Event Notification Report for May 06, 2025

LOST BRACHYTHERAPY SEED

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

"On May 30, 2025, the radiation safety officer (RSO) at HCA HealthONE Sky Ridge notified the Colorado Department of Public Health and Environment via phone call that a prostate brachytherapy seed containing 2.5 mCi of palladium-103 was discovered to be missing during the licensee's inventory. The inventory was conducted on May 7, 2025, but the actual date of loss is unknown."

Colorado Event Number: CO250015


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 PACKAGES

The following information is a summary provided by the Illinois Emergency Management Agency (Agency) via phone and email:

On May 7th, 2025, the Agency received a notification from Bard Brachytherapy in Carol Stream, IL to advise of four missing packages of I-125.

Package A: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package B: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package C: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package D: 40 sources, activity - 1494.800 MBq (40.40 mCi)

Source model number: STM 1251

The package was sent via [common carrier] from Chicago O'Hare Airport on May 2nd, 2025. The package destination was East London, Africa.

An investigation by the Agency is ongoing.

Illinois Item Number: IL250018

* * * UPDATE ON 05/08/2025 AT 1501 EDT FROM GARY FORSEE TO JORDAN WINGATE * * *

"On May 7, 2025, Bard Brachytherapy reported to the Agency the apparent loss of (4) packages containing a total of (158) I-125 brachytherapy seeds with an activity of 0.59 mCi each. The packages were shipped to a client in South Africa via [common carrier] at Chicago O'Hare Airport on May 2, 2025. Data available at the time of the report indicated the packages had been lost while in the possession of the carrier. The following day, May 8, 2025, the licensee advised the packages had actually arrived timely in South Africa on May 4, 2025. No public exposures resulted from this incident. Pending the licensee's written report and explanation on gaps in accountability, this matter is considered closed."

Notified R3DO (Ruiz), 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 OPEN SHUTTER

The following information is a summary provided by the Nevada Department of Health and Human Services (the Department) via phone and email:

On May 6, 2025, the licensee reported to the Department a stuck open shutter on a Berthold LB 7440 gauge (150 mCi Cs-137, serial number 794). The fixed gauge remains installed pending the arrival of a contractor to replace the failed shutter.

Area surveys at 1 foot were 0.2 mR/hr. The gauge is in the wet mill and has little, if any, foot traffic by it. Due to the location and survey results being unchanged from normal operation, there is no additional exposure expected to the mine or mill staff until the gauge can be repaired by the contractor. The ladder to the gauge has been blocked and the walkway has been cordoned off.

This is the third occurrence in less than a year (6/18/2024, 7/8/2024, 5/6/2025) of the same model with the shutter being stuck in the open position. The licensee was reminded to report the failure to the manufacturer in accordance with the operations and maintenance manual for the gauge.

Nevada Item Number: NV250004

EN Revision Imported Date: 6/20/2025

EN Revision Text: SPECIFIED SYSTEM ACTUATION - AUTOMATIC START OF EMERGENCY DIESEL GENERATOR

The following is a summary of information that was provided by the licensee via phone and fax:

At 2108 EDT, on May 6, 2025, with Unit 3 in mode 5 at zero percent power, the plant received main steam line isolation, containment isolation phase 'A', and a safety injection signal which caused the emergency diesel generator to automatically start. The initiation signals were cause by inadvertent clearing of the pressurizer pressure low interlock during maintenance. There was no impact to decay heat removal, no injection into the core, and no loading of the emergency diesel generator. Operations staff responded and returned the plant to normal mode 5 operations.

There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

* * * RETRACTION FROM TED DI ANGELO TO BRIAN P. SMITH AT 1238 EDT ON 06/19/25 * * *

The following is a summary of information that was provided by the licensee via phone and email:

"Millstone Unit 3 is retracting NRC event notification (EN) 57694 regarding the inadvertent main steam line isolation, containment isolation phase 'A' and a safety injection (SI) signal which caused the emergency diesel generators to automatically start on May 6, 2025. This was reported as a valid actuation under 10 CFR 50.72(b)(3)(iv)(A). Subsequent evaluation has determined that the actuations were the result of an invalid signal caused by pinching a wire during a maintenance activity, which automatically unblocked the P-11 permissive.

"P-11 is a reactor protection permissive that automatically enables SI actuation when pressurizer pressure increases above 2000 psia. The permissive was unblocked as the result of the spiked pressurizer pressure indication caused by the pinched wires coincident with bistables associated with a separate pressurizer pressure channel tripped to support rescaling activities. With the plant shutdown, steam line pressures were low which met the condition to require a SI actuation with P-11 unblocked. This unblocking and resultant actuation was not a result of valid signals and was not an intentional manual actuation. The pinching of a wire causing a spike is not a valid signal and was not representative of actual plant conditions.

"Therefore, this condition is not reportable, and NRC EN 57694 is being retracted.

"The basis for this conclusion has been provided to the acting NRC Senior Resident Inspector."

Notified R1DO (Warnek)

DEGRADED CONDITION

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

"On May 6, 2025, with Callaway Plant in mode 3 ascending from refueling outage 27, plant personnel identified a dry white residue resembling boric acid at the interface between the reactor vessel and bottom-mounted instrument nozzle No.48. At 2220 CDT, the shift manager determined that a reactor coolant pressure boundary leak had been identified. The determination was based on the residue appearing to be in the annulus of the nozzle where it penetrates the bottom head and the residue did not previously exist during earlier inspections of the area during refueling outage 27.

"Detailed examination of the apparent leak has not yet been performed due to radiological conditions, but the condition is being treated as a reactor coolant pressure leak. As such, the condition is being reported pursuant to 10 CFR 50.72 (b)(3)(ii)(A) as an eight-hour, non-emergency notification.

"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 apparent leak placed the plant in LCO 3.4.13.B. The plant is evaluating the leak repair corrective actions and preparing for cooldown.

60-DAY NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION

The following is a summary of information that was provided by the licensee via phone and fax:

"Millstone Power Station Unit 3 is submitting a 60-day telephonic notification in lieu of a licensee event report (LER) submittal as allowed by 10 CFR 50.73 (a)(1) for an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A).

"On May 6, 2025, at approximately 2108 EDT, while Millstone Power Station Unit 3 was in mode 5 during a refueling outage, an invalid safety injection (SI) signal was initiated. The actuation was not the result of intentional manual actuation and not in response to actual plant conditions requiring safety system operation. This resulted in the automatic start of both emergency diesel generators (EDGs), and the complete initiation on both trains of the following: main steam line isolation, containment isolation phase 'A', and safety injection signal. No injection into the reactor coolant system occurred, and the EDGs remained unloaded. All equipment not administratively locked out responded as designed, and the plant remained stable throughout the event. Control room operators responded in accordance with appropriate operating procedures and restored the affected systems. 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)- including safety injection signal, containment isolation signal, and start of both emergency diesel generators.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector was notified of the event."