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."

AGREEMENT STATE REPORT - LOST I-125 SEED

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

"The Department received notification from the licensee of a lost I-125 seed used for localization. A patient was implanted with two, approximately 0.050 mCi I-125, seeds on September 20, 2024, with the placement of the seeds verified by x-ray. The patient returned to the hospital on September 26, 2024, to have the tissue, including the seeds, removed. The seeds were then sent to pathology where only 1 seed was found. The operating room and patient were surveyed but the seed was not located. The Department has requested additional information and continues to investigate the event.

"Arizona License Number- 07-478

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

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 - DAMAGED MOISTURE DENSITY GAUGE

The following information was provided by the Colorado Department of Public Health and Environment (the Department) via email:

"On 09/26/2024, the Department was notified by the CTL/Thompson, Inc. radiation safety officer (RSO) that a possible incident with a moisture density gauge occurred at a job site in Granby, CO. The RSO stated he had no further information to provide [about the event]. The Department compliance lead spoke with the RSO over the phone and identified the assistant RSO (ARSO) over that job site. [When contacted] the ARSO stated that a technician was driving on a job site when the incident occurred. The latches were closed on the transportation case, but not fixed with locks since additional testing was going to be performed. While driving over the uneven terrain of the job site, the truck jostled causing the tailgate to open and the transportation case flipped over towards the edge of the truck bed. The latches on the transport case released and caused the gauge (Troxler model 3430, 8 mCi Cs-137, 40 mCi Am-241/Be) to come out and land on the ground, resulting in damage to the gauge."

Colorado Event Report ID: CO240024

AGREEMENT STATE REPORT - STUCK SHUTTERS

The following information was provided by the Louisiana Radiation Protection Division via email:

"This event is considered an equipment failure with open shutters. The failure occurred while Syngenta Crop Protection was performing their required license condition shutter checks on August 29, 2024. There were two nuclear gauges that failed the shutter operational checks.

"The two nuclear gauges are in the failed open shutter position.

"The first gauge is a Texas Nuclear series 5100, model 5189 and serial number 51, with a source activity of 25 mCi [Cs-137] and the second gauge is a RONAN Engineering, model SA1-F37 and serial number 6268CM, with a source activity of 2000 mCi [Cs-137 and Co-60].

"Syngenta Crop Protection is planning to bring a third party to work on or replace the nuclear gauges. BBP Sales will be the third party. Syngenta Crop Protection plans on having BBP Sales out to the facility as soon as possible."

LA Event Report ID Number: LA20240010

AGREEMENT STATE REPORT - FOUND GAUGE

The following information was provided by the California Radiologic Health Branch (RHB) via email:

"RHB was notified on 9/30/24 that Los Angeles (LA) County Radiation Management recovered an InstroTek CPN MC-1 Elite number 31069 (containing nominally 50 mCi Am-241/Be and 10 mCi Cs-137 sources) from an apartment complex in Long Beach, CA. Long Beach Fire and Police Department responded to a call from the apartment complex management that the transportation box was left in their parking garage for approximately a week. An LA County health physicist verified that the box did contain a moisture density gauge, which is owned by Leighton and Associates according to transportation paperwork found inside the unlocked transportation case. The Cs-137 source rod was locked in the shielded location. The gauge was removed from the property and secured in a storage locker.

"RHB contacted the company radiation safety officer, who was unaware that the gauge was missing. Follow-up investigation is in process to determine how and when the gauge went missing and why the licensee was unaware that it was missing."

California 5010 Number: 093024

LOSS OF SEISMIC MONITORING FOR EMERGENCY PLAN ASSESSMENT

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

"At 2235 on 10/03/2024, the Vogtle 1 and 2 seismic monitoring panel experienced an electrical fault, rendering the panel nonfunctional. Compensatory measures for seismic event classification have been implemented in accordance with Vogtle procedures.

"This is an eight-hour, non-emergency notification for a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the seismic monitoring panel is the method for evaluating that an operational basis earthquake (OBE) threshold has been exceeded following a seismic event. This is in accordance with Initiating condition `seismic event greater than OBE levels' and emergency action level HU2.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

PART 21 - NON COMPLIANT CONTACTORS

The following is a synopsis of information provided by MPR Associates, Inc. (MPR) via fax:

On August 9, 2024, MPR received information that electrical contactors (Models AF80 and AF116) provided by Asea Brown Boveri Ltd. (ABB) contain a microcontroller. The fact that these contactors contain a microcontroller was not included in MPR's analysis during their commercial grade dedication process. Two contactors were supplied to Beaver Valley Power Station (ABB AF116-30-11-13) where one was installed in the excitation system for one emergency diesel generator. Five contactors were supplied to Davis-Besse Nuclear Power Station (ABB AF116-30-11-13), but none were installed.

MPR is currently working to provide information to support continued use of the installed contactors. MPR is also working to identify a replacement contactor that is suitable for the application.

Responsible MPR officer:
Robert Coward, Principal Officer
MPR Associates, Inc.
320 King Street
Alexandria, VA 22314
703-519-0200