Event Notification Report for December 20, 2024

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

DEGRADATION OF SAFETY ITEM

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

"At approximately 1030 EST, on 12/12/2024, Nuclear Criticality Safety (NCS) staff were notified that the polyvinyl chloride (PVC) piping of a passive overflow item relied on for safety (IROFS, SGD-147) for Uranium Recovery and Recycle Services (URRS) vessel V-756A was in a deformed condition. V-756A and V-756B are interconnected URRS dissolver product hold tanks. The V-756B redundant passive IROFS overflow (SGD-130) is constructed of steel. NCS staff reviewed the condition of the PVC overflow piping and determined the overflow was deformed into a position that would restrict flow to the point that it could not provide its intended safety function. The safety function of the IROFS is to prevent backflow of uranium bearing material into water and nitric acid systems by providing an overflow path below the height of the water and nitric acid inputs into V-756A/B. The SGD-130 passive overflow was available to perform its intended safety function. The issue was entered as a red-book item in the corrective action program (CAP) as IR-2024-13041.

"Per criticality safety evaluation, CSE-4A, and supporting calculation note, CN-SB-11-031, with the passive overflow IROFS SGD-147 in a failed condition, the overall likelihood index (OLI) for the fault tree scenario increased from -6 to -3 which does not meet the OLI of -4 necessary to meet 10 CFR 70.61 performance requirements. The result is reportable per 10 CFR Part 70 Appendix A(b)(2), 'Loss or degradation of items relied on for safety that results in failure to meet the performance requirements of 10 CFR 70.61.'

"Operations for the dirty dissolver process are down pending further investigation and development of compensatory actions. A causal analysis will be performed and corrective actions to prevent recurrence will be documented in the CAP.

"Further investigation determined that on 12/12/2024, during third shift URRS, while dirty dissolver operations were down, a centrifuge malfunction occurred that necessitated spill clean up of the centrifuge platform area in the ground floor level below the platform. Based on interviews of URRS personnel, it was determined that to clean up the two spill locations, two separate steam-driven eductors with suction wands were utilized to transfer spill solutions to V-756A in roughly the same timeframe. The apparent cause of the PVC overflow piping deformation is excessive steam vapor influx into V-756A from the simultaneous spill cleanup activities.

"A review of the site maintenance database identified one completed maintenance work order for the replacement of V-756A overflow piping for PVC pipe deformation. Additional review of previous maintenance activities for the V-756A will be performed to determine if there were other instances of deformation of the overflow piping for V-756A. This occurrence in September 2024 was not brought to the attention of management or engineering staff to ensure comprehensive follow-up and corrective actions. The occurrence was not captured as red-book CAP item for a degraded or failed IROFS."

* * * UPDATE ON 12/16/24 AT 1030 EST BY SAMUEL COLVARD * * *

The following information was submitted on 12/13/24 at 1030 EST via NRC form 361A:

"Number and types of controls necessary under normal operating conditions: For scenario 4.3 of CSE-4-A supporting Calculation Note, CN-SB-11-031, two passive overflow IROFS controls (SGD-130 and SGD-147) are necessary under normal operating conditions to prevent a backflow condition into the nitric acid supply.

"Number and types of controls which functioned properly under upset conditions: Passive overflow IROFS (SGD-130) on V-756B is constructed of metal and will not deform when exposed to steam. Criticality safety staff reviewed the SGD-130 overflow for V-756 A/B and determined it could perform its safety function.

"Number and types of controls necessary to restore a safe situation: The PVC overflow IROFS SGD-147 for vessel V-756A was replaced on 12/12/2024. An extent of condition review for process vessels with PVC/plastic pipe passive overflows with potential exposure to excess heat has been initiated.

"Safety significance of events: Passive overflow IROFS SGD-130 remained available and a review of tank level data logging confirmed there was no overflow of V-756 A/B and there was no backflow condition into the deionized water and nitric acid systems.

"Safety equipment status: The passive overflow IROFS control SGD-147 for V-756A/B was replaced on 12/12/2024. The IROFS controls necessary to meet 10 CFR 70.61 performance requirements are in place.

"Status of corrective actions: Operations for the dirty dissolver are down pending further investigation and development of compensatory actions. A causal analysis will be performed and corrective actions to prevent recurrence will be documented in the corrective action program."

Notified R2DO (Franke), NMSS Events (email).

AGREEMENT STATE REPORT - IRRADIATOR EVENT

The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:

During a routine inspection conducted by the Department on December 3, 2024, inspection and maintenance records indicated that a float switch for a panoramic pool irradiator had failed on August 13, 2024. Between December 3, 2024, and December 13, 2024, the licensee evaluated the event for reporting applicability. On December 13, 2024, the licensee reported the event to the Department. The licensee is reporting that the float switch on a Nordion (model JS8900) continuous panoramic pool irradiator (serial number IR97) failed on August 13, 2024, during routine maintenance and inspection checks. The float switch was replaced on August 13, 2024. Specifically, the float did not operate the full length to the hard stop. The licensee is reporting no current health and safety concerns. This event is under investigation by the Department.

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The float switch alarms radiation workers of low water levels which would result in higher radiation levels.

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.