Event Notification Report for October 04, 2024

EN Revision Imported Date: 10/4/2024

EN Revision Text: AGREEMENT STATE REPORT - MISSING GAUGES

The following is a summary of information provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via phone:

In the conduct of their regulatory duties, RHB established a program to collect and store nuclear gauges from closed or abandoned mining sites. This initiative is aimed at preventing improper disposal of nuclear gauges during reclamation operations.

On September 6, 2024, RHB inspected one such coal mining facility located in Helton, KY, in an attempt to recover six fixed Cs-137 level gauges with an aggregate activity of approximately 700 mCi. The storage facility for the gauges was found open and the gauges were missing. The last recorded inventory of the gauges occurred in 2021. Local law enforcement and state emergency operations were notified. It is believed that the gauges were improperly discarded either by the previous owner or by the reclamation company.

RHB will continue to investigate this event and provide updates in accordance with SA-300. No risk to the public is anticipated from this event.

* * * UPDATE ON 9/16/2024 AT 0959 EDT FROM RUSSELL HESTAND TO SAMUEL COLVARD * * *

The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email:

"RHB is in the process of repossessing nuclear gauges from abandoned coal mines. In the process of assessing the number and state of each gauge, it was discovered that the building at the [Big Laurel #1 prep plant] was demolished. The storage cabinet located in that building was missing. On September 6, 2024, an onsite investigation of the facility was performed. The storage cabinet was located on the property. The storage cabinet was damaged and the contents of the cabinet (6 gauges with 700 mCi of Cs-137) were missing.

"The last known pictures and inventory from a routine inspection on June 23, 2021, showed the gauges stored in the locked metal cabinet at the warehouse where Big Laurel #1 prep plant, operated by Bledsoe Coal, then Revelation Energy and later under reclamation by Black Mountain Resources, are now gone.

"On September 10, 2024, at 1153 EDT, RHB was notified of a smelter in West Virginia that had their portal monitors alarmed. The load was returned to its origin site located in Hazard, Kentucky. RHB representatives were dispatched to the facility. Upon arrival at the scrapyard facility, two gauges were present. The gauges were compared to the last known inventory at Big Laurel. Both gauges were positively identified as property of said plant. Both gauges were surveyed for removable contamination. All levels for removable contamination were at or below background. The two gauges were then packaged and secured for transport to RHB in Frankfort, Kentucky. RHB has possession of the two gauges.

"On September 13, 2024, RHB was notified that that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel will be dispatched on September 17, 2024, to secure the additional gauge. The gauge will be stored at RHB in a secure location."

Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email)

* * * UPDATE ON 10/03/2024 AT 0938 EDT FROM RUSSELL HESTAND TO NATALIE STARFISH * * *

The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email:

"On Friday September 13, 2024, RHB was notified that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel were dispatched on September 17, 2024 to secure the additional gauge. The gauge is stored at RHB in a secure location.

"On Thursday September 19, 2024 RHB was dispatched to a recycling center in Hazard Kentucky to retrieve two more gauges. A third gauge was reportedly cut up and disposed. Surveys of the area where the gauge was supposedly cut-up were conducted. Soil Samples were retrieved. Results are still pending, but no increased levels were detected.

"RHB has recovered five gauges. Three were confirmed by serial number to be from Revelation Energy. Two of the gauges no longer have serial numbers. All five are believed to be from Revelation Energy. The unaccounted sixth gauge is believed to have been cut up and sent to waste weeks ago. RHB went to the location where it was cut and took surveys and soil samples. Lab testing revealed only background radiation. It is not believed that the cesium was compromised.
"Five of the six gauges have been through one half life and the sixth has an original assay date of November 2001."

Notified R1DO (Deboer), NMSS Events (email), ILTAB (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

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the New York State Department of Health via phone and email:

"Notification was received by email on 9/13/24 from Mt. Sinai Hospital, NYC license number 75-2909-04, of an event that took place on 9/6/24. The event involved treatment of the liver with Y-90 microspheres, and only 40 percent of the intended dose was delivered, which they said was due to stasis. The dose delivered to the left lobe of the liver was 58.8 Gy compared to a prescribed dose of 147 Gy."

NYC Event Number: NYC-24-0913

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 - MEDICAL MISADMINISTRATION

The following information was provided by the New York State Department of Health via phone and email:

"Notification was received by phone call on 9/24/24 and email on 9/26/24, from Memorial Sloan Kettering Cancer Center, NYC license number 75-2968-01, of an event that took place (or was discovered) on 9/24/24. They say the event involved a Y-90 microsphere procedure with a dose to a site other than the treatment site that exceeded 0.5 Sv and was 50 percent or more in excess of the dose expected."

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

The unintended dose was to the stomach and duodenum. The estimated excess dose to the affected tissue was 99 Gy. This information is tentative pending further investigation.

NYC Event Number: NYC-24-0924

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.

ALERT - FLOODING ONSITE

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

At 1507 EDT on 9/27/2024, Nuclear Fuel Services (NFS) Erwin declared an Alert due to flooding onsite in the protected area due to Tropical Storm Helene. The Headquarters Operations Officer was notified of the Alert at 1518 EDT. All operations have been suspended and all non-essential employees have been sent home. Essential personnel are staging sandbags around vital areas to protect material storage areas. There was no release in progress and water has begun to recede. Plant personnel are conducting walkdowns of the site.

State and local authorities have been notified.

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)

* * * UPDATE ON 9/27/2024 AT 2030 EDT FROM JORDAN LLOYD TO ERNEST WEST * * *

At 2020 EDT on 9/27/2024, NFS Erwin terminated the declared Alert due to water receding from the protected area. Vital areas are unimpacted; No water entered into any vital areas.

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Suber), NMSS (Helton), IRMOC (Grant).

AGREEMENT STATE - COURIER VEHICLE ACCIDENT

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

"The Department was notified at 0815 [CDT] on September 27, 2024, by the licensee, that one of their courier vehicles had been involved in a vehicle accident on I-35 North, between Denton and Valley View, Texas. The accident resulted in the death of a driver of an 18 wheeler but was not related to the presence of radioactive material (RAM). The courier driver was injured with a broken leg and was transported to the hospital with non-life threatening injuries. The roadway was shut down for several hours due to diesel fuel, oil, and debris from the collision. There was no radiological involvement as part of the closure. The shipment was six `ammo' boxes containing 10 doses of F-18. Five of the containers were located in the courier vehicle and transported to a nearby hospital. The packages were surveyed on arrival at the hospital by hospital staff and placed in a secure area to await the licensee's personnel. The five packages were subsequently retrieved by the licensee. The sixth package was ejected from the transport vehicle and was not transported to the hospital with the other five packages. The licensee retrieved and surveyed [the sixth] package at the accident scene. There was no contamination or release of RAM. The investigation [by the Department] continues."

Texas Incident Number: TBD

OFFSITE AGENCY NOTIFICATION

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

"At 1000 CDT, on October 3, 2024, Kewaunee Power Station was informed that the Wisconsin Department of Health Services (WDHS) was notified of an asbestos worker qualification issue specific to several workers at the Kewaunee Solutions Decommissioning Project. This notification was made by a subcontractor performing asbestos abatement work at the site and involves a lack of documentation of the worker qualifications.

"The NRC Regional Inspector has been notified."