Event Notification Report for March 07, 2025

EN Revision Imported Date: 3/7/2025

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SAFETY INSTRUMENT

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

"At approximately 2100 EST, on December 24, 2024, the licensee's staff noticed a tear in the Mylar window on one of their Thermo-Fisher FC-185 beta gauges, thus causing the system to be shut down. The system was put back into service at approximately 0000 on December 25, 2024. The licensee's radiation safety officer contacted the Department to report the incident at 1502 on December 25, 2024. The Thermo-Fisher Model TFC-185 contains 1250 mCi of Kr-85. The source model number is a Kr85-4, and the serial number is KA-2197. There were no radiation exposures resulting from the service of the gauge."

* * * UPDATE ON 03/06/2025 AT 0840 FROM ANDREW ROXBURGH TO BILLY NYTKO * * *

"The licensee submitted its 30-day written report on January 16, 2025. The report indicated that the Mylar window was replaced at 2350 on December 24, 2025. The report also indicated that there were no increased radiation exposures to individuals during the repair. The Department considers this event closed."

Notified R1DO(Ford) and NMSS Events (email)

AGREEMENT STATE - LOST INDUSTRIAL RADIOGRAPHY CAMERA

The following is a summary of an email received from the North Carolina Department of Health and Human Services, North Carolina Radioactive Materials Branch (NC RMB):

"The NC RMB is currently investigating a missing industrial radiography camera. It is unknown at this time whether the camera was missing or stolen. The licensee reported that they stayed the night at a hotel in Kernersville, NC, and discovered the next morning that the camera was missing. They immediately notified NC RMB and the local police department. They are currently reviewing hotel surveillance cameras and waiting for the police to arrive."

NC Event Number: 250003

Device Info:
Model: Spec 150
S/N: 0320
Source: Ir-192
Activity: 74.0 Ci

Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, EPA EOC, FDA EOC, and FEMA National Watch Center. Emailed: Nuclear SSA and CWMD Watch Desk.

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received from the Texas Department of State Health Services:

"On February 27, 2025, the licensee reported that the shutter on a Vega model SH-F2C-45 containing a 500 millicurie (original activity) cesium-137 source was found stuck in the open position during routine testing. Open is the normal operating position. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10175
NMED number: TX250014

DAMAGED I-125 SEED

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

"During a surgical excision procedure [that occurred on 5/20/2022] in the operating room (OR), a lesion which was previously localized with an I-125 seed was extracted from the patient. A trunode [gamma probe] device was used to identify the location of the seed and to guide the surgeon for the dissection of the breast tissue. After the dissection, the physician visualized the seed on the outside of the tissue specimen while it was still within the breast. Once the specimen was removed and scanned, there were no counts obtained in the patient. The specimen was then placed in a faxitron [x-ray machine] and an image was taken, but no visualization of the seed [occurred]. The surgeon immediately scanned the breast tissue to evaluate if the seed had been left behind. There were zero counts within the breast. The physician then scanned the drapes and sponges and did not identify the seed. The surgeon then proceeded to scan the suction tubing and ultimately the manifold of the suction equipment and was able to identify the seed in the manifold. The OR team then contacted nuclear medicine [personnel] and informed them to secure the suction manifold and secure it in the specimen safe in the frozen room. The manifold was placed in a red biohazard bag and secured in the safe. The operating room and the suction equipment were then surveyed by the surgical techs; the room and equipment measurements were background.

"A nuclear medicine technologist retrieved the manifold from the safe and took the manifold to histopathology to remove the seed. The manifold had to be opened with a screwdriver and trained personnel in histopathology removed the seed. The seed was recovered, but it was in two pieces. One half was the titanium capsule, and the other half was the titanium capsule and the silver rod with the chemically affixed iodine-125. The two halves were then placed in a lead pig. The biohazard bag, manifold, and contents of the manifold measured radioactive and were labeled and placed in storage in the nuclear medicine hot lab.

"All personnel in histopathology and the nuclear medicine technologist were checked for radioactive contamination. Everyone was negative for radioactive contamination. The trash and work area were also tested and were negative. The nuclear medicine technologist then notified his direct report authorized user (AU), the surgeon, and the radiation safety officer (RSO). The AU and surgeon, after hearing the seed was in two halves, made the decision to recall the patient to the hospital to verify background for a third time. The survey was again background, and the AU determined to not initiate potassium iodide treatment regimen. The RSO and nuclear medicine technologist then surveyed the OR personnel, biohazard containers, surgical trash, and operating room. All measurements were background. Wipe tests were performed of the neptune suction machine and the I-125 source. The wipe test of the Neptune was background, and the wipe test of the source indicated to be I-125.

"The RSO has been in constant communication with an Ohio Medical Physicist Consultant (OMPC) health physicist, to make sure all protocols were followed correctly. The RSO also contacted the NRC regional III Health Physicist, to see if this is an incident that needs to be reported to the NRC. 10 CFR part 20, 30 and 35 were reviewed over the phone and it was determined at that time the broken seed was not a reportable event. The NRC regional III Health Physicist later emailed OMPC health physicist with two other reporting requirements for review to determine if a report was needed. After reviewing 10 CFR 30.50 and 10 CFR 35.3067 it was determined it was not a reportable event. The seed and the contaminated suction module will be stored in the nuclear medicine hot lab until it is deemed safe to dispose of properly."

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

The I-125 seed contained an estimated activity of 291 microcuries.

EN Revision Imported Date: 3/7/2025

EN Revision Text: MAIN STEAM ISOLATION VALVE FAILED TO CLOSE

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

"At 0101 EST on 03/01/25, while shutting down for entry into a scheduled refueling outage, the station discovered that a single main steam isolation valve '4A MSIV' did not fully close on demand. All other equipment operated as expected.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v).

"The NRC Resident Inspector has been notified."

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

Unit 4 will remain in mode 4 until corrected. The MSIV was closed by isolating instrument air.


* * * RETRACTION ON 03/06/2025 AT 2023 FROM BOB MURELL TO ROBERT THOMPSON * * *

The following information was provided by Florida Power and Light (FPL) via phone and email:

"The purpose of this notification is to retract EN 57578. Notification of the event to the NRC was initially made as a result of a single main steam isolation valve (MSIV). The `4A' MSIV failed to fully close on demand during a planned refueling outage shutdown.

"Subsequent to the initial report, FPL has concluded that the '4A' MSIV would have fully closed during an accident scenario based on steam flows that would have been present.

"Therefore, this event is not considered an event or condition that could have prevented fulfillment of a safety function and is not reportable to the NRC pursuant [to] 10 CFR 50.72(b)(3)(v)(D).

"The NRC resident inspector has been notified."

Notified R2DO (Penmetsa).

TRANSPORT OF CONTAMINATED PERSON OFFSITE

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

"On March 5, 2025, at 0418 CST, a contract employee was transported to an off-site medical facility for treatment. The individual was determined to have low levels of contamination prior to being transported.

"This event is reportable [in accordance with] 10CFR50.72(b)(3)(xii) any event requiring the transport of a radioactively contaminated person to an off-site medical facility for treatment."

The NRC resident inspector has been notified.

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

A qualified radiation health physics technician traveled with the contaminated individual to ensure no spread of contamination to the ambulance or to the medical facility.

FITNESS FOR DUTY EVENT

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

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

The licensee notified the NRC resident inspector.