Event Notification Report for August 09, 2024

EN Revision Imported Date: 8/9/2024

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).

* * * UPDATE ON 7/15/2024 AT 1005 EDT FROM JONATHAN WALLICK TO ERNEST WEST * * *

"[The licensee has] additional elements to report, under license technical specification 6.7.2.1 (h):

"Fuel element 3361, stainless-steel clad: Substantial cladding damage, but not an apparent breach. It has a severe scratch approximately one eighth of an inch wide along most of the element, and two other substantial scratches. The top of the main scratch terminates in what appears to be a cracking pattern, though likely not fully through the cladding, as no fission product release was detected. The element also exhibits apparent rust on the triangular spacer, covering approximately 10 percent of the serial number face surface. It will not be used in the future. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was transferred to our facility after previous use at Michigan State University in 1989, also having been previously used at General Atomics in San Diego. Estimated manufacture [date] in 1964.

"Fuel element 7932, stainless-steel clad: Substantial cladding damage, but not an apparent breach. It has multiple deep scratches, disconnected at the ends, though running in parallel for lengths down a side of the element for nearly the entire length. [The element] gives the appearance of potential separation, but no fission product release was detected. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was purchased directly from General Atomics new in 1974.

"Fuel element 9473, stainless-steel clad: Multiple deep scratches on several sides with little to no light reflection. Scratches are typical on elements, however, the appear to threaten the integrity of the cladding and further use may result in release, though none has been detected yet. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. None of our inspection records show a history of any damage. It was in service prior to this inspection. This element was purchased directly from General Atomics new in 1980.

"Fuel element 5888, stainless-steel clad: Several concerning scratches and a large, repeatedly damaged scratch, indicating improper handling and threatening cladding integrity. No fission product release detected, but further handling may result in even minor damage sufficient enough to enable a release. It will not be used in the future unless thorough non-destructive evaluation concludes sufficient cladding integrity remains. Inspection records show small amounts of damage; however, [the records were] not fully indicative of the degree [of damage] observed during this inspection. The element has not been in service at this facility. It was obtained from the fuel repository at Idaho National Lab in 2016, which transferred the element from General Atomics, originally used starting in 1970.

"Fuel element 5671, stainless-steel clad: Appears to have oddly spaced and shaped bands of rust around the fuel section of the element. Coloration and lack of light reflection strongly suggest an abnormal corrosion, prominent on all sides of the element in varying degrees. Gently rubbing with a soft cloth resulted in minimal transfer of material, only some coloration but no discernable particulate, indicating the defects are integrated into the cladding and not freely releasable. No obvious mechanism exists to explain the features, though other elements on site have a similar pattern, none exhibit the degree of discoloration or loss of luster. The element was in storage at the facility but had been previously used. It will not be used in the future. It was originally purchased new from General Atomics in 1968.

"[The licensee is] still working through fuel inspections. There will likely be future updates."

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

* * * UPDATE ON 7/25/2024 AT 0903 EDT FROM JONATHAN WALLICK TO SAMUEL COLVARD * * *

"[The licensee has] an additional element to report, under license technical specification 6.7.2.1 (h):

"Fuel element 6551 (stainless-steel clad): Corrosion of top fitting and upper canister weld, but not an apparent breach as no fission product release was detected. It will not be used in the future. This is the first close inspection that the element has undergone at our facility other than briefly viewing upon its arrival. It was in storage prior to this inspection. This element was transferred to our facility after previous use at the VTT FiR-1 reactor in Finland in 1/2021. Estimated manufactured in 9/1970, and delivered to the Finland reactor in 11/1970.

"[The licensee is] still working through fuel inspections. There will likely be future updates."

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

* * * UPDATE ON 08/08/2024 AT 0918 EDT FROM JONATHAN WALLICK TO ROBERT THOMPSON * * *

"[The licensee has] an additional element to report, under license technical specification 6.7.2.1 (h):

"Fuel element 5708, stainless-steel clad: Was found to have a small bolt bonded to the top of the element, approximately 1/2" long, machine size 10. The bolt appears to have galvanically corroded to the top of the element and cannot be removed, suggesting it has been in place for decades. Top-down views show significant corrosion that is spreading to the upper weld of the element, but not an apparent breach, as no fission product release was detected. It will not be used in the future. Previous inspections did not note any problems with the element. It was in storage prior to this inspection, last in core in 2007. This element was procured new from General Atomics in 1969 by our facility.

"[The licensee is] still working through fuel inspections. There will likely be future updates."

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

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

"On July 30, 2024, the licensee, WRB Refining, LP - Wood River Refinery (IL-01282-01) in Roxana, IL, discovered a stuck open shutter on a fixed gauge. They reported this to the Agency on July 31, 2024. The Vega Americas level indicator gauge is located on the 'Coker North Drum 8 Top Gauge' and contains 5000 mCi of Cs-137 (assay date 11/10/2008) with serial number 8626CM, source holder model number SHLG-2-30, source holder serial number 13541754, and tag number LX0544CK. The gauge will be serviced soon. Updates will be provided as available."

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

This poses no safety hazard to the public.

Illinois Item No. IL240017

AGREEMENT STATE - STUCK OPEN SHUTTER

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On August 1, 2024, the Department was notified by the licensee that the shutter of a Vega model SH-F2B gauge containing 200 millicuries (original activity) of cesium - 137 was stuck in the open position. Open is the normal operating position. The problem was discovered during routine testing. The licensee reported there was no risk of additional radiation exposure to any individual.

"Additional information will be provided as it is received in accordance with SA-300."

Texas incident number: 10117
NMED number: TX240020

AGREEMENT STATE REPORT - LOST CALIBRATION SOURCE

The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via email:

On August 1, 2024, the BRC received a notification from the Jacksonville Cardiovascular Center mobile trailer that a 174 microcurie Cs-137 Evial calibration source was missing. The source was last inventoried at the end of June, 2024.

Device: Evial
Manufacturer: EZAG
Model Number: 3350
Serial Number: 1792-20-18

Florida Incident Number: FL24-068

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 - MISSING SHIPMENT

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On August 2, 2024, the Department was notified by a Texas licensee that they had shipped 118 millicuries of iodine-125 seeds to a vendor in the state of Florida on July 26, 2024. The package was shipped standard overnight shipping. The Texas licensee reported that on August 2, 2024 the vendor contacted them and requested a status update of the shipment. The Texas licensee looked up the shipping information on the shipper's web site and it only showed that the material had been picked up by the shipper at the Texas licensee's location. The Texas licensee has not been able to get any additional information from the shipper. The Texas licensee has opened a case with the shipper. Additional information will be provided as it is received in accordance with SA-300.

"The licensee reported the iodine-125 seeds involved in this event are not an exposure risk to any individuals."

Texas incident number: I-10118

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

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:

"The licensee reported that around 0800 EDT on August 1, 2024, it was discovered that a break-in had occurred at a construction site. Their portable nuclear gauge (PNG) containing 8 mCi Cs-137 and 40 mCi of Am-241/Be was stolen. The construction site is a locked and secured fenced area with the licensee's Conex box inside that secured area. The PNG was located inside the Conex box, locked inside its own secured steel storage box, secured via chains and locks to the inside of the Conex box. The steel box containing the PNG was also locked with chains and locks.

"The fenced area was broken into and the doors to the Conex box were forced open with a large sheepsfoot roller, allowing the thieves' access to the steel box containing the PNG.

"RMB's investigation is ongoing. A follow-up report will be made to close and complete the record."

NC event number: NC24004

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 - DOSE TO UNINTENDED ORGAN

The following information was obtained from the California Department of Public Health, Radiologic Health Branch, via email:

"University of California at Los Angeles (UCLA) reported a medical event had occurred on Friday, July 26, 2024, during a Y-90 Therasphere liver cancer treatment. Patient SPECT imaging performed on August 1, 2024, showed that all of the Y-90 activity was in the patient's stomach tissue rather than in the intended left lobe of the liver. The licensee reported that the dosage of Y-90 administered was in conformance with the written directive. UCLA is continuing to investigate to determine how the Y-90 Theraspheres ended up in the stomach tissue and will address the cause in their 15-day written report to the Radiologic Health Branch.

"Per the licensee's documentation, a dosage of 0.77 GBq was delivered to the patient, with 0.74 GBq expected to go to the treatment site to result in a dose of 178.9 Gy to the treatment site."

California event number: 5010-080124

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 - LOST STRONTIUM-90 SOURCES

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

"On August 1, 2024, the Agency was advised by the radiation safety officer (RSO) for Eastern Illinois University that twelve strontium-90 button sources were missing from inventory. As the sources had been secured in a locked cabinet, they were likely mistakenly included in a low-level radioactive waste pickup that occurred on July 8, 2024. The RSO was not present for the shipment, nor was the waste pickup coordinated with relevant radiation safety program staff. The sources were identified as missing when the RSO did a sealed source inventory on August 1, 2024. The sources were not itemized on the waste manifest and while this is the most likely disposition, it cannot be verified at this time.

"The twelve sources were 0.5 microcurie Sr-90 button sources when assayed in 1970. All were manufactured by The Nucleus, Inc. as model Sr-90-S-5, with serial numbers 6/2/70-1 through 6/2/70-12. They are now decayed to approximately 0.14 microcuries each and do not represent a radiation safety concern. The Agency has already conducted a reactive inspection. The licensee is assessing the availability of documentation through the waste broker (NAC Philotechnics). Pending that documentation and a response to the Notice of Violation, this matter is considered closed."

Illinois item number: IL240018

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