi on the second fraction). This resulted in an under dose of 35.6 percent. The authorized user and prescribing physician have been notified. The licensee has not reported whether the patient has been notified.

"The Agency will follow up with licensee RSO to determine the event cause and corrective actions.

"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."


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.

INVALID PARTIAL CONTAINMENT ISOLATION

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

"At 1928 CDT on May 13, 2024, River Bend Station (RBS) was operating in Mode 1 at 100 percent power when an invalid isolation signal actuated multiple containment isolation valves in more than one system. The invalid isolation signal was caused by voltage perturbations on the offsite power distribution system due to multiple lightning strikes in the vicinity of RBS.

"The event caused one containment isolation valve to isolate in the floor and equipment drains system, and two containment isolation dampers to isolate in the auxiliary building ventilation system.

"This event was a partial system isolation for the affected systems and did not result in a full train actuation.

"This event meets the reportable criteria for 10 CFR 50.73(a)(2)(iv)(A) and is being reported as any event or condition that resulted in manual or automatic actuation of any systems listed in paragraph (a)(2)(iv)(B). This notification is being provided in lieu of a Licensee Event Report as indicated in 10 CFR 50.73(a)(1)."

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

The valve and dampers were immediately re-opened. The standby gas treatment system automatically initiated due to the closure of the containment isolation dampers in the auxiliary building ventilation system.

NONCOMPLIANCE WITH TECHNICAL SPECIFICATION

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

"On July 3, 2024, at 0907 EDT, a reactor operator (RO) was in the process of commencing a routine startup. During the startup, the RO switched on the ventilation fans for less than 1 second with the key in the console.

"[With the key in the console] the reactor did not meet the definition of 'reactor secured' and thus the confinement requirements of technical specification (TS) 3.4.2 were still required to be met. [Ventilation fans running in this condition violates the confinement requirements of TS 3.4.2.]

"The RO notified the director of radiation facilities and logged the action. Throughout the duration of the event all control rods were fully inserted.

"The director notified the NRC project manager."