Event Notification Report for August 01, 2024

LOST AND RECOVERED SOURCE

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

"A Class 7 package (approximately 10 Ci of Ir-192 for use in a high dose rate remote afterloader for radiation oncology) was delivered to Saint Francis Hospital, [in] Hartford, CT. The package was delivered to hospital shipping/receiving and signed for at 1030 [EDT]. The package was then routed to [the] oncology department. When reaching oncology, it appears the package was mistaken for a 'chemotherapy' package instead of a 'radiation oncology' package and placed in storage in the chemotherapy department. Later, a medical physicist anticipating delivery of the package today inquired about the package with the delivery service and was informed that the package had been delivered. The physicist then began searching for the package and was able to locate it in the chemotherapy department. The physicist retrieved the package and began the check-in process at about 1500 per standard operating procedures. The physicist stated that the package was unopened, undamaged, and still sealed.

"The RSO received notification from radiation oncology that the package was missing prior to when the package was eventually found. The package was stored in a secured area, but its location was unknown to trained staff for the interim period, so the decision was made to make notification of the incident.

"This is an initial assessment. The radiation safety staff along with management will be conducting an investigation to determine more precise timelines, details, and evaluating corrective action options to prevent recurrence."

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - FOUND SOURCE

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

"On 7/16/2024, the Agency was notified that the licensee found a box with seven calibration rod sources stored in the previous radiation safety officer's desk. The licensee had previously been cited for poor source accountability. The replacement of the radiation safety officer (RSO) and the use of a consultant were implemented as corrective actions. Locating and reporting these sources is a result of those efforts. The New England Nuclear gamma reference rod source set (Catalog No. NES-100T) contains a Co-57, Co-60, Cd-109, Ba-133, Cs-137, Mn-54, and Na-22 source - each with a nominal activity of 7 microcuries. While the sources were labeled as exempt when distributed in 1977, the Co-60 and Cd-109 sources appear to no longer be exempt under current regulations (10 CFR 30.71 Schedule B), nor does any exemption exist that grandfathers these sources. Wipe tests were performed and indicated no leakage.

"In accordance with SA-300, section 5.6.2, 'found sources' are to be reported when they exceed 10 times the value specified in Appendix C to 10 CFR Part 20. The Cd-109 source contained 12.9 microcuries when assayed 9/6/77, so, it remains reportable. The sources were placed on the licensee's sealed source inventory. Corrective action is adequate, and this matter is now considered closed."

IL Event Number: IL240016

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

CONTROL ROOM ENVELOPE FAILED SURVEILLANCE

The following information was provided by the licensee via email:

"At 0146 CDT on June 7, 2024, River Bend Station (RBS) was operating at 100 percent power when a loss of control room envelope (CRE) was declared due to failing to meet Technical Specification (TS) 3.7.2, Surveillance Requirement (SR) 3.7.2.4, during surveillance testing. Mitigating actions were established which included the ability to issue potassium iodide to control room staff. With mitigating actions in place, the dose consequence to control room staff continued to be less than the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event.

"The CRE is considered a single train system at RBS, therefore, this event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC resident inspector has been notified."

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

The failed surveillance (SR 3.7.2.4) was for unfiltered air in-leakage greater than 300 cubic feet per minute.

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

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

"At 1641 EDT, with Unit 2 in Mode 1 at 94 percent power and increasing in power after a forced outage, the reactor automatically tripped due to an electrical trouble turbine trip. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by the auxiliary feedwater (AFW) and steam dump systems. Unit 1 is 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) and in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system.

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