Event Notification Report for November 27, 2024

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"Sacred Heart's failure to notify the Florida BRC at the time of the occurrence, 10/15/24, was identified by [the Florida BRC inspector] during a routine inspection.

"Sacred Heart intended to inject the patient with 6 mCi of Tc-99m mebrofenin which would travel to the gallbladder. Instead, the patient received 6 mCi of Tc-99m methyl diphosphonate which targeted the bladder wall. The dose received [by the patient] is estimated at 1.6 mGy. Sacred Heart states the syringe had the expected markings of mebrofenin, and the error was caused by the supplier in Alabama.

"The patient and primary physician were notified of the occurrence."

Florida Incident Number: FL24-110


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 - LOST MOISTURE DENSITY GAUGE

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

"The Florida BRC received initial notification at 1830 [EST] from licensee (4696-7) UES Professional Solutions of a lost in transit density gauge. More information about this incident was received at 2000 from the licensee's radiation safety officer (RSO).

"The licensee's technician noticed the soil moisture density gauge was missing from the back of his pick-up truck around 1530 [on 11/19/2024] when he returned to the job site after lunch. He realized the tailgate was open and, when he went to close it, he noticed the gauge wasn't there. The technician last used the gauge during a subgrade test right before he went to lunch around 1430. He thinks the gauge was lost while at lunch. The technician called his supervisor at 1730, who contacted the RSO. The employee admitted that the gauge case was not locked, but the gauge was secure in the case. The RSO and technician retraced the route several times, but were not able to locate the gauge.

"The density gauge is a Troxler [model] 3430 with serial number 31852 [nominally containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be]."

Florida Incident Number: FL24-111

* * * UPDATE ON 11/20/2024 AT 1522 EST FROM MARK SEIDENSTICKER TO ERNEST WEST * * *

"A Jacksonville area inspector responded [on 11/20/2024] and reported their findings. UES Professional Solutions terminated the employee [on 11/19/2024] and used GPS tracking to retrace the route, but did not find the gauge. The Jacksonville Police Department was notified and is also waiting on video surveillance footage from the [restaurant] where the employee stopped."

Notified R1DO (Bickett), NMSS Events Notification (email), and ILTAB (email).

* * * UPDATE ON 11/21/2024 AT 0710 EST FROM MARK SEIDENSTICKER TO TENISHA MEADOWS * * *

"At 1630 EST on Wednesday 11/20/2024, the RSO called and stated an individual found the gauge. The licensee has the gauge back in their possession and are sending it to Troxler for testing before returning to service."

Notified R1DO (Bickett), NMSS Events Notification (email), and 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 - STUCK SHUTTER

The following information was provided by the Louisiana Department of Environmental Quality (LDEQ) via email:

"On November 20, 2024, LDEQ was notified by Blue Cube Operations LLC, that during a semi-annual equipment inspection, it was determined that a level density gauge shutter was malfunctioning and would not fully close.

"The density gauge was a TN Technologies Inc. Model: 5201 serial number: B465, and equipped with a TN Technologies Inc. Cs-137 100 mCi source - serial number: GK-9492.

"No release or exposure to personnel [occurred]. Blue Cube Operations called the vendor to service the level density gauge. The vendor removed the fixed gauge from operations. The fixed gauge with source was secured and is waiting for disposal."

LA Event Report ID Number: LA20240012

DIVISION 3 DIESEL GENERATOR INOPERABLE

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

"At 1158 EST on 11/26/24, the Division 3 diesel generator was declared inoperable due to failure of the right bank air start motor during a planned monthly surveillance run. Troubleshooting of the issue is in progress. This condition could prevent the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). All other emergency core cooling systems were operable during this time.

"There was no impact on the health and safety of the public or plant personnel. 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 Division 3 diesel generator supports high pressure core spray, a single train system.

EN Revision Imported Date: 11/27/2024

EN Revision Text: TECHNICAL SPECIFICATION ABNORMAL OCCURRENCE

The following report was provided by the licensee via email:

"This event is being reported as an 'Abnormal Occurrence,' per the University of Missouri Research Reactor technical specification (TS) 6.6.c, which requires 'Abnormal Occurrences,' defined by TS 1.1, be promptly reported to the NRC Operations Center within one working day.

"At approximately 1440 CST on 11/25/24, during the banking of all four control rods at 50 kW, the '1S3' control blade selector switch became inoperable. The control blade selector switch allows selection of the control blades for manual operation. The inability to select control blades for manual operation resulted in a violation of TS 3.2.a, which requires all control blades, including the regulating blade, be operable during reactor operation.

"The reactor was immediately scrammed and placed in a safe shutdown condition. All applicable safety functions were completed as expected. As a result, there was no impact on the health and safety of the public or facility staff due to this condition. Investigation determined that the internal spring of the '1S3' switch had failed, preventing the switch from selecting a specific control blade for manual control. The spring was replaced and approval to proceed per TS 6.4.c was obtained from the reactor facility director. Post-maintenance testing was completed at 1525 CST on 11/25/24, prior to returning the reactor to normal operations."

The NRC project manager has been notified.