Event Notification Report for December 19, 2024

AGREEMENT STATE REPORT - LOST EXIT SIGN

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

One tritium exit sign was determined to be lost by the licensee.

Manufacturer: Isolite Corporation
Number of signs: 1
Model: 880-12-6
Activity: 12.57 Ci, H-3

Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))

Colorado Event Report ID Number: CO240031

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 EVENT

The following is a summary of information provided by the Vermont Department of Health via email:

A patient was prescribed 49.2 mCi of Y-90 TheraSphere microspheres, but received 33.6 mCi. This is a 30 percent difference in the prescribed dose and is reportable in accordance with 10 CFR 35.3045.

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 - AUTOCLAVE CONTAMINATION

The following report was received by the Texas Department of State Health Services (the Agency):

"On December 11, 2024, the Agency received an email from the licensee requesting information on reporting a contamination incident that occurred in their biosafety level 3 (BSL-3) laboratory involving 200 microcuries of C-14. The incident occurred on Friday, December 6, 2024, and was discovered on December 7, 2024, when the sample had cooled and access could occur.

"The licensee's researcher had labeled a sample of the material they were using with the C-14. After the use was concluded, the researcher doused the material with a fluid to kill the bacteria.

"The sample was placed in a `red bag' for disposal, but [the sample] was inadvertently placed on a tray that was moved to the autoclave. The sample was put through the autoclaving process where the plastic container it was in ruptured due to the heat and pressure. Some material spilled onto the tray, and some material was in the drain of the autoclave. It was not until December 7, 2024, when the material cooled, that any assessment could confirm the presence of radioactive material and any evaluation for contamination could be made. The drain [exposure rate] was four times background, and the tray contained most of the contamination and material. The BSL-3 laboratory and vivarium have been closed until such time as decontamination can be completed.

"There was no contamination of personnel, no contamination outside of the autoclave, and no contamination in the actual BSL-3 laboratory. Additional information will be provided in accordance with SA-300."

Texas Incident Number: I-10150

Texas NMED Number: TX240048

AGREEMENT STATE REPORT - LOST SOURCE

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

"[The licensee] contacted the Florida BRC to notify them about a lost source of Cs-137 [with a remaining activity of 127 microcuries of Cs-137 as of 4/4/2024]. The source was last seen in April, 2024. West Coast Nuclear Pharmacy is no longer operating and has been purchased by RLS Pharmacy (4688-2). The source was not located during the transport of material from West Coast Nuclear Pharmacy to RLS Pharmacy. The last BRC inspection of West Coast Nuclear Pharmacy occurred on November 20, 2024. This incident was referred to materials for further action."

Device Type: Cs-137 E-vial
Manufacturer: NAS
Model number: MED 3550
Serial number: 13767

FL Incident Number: FL24-114

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 - LOST STATIC ELIMINATOR

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

One static eliminator was declared lost by the licensee. The licensee believes the device was lost during shipment back to the manufacturer on 07/02/2024.

Licensee: Avago Tech
Manufacturer: NRD, LLC
Quantity: 1
Device: Static Eliminator
Model: P-2042
Isotope: Po-210
Original activity: 5 mCi as of 4/27/2023
Decayed activity: 0.254 mCi as of 12/12/2024

Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))

Colorado Event Report ID Number: CO240032


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

CONCURRENT REPORT

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

"Global Nuclear Fuel - Americas (GNF-A) is making a concurrent report to the NRC for an OSHA (Occupational Safety and Health Administration) reportable event under 29 CFR 1904.39.

"At approximately 1655 EST, on December 16, 2024, the North Carolina Department of Labor was notified that an employee was injured while operating an electric powered pallet jack resulting in a partial amputation of the left thumb soft tissue. The employee was inside the airborne controlled area but was surveyed and free released with no contamination. Root cause investigations and corrective actions were begun. Because the North Carolina Department of Labor was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

LOSS OF OFFSITE EMERGENCY NOTIFICATION SYSTEM CAPABILITY

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

"Comanche Peak Nuclear Power Plant (CPNPP) experienced an unplanned loss of the alert and notification system (ANS) method of outdoor warning primary siren capability for 30 hours from 12/17/24, 0900 CST to 12/18/24, at 1500.

"The capability to activate the sirens was lost during a planned activity to upgrade CPNPP radio system components. The loss of the capability to activate the sirens was not anticipated as part of the planned modification.

"The condition was discovered on 12/18/24, at 1430 while performing periodic testing on the ANS. The siren capability was restored at 1500 when the back-up radio repeater was powered on. The FEMA approved back-up alerting method (route alerting) was available during the loss of ANS siren capability.

"The CPNPP ANS system is currently functional on the back-up radio repeater. There were no plant activities that would have required siren activation during the loss of capability period."

The NRC Resident Inspector has been notified.