Event Notification Report for October 17, 2024

AGREEMENT STATE REPORT - STOLEN SOIL DENSITY GAUGE

The following report was received via email from the Maryland Department of the Environment (MDE):

"On October 9, 2024, at 1549 EDT, the MDE emergency response center received a telephone report of a suspected stolen soil density gauge was captured by police. The report came from the Prince George's County Police to get guidance on the subject. MDE has called the Prince George's County Police contact person and are waiting for a response. Details about the gauge are not yet available.

"This report is based on 10 CFR 20.2201(a)(1)(i) because soil density gauges have a typical activity of 9 mCi of Cs-137 and/or 44 mCi of Am-241.

"An investigation will be conducted and follow up reports are to be expected."

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 - MISSING SOURCE

The following information was received from the office of Alabama Radiation Control via email:

"This report is connected to NMED item 140245, Nuclear Regulatory Commission Event Notification Number 50082 [Damaged Moisture Density Gauge, May 2, 2014], and Alabama Incident number 14-14. Alabama Radiation Control received an email from Troxler Electronic Laboratories on October 9, 2024. The licensee returned the gauge involved in this incident to Troxler in July of 2022. The device was retrieved for service this month. The Troxler representative reported that the cesium-137 source was not present at servicing. The americium-241/beryllium source was present and is being prepared for disposal. We are investigating with the licensee, transportation department contacts, and others."

Model: CPN MC-3
Serial Number: M30129990
Activity: Nominal activity of 10 millicuries cesium-137 and 50 millicuries of americium-241/beryllium.

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

NONCOMPLIANCE WITH TECHNICAL SPECIFICATION

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

"University of Missouri Research Reactor (MURR), a 10 MW reactor, is reporting an abnormal occurrence as required per Technical Specification (TS) 1.1 b and c. One of two redundant switches on the Fluxtrap irradiations reactivity safety trip device failed reactor pre-startup checks on October 14, 2024. This failure would have prevented the switch from sending a scram input to the reactor protection system. MURR TS 3.2.g.21 requires a 1/N logic of 2, meaning both switches must be operational during operation of the reactor.

"The faulty switch was last confirmed operating properly prior to reactor startup on October 7, 2024. MURR cannot positively state when the switch failed. This condition could have existed during operations at some point between October 7 and October 13, 2024.

"The second switch was verified to be operable. The faulty switch and its associated wiring were replaced, retested satisfactorily, and the reactor was returned to operation the evening of Monday, October 14, 2024 with authorization from the Facility Director.

"MURR will follow up with a written report to the NRC within 14 days as required by TS 6.6.c.

"NRC Project Manager has been notified."

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

A causal investigation is in progress. Equipment age is the potential cause of the failure.

FITNESS FOR DUTY REPORT

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

"A licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access has been terminated.

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 10/17/2024

EN Revision Text: FITNESS FOR DUTY

The following information was provided by the licensee via email:

A non-licensed contract supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access has been terminated.

The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Bureau) via email:

"On October 10, 2024, the licensee informed the Bureau of a medical event involving a treatment with TheraSpheres. It is reportable per 10 CFR 35.3045.

"On October 9, 2024, a patient was receiving a [Y-90] TheraSphere treatment. Only 32.7 percent of the prescribed activity (15.975 mCi) was administered to the patient. The physician and the patient were informed on October 9, 2024, following the treatment.

"It is suspected that the cause was an occlusion within the catheter which prevented the proper flow of fluid and TheraSpheres into the patient. The official cause is still under investigation.

"The Bureau will perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report ID: PA240019

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.

LOST SOURCE

The following is a summary of information provided by the National Oceanic and Atmospheric Administration (NOAA) via phone:

A current authorized user was on site in August to test and calibrate systems. They verbally notified the radiation safety officer (RSO) on August 26, 2024, that the spare Ni-63 electron capture detector (ECD) was not in the respective gas chromatograph (GC) which is normally located in the sea-going CFC van. On August 27, the authorized user and the RSO began a search for the missing ECD. The RSO contacted the previous authorized user on August 27, 2024, and they reported that they did not recall reinstalling the spare ECD in March 2020 due to the cruise being cancelled due to COVID. On September 1st, 2024, that authorized user sent a photo of the box used for shipping the ECD, noting that the photo was from July 14, 2021, and the box was present in the sea-going van in Seattle, Washington. A further search was conducted in the sea-going van by the RSO, and the other authorized user, but the ECD and the shipping box have not been located. This search was suspended on October 10, 2024. The licensee will continue looking for the missing ECD.

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

Device Information:
Manufacturer: Shimadzu
Model: GC-8A
Source S/N: 2191
Activity: 8.3 mCi

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 - THERASPHERE DEVICE FAILURE

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

"The Agency was contacted on October 10, 2024, by Northwestern Memorial Healthcare in Chicago, IL, to advise of a suspected TheraSphere device failure. There was no associated medical event, nor any contamination resulting from the equipment failure.

"Reportedly, on September 23, 2024, during the administration of Y-90 TheraSpheres, the treatment was immediately halted by the authorized user (AU) following infusion of 3 mL of saline through the system due to observation of excessive air bubbles present in the outlet line. Both the [authorized medical physicist] (AMP) and the AU noticed what appeared to be flakes in the bottom of the 'V' vial and possible microspheres in the outlet line. The source vial and attached microcatheter were removed following standard procedures. The licensee followed the standard protocol and determined that the patient received 42.18 Gy of the prescribed 45.48 Gy. No follow up or medical action was required of the patient. No contamination of staff, patient, or the area was identified. Staff were interviewed to determine possible causes of the leak, with no deviations from the protocol noted. No initial defects in the administration kit were noted, however, after concluding their investigation, the licensee made the determination of a reportable equipment failure on October 9, 2024. The investigation remains ongoing, and a report was sent by the licensee to the manufacturer on October 9, 2024. This matter is reportable under 32 Illinois Administrative Code 340.1220(c)(2)."

NMED number: IL240023

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

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

"This 60-day optional telephone notification is being made in lieu of a licensee event report (LER) submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 1342 EDT, on September 10, 2024, the reactor water cleanup (RWCU) inboard primary containment isolation valve (PCIV), and the reactor recirculation pump sample inboard PCIV, unexpectedly closed. At the time of this event, work was in progress replacing a control relay in the residual heat removal (RHR) shutdown cooling inboard isolation PCIV circuitry. This relay replacement required lifting the leads of several wires. The neutral side of the relay was electrically connected with the actuation logic for the inboard RWCU and reactor recirculation pump sample PCIVs; the lifting of this lead resulted in the unexpected closure of these PCIVs.

"The actuation was not initiated in response to actual plant conditions, nor an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.

"During this event the PCIVs functioned successfully, and the actuations were complete. This event did not result in any adverse impact to the health and safety of the public.

"The NRC Resident Inspector was notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Unit 2 was not affected.

CONCURRENT REPORT - FIRE DOOR MALFUNCTION

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

"At approximately 1600 EDT, on October 16, 2024, the New Hanover county deputy fire marshal was notified that a non-IROFS (item relied on for safety) fire door was damaged and incapable of fulfilling its function. Specifically, the door would not latch properly and stay fully closed. A fire watch was initiated and repairs started. The door latch was repaired and returned to full operation at 0730, on October 17, 2024. The fire marshal was informed and the fire watch terminated. Because the New Hanover county deputy fire marshal was notified, a concurrent notification to the NRC Headquarters Operations Center is being made per 10 CFR 70, Appendix A(c).

"The NRC region will be notified."