Event Notification Report for May 15, 2024

LOST TRITIUM EXIT SIGNS

The following information was provided by the licensee via telephone:

During an inspection in early March 2024, the licensee could not locate ten tritium exit signs. On May 7, 2024, after searching for the signs, the licensee declared the signs lost. The licensee does not know when the signs were lost. The total activity was 118.7 curies.

The licensee notified the NRC Region 4 inspectors.

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

MEDICAL EVENT - Y-90 OVERDOSE

The following information was provided by the licensee via telephone:

A patient had a written directive to receive 90 Gy of Y-90 TheraSpheres to the liver. When the order was entered into the system, the wrong activity was entered. The higher activity of 360 Gy Y-90 TheraSpheres was then administered to the patient. The calculated dose to the liver may exceed 50 rem.

The patient and referring physician were informed. No health effect or permanent functional damage is expected.

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 - STUCK SOURCE

The following was received from the Texas Department of State Health Services (the Department) via email:

"On May 7, 2024, the Department was notified by the licensee that on May 1, 2024, one of its radiography crews was unable to fully retract a 82.92 curie iridium-192 source into a QSA 880D exposure device. The radiographers had cranked the source out to test a weld, but when they tried to retract the source back to the fully shielded position they could not. The radiographers immediately notified the licensee's site radiation safety officer (SRSO), set up new barriers, and warned other individuals in the area. After a licensee manager arrived at the location, it was determined that a bend in the guide tube was too sharp to allow the source to be retracted. Using a set of 6.5 foot tongs, the SRSO repositioned the guide tube, and a radiographer was able to return the source to the fully shielded position. No individual received an exposure that exceeded 100 millirem. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10104
Texas NMED Number: TX240014

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The radiation safety officer for Endeavor Health Clinical Operations (IL-01248-02) contacted the Agency at 1115 CDT on 5/8/2024 to report a medical underdose. The patient had been prescribed two administrations of Y-90 TheraSpheres. The first administration was completed without incident. The second administration (a separate written directive) resulted in only 14 percent of the dose being delivered (17.1 Gy of 122.14 Gy prescribed). The administering physician reported initial resistance due to a kinked catheter at the distal end. Both the patient and the referring physician were notified. The licensee met the reporting requirements. A reactive inspection is scheduled to be performed on 5/16/2024."

IL Event Number: IL240012

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.

TECHNICAL SPECIFICATION VIOLATION

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

"During a routine source check on 5/10/2024, it was noted that three of the six iodine-131 processing hot cell radiation monitors were located incorrectly. Upon investigation, it was discovered that on 4/19/2024 the filter banks were switched between bank 'A' and bank 'B'. During this filter bank switch, the detectors monitoring the filter banks were also not changed. This led to processing iodine three times between 4/19/2024 and 5/10/2024 without meeting the conditions of Technical Specification 3.10.c regarding monitoring requirements. The event was corrected on 5/10/2024.

"Several detectors were monitoring the suite during the period from 4/19/2024 and 5/10/2024, including the off-gas (stack) radiation monitor per Technical Specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room DAC monitors, and the remaining three iodine-131 processing hot cell radiation monitors. No in-service monitors indicated abnormal rises in iodine levels.

"After the detectors were returned to service in the correct location, it was noted that the readings on the filter banks were very low. These readings provide supporting evidence that they were not being loaded while the detectors were incorrectly located."

INOPERABILITY OF BOTH TRAINS OF UNIT 2 LOW HEAD SAFETY INJECTION

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

"At 0917 EDT on May 13, 2024, a control room operator erroneously rendered the `B' train of the Unit 2 residual heat removal (RHR) system inoperable. This occurred while the `A' train of the Unit 2 RHR system was out of service for preplanned maintenance. RHR serves as the low head safety injection (LHSI) subsystem for the emergency core cooling system (ECCS) and because of this, Unit 2 was without a required train of ECCS from 0917 EDT to 0921 EDT.

"No other equipment issues were identified.

"The LHSI subsystem is credited by the analysis for a large break loss of coolant accident at full power.

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

"The NRC resident inspector has been notified.

"There is no release of radioactive material associated with this event."

AGREEMENT STATE REPORT - LOST CAMERA

The following synopsis was received via phone and email from the New Mexico Radiation Control Bureau:

At 1230 MDT on 05/09/2024, a Delta 880 industrial radiography camera containing an activity of 74 curies of iridium (Ir-192) has been determined to be lost on a closed non-public road on an oil field lease. The camera serial number is D15729. The sealed source serial number is 93189M.

Local law enforcement has been informed, details to follow.

NM Event number: ENTS 18002

Notified the following external agencies: DHS Senior Watch Officer, FEMA Operations Center, USDA Operations Center, HHS Operations Center, DOE Operations Center, CISA Central, EPA Emergency Operations Center, FDA Emergency Operations Center, Nuclear SSA (email), FEMA National Watch Center (email), CWMD Watch Desk (email)

* * * UPDATE ON 5/14/2024 AT 1723 EDT FROM VICTOR DIAZ TO SAMUEL COLVARD * * *

The following is a summary of information received from the New Mexico Radiation Control Bureau via phone and email:

The Delta 880 camera has been found by a member of the public and is in process of being transferred to a representative of the Department of Energy (DOE) Radiological Assistance Program for inspection and transfer to a DOE facility. The device has an automatic locking mechanism and there is no indication of public exposure at this time.

Notified R4DO (Josey), NMSS Regional Coordinator (Williams), IRMOC (Grant), ILTAB (MacDonald), INES National Officer (email), NMSS Events Notification (email), NMSS INES Coordinator (email).

Notified the following external agencies: DHS Senior Watch Officer, FEMA Operations Center, USDA Operations Center, HHS Operations Center, DOE Operations Center, CISA Central, EPA Emergency Operations Center, FDA Emergency Operations Center (email), Nuclear SSA (email), FEMA National Watch Center (email), CWMD Watch Desk (email), CNSNS-Mexico (email).

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 RADIOGRAPHY SOURCE

The following is information received from the Washington State Department of Health via email:

"On 05/07/2024, three radiographers started work around 1000 [PDT] and were in the process of completing a second shot about 12-feet off the floor when the collimator attached to the source fell to the ground. This caused a bend/crimp in the guide tube preventing the radiographers from retracting the source back into its shielded position within the exposure device. After several attempts at retracting the source, the radiographers contacted the radiation safety officer (RSO) at 1026 PDT. The boundaries were expanded and the workers guarded the area. No other workers or contractors were present at the time.

"At 1130 PDT, the RSO arrived with additional shielding (lead shot bags) and tools. The RSO made a first approach to the source and observed that the collimator was facing northwest. The RSO, using a long reaching tool to manipulate the collimator, turned it to face the ground. No change in activity was recorded and it was determined that the source was not within the collimator. The RSO placed a 25-pound bag of lead shot on the guide tube just below the collimator. No change in activity was observed. The team then retreated. The technician approached the source and placed a second bag further down the guide tube. Survey meters read a substantial decline in activity. The RSO then returned to the source and placed several more bags on the source location. After the source was shielded, the RSO inspected the guide tube and located a slight pinch in the tube. The RSO then used a tool to partially remove an irregularity from the guide tube and requested the technician to crank the source back into the camera. The source was returned to the camera successfully. The RSO removed the damaged guide tube from service.

"The total exposure to the lead radiographer was 10.75mR. The first assistant radiographer exposure was 3.9mR. The second assistant radiographer exposure was 3.6mR. The RSO had an exposure of 20mR on their arm and 4.3mR on their trunk.

"The camera is a Sentinel model 880 with an Ir-192 source of 38.7 Ci."

Washington Incident No.: WA-24-013

UNIT 2 MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"On May 15, 2024 at 0427 EDT, DC Cook's Unit 2 reactor was manually tripped due to difficulty maintaining steam generator water levels.

"DC Cook Unit 2 had removed the main turbine from service at approximately 0354 EDT during a planned down-power to repair a steam leak on the high pressure turbine right outer steam/stop control valve upstream drip pot. Stable steam generator water levels were unable to be maintained. As a result, DC Cook Unit 2 was manually tripped with reactor power stabilizing at approximately 20 percent.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'Reactor Protection System' actuation as a four hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the 'Auxiliary Feedwater System', as an eight hour report.

"The reactor trip was not complicated and all plant systems functioned normally. The DC Cook NRC Resident Inspector was notified."