Current Event Notification Report for October 23, 2023

EN Revision Imported Date: 10/23/2023

EN Revision Text: LOST SOURCE

The following is a summary of information provided by the licensee via phone:

On February 24, 2023, the Radiation Safety Officer (RSO) noticed a missing source during an annual radioactive material audit. The missing radioactive source is a Nano Tritium sealed source from City Labs (Model: P100a, S/N: 1020140018) containing 94 mCi of H-3. The RSO notified the principle investigator to begin a search for the sealed source, however, the source could not be located. The RSO believes the missing radioactive source may have been confused with an identical non-radioactive battery during previous audits, and the length of time the source has been missing is unknown.

* * * UPDATE ON 10/20/23 AT 0925 EDT FROM JOSHUA YOUNG TO ADAM KOZIOL * * *

The missing 94 mCi tritium sealed source was located in a test chamber in the lab where it was last suspected to have been used. Lab was not regularly utilized and was being organized as a corrective action from the lost source. No exposure caused by this incident.

Notified R3DO (Orth), NMSS (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 - MISSING RADIOPHARMACEUTICAL PACKAGE SHIPMENT

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

"The Agency was notified October 12, 2023, by GE Healthcare in Arlington Heights, IL to advise that a radiopharmaceutical package was missing [during shipment]. The last known location was a shipping facility in Fort Worth, TX when it was last scanned by shipping personnel on October 10, 2023, at 0035 CDT as 'arrived.' This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.

"The 16 cm cubed package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10 mL shielded vial. The activity of indium-111 was 1.535 mCi at the time of shipment but has since decayed to approximately 0.6 mCi. It was reportedly offered for shipment on October 9, 2023, for delivery to a customer in Carrollton, Texas on October 10, 2023. Upon failure to arrive, the licensee initiated a search, and after a review of online tracking data and conversations with shipping personnel, GE Healthcare logistics were informed that the shipping facility has initiated a search for the package and that it is currently unaccounted for in their system. The shipping facility's tracking system last showed the package as 'arrived' as of 0035 CDT on October 10, 2023."

Illinois Incident Number: Il230029

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 SOURCE
The following information was provided by the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email:

"On October 11, 2023 at 1558 EDT, the Maryland Department of the Environment Radiological Health Program was contacted via phone from the Radiation Safety Officer (RSO) of Testing Technologies, Inc. (TTI), and reported that a source disconnect had occurred on 10/10/2023, at about 1000 EDT while working at College Park, Maryland. TTI has an active authorization and reciprocity recognition to practice industrial radiography in Maryland with US NRC license (number 45-25007-01). TTI has a Virginia (Maryland reciprocity license number 94-031-01) and an NRC license; and they are also authorized to retrieve sources. The radiography device was QSA Global, Sentinel 880, device serial number D6011, which contains 50 Ci of Ir-192.

"The incident occurred when the TTI radiographer was taking images of a pipe in the well and while cranking back at finishing, the source became stuck at about the half-way position. The radiographer was aware that the source disconnection from the tube had happened and the source was lodged in a 14 feet deep hole. The radiographer later retrieved the source. The radiographer reported the incident to the TTI RSO.

"The RSO reported that there was no exposure to the public. A dose of 40 mrem was received by the radiographer.

"MDE/RHP will finalize a reactive investigation."

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Hays Gulch Plant and several walkdowns of the facility, six exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number: SLX60 (7.5 Ci of H-3 each).

Event Report ID No.: CO230037



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 EXIT SIGN

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Crawford Trail and several walkdowns of the facility, one exit sign was reported as lost. The sign was manufactured by Isolite Corporation, model number 2000 (11.5 Ci of H-3).

Event Report ID No.: CO230036


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 EXIT SIGNS

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Parachute Creek Gas Plant and several walkdowns of the facility, eight exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number SLX60 (8.1 Ci of H-3 each).

Event Report ID No.: CO230038



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 EXIT SIGNS

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On September 8, 2023, six exit signs were removed by a construction company and taken to an unknown location. The Carbondale Community School representative reported that they may have been taken to a landfill. The signs were manufactured by Self Powered Lighting, Inc., model number 700 Series (7.1 Ci of H-3 each).

Event Report ID No.: CO230039

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 SEED SOURCE

The following is a summary of information provided by the Georgia Radioactive Materials Program via email:

On September 14, 2023, the licensee determined that an iodine-125 seed used for non-palpable lesion localization had been lost. Two seeds had been previously implanted in a patient. On September 12, 2023, a specimen containing both seeds was removed from the patient. When transported to pathology lab, only one seed was located in the specimen. It was confirmed through survey and imaging that the seed was no longer in the patient, and it is suspected that the seed was lost in the operating room. At the time of the loss, the seed had an activity between 0.218 and 0.221 millicuries. After conducting a search of the operating room, the surgical equipment, and the pathology lab, the radiation safety officer declared the source lost on September 14, 2023.

Georgia NMED Incident Number: 71

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

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"On 10/19/2023, at approximately 1110 [CST], with Unit 1 in mode 1 at 100 percent power, the reactor automatically tripped. All control rods fully inserted into the core following the trip. All safety functions operated as designed. The cause of the trip is being investigated.

"Operations responded and stabilized the plant. Auxiliary feedwater actuated as expected. Decay heat is being removed by the steam generator through the steam generator power operated relief valve. The trip was complex as non-safety related power was lost to both Unit 1 and Unit 2. Unit 1 is currently in mode 3 and on natural recirculation as both reactor coolant pumps are without power. Unit 2 is currently in a refueling outage with all fuel in the spent fuel pool (SFP). SFP cooling was lost for approximately 70 minutes. No impacts to the SFP temperature were observed.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Due to the actuation of the auxiliary feedwater system following the reactor trip, this event is being reported as a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(3)(iv)(A). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

* * * UPDATE ON 10/19/2023 AT 1646 EDT FROM MARTIN CABIRO TO ERNEST WEST * * *

The second paragraph of the original report is amended as follows to correct information regarding the spent fuel pool for Unit 2:

"Unit 2 is currently in a refueling outage with all fuel in the spent fuel pool (SFP). SFP cooling was maintained at all times with one train of SFP cooling. The second train lost power and was restarted approximately 70 minutes [after power was lost]. No impacts to the SFP temperature were observed."

Notified R3DO (Orth) and IR MOC (Crouch) and NRR EO (Felts) via email

LOSS OF SEISMIC MONITORING CAPABILITY

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

"Reporting due to loss of emergency preparedness capabilities. Seismic monitoring capability is non-functional due to loss of power. These monitors do not have a credited compensatory measure.

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

The NRC Resident Inspector has been notified. The licensee intends to notify state and local officials.

PART 21 INTERIM REPORT - DEVIATION IN THE CALIBRATION CERTIFICATES FOR AN ACOUSTIC EMISSION INSTRUMENT

The following is a summary of information provided by the MISTRAS Group via fax:

On June 10, 2021, calibration certificates for an acoustic emission (AE) instrument were found to have been falsified (reference Notice of Violation 99902109/2023-201-02). The AE system was used for testing of lift rigs used for reactor head and internals. A 10 CFR Part 21 evaluation was initiated on June 15, 2021, and is now essentially complete. The final report will be made available by November 1, 2023.

The following reactor plants were affected: DC Cook, Kewaunee, Surry, Millstone, North Anna, Robinson, Oconee, Arkansas Nuclear One, Beaver Valley, Turkey Point, St. Lucie, Seabrook, Shearon Harris, Vogtle, Farley, Sequoyah, Watts Bar, and Prairie Island.

For questions, contact Donald D. Smith, Quality Assurance Director, MISTRAS Group, Inc., (630) 418-7301, donald.d.smith@mistrasgroup.com

NOTIFICATION OF UNUSUAL EVENT DECLARED

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

"Fire potentially degrading the level of safety of the plant."

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

At 0907 EST, the licensee declared a notification of unusual event, under emergency action level HU.4, due to multiple fire alarms and CO2 discharge in the emergency diesel building. When the plant fire brigade entered the building, there was no indication of fire or damage to any plant equipment. The cause of the multiple alarms is under investigation.

State and local authorities were notified and no offsite assistance was requested. Both units remain at 100 percent power.

The NRC Resident Inspector has been notified.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).

* * * UPDATE FROM TYSON JONES TO KAREN COTTON AT 1007 EDT ON 10/21/23 * * *

At 1007 EDT, Watts Bar terminated the notification of unusual event. The basis for termination was that no fire or damaged plant equipment was found. The NRC Resident Inspector has been notified.

Notified R2DO (Miller), IR-MOC (Crouch), NRR-EO (Felts), DHS-SWO, FEMA Ops Center, CISA Central, FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).

* * * RETRACTION ON 10/22/23 AT 0925 EDT FROM TYSON JONES TO KAREN COTTON * * *

"Watts Bar Nuclear Plant (WBN) is retracting Event Notice 56809, Notice of Unusual Event, based on the following additional information, not available at the time of the initial notification.

"Specifically, in accordance with the emergency preparedness implementing procedures, WBN reported a condition that was determined to meet emergency action level (EAL) HU4, Initiating criteria number 1, receipt of multiple (more than 1) fire alarms or indicators and the fire was within any Table H2 plant area, which includes the diesel generator building. It was further determined that multiple fire detection zones actuated (spurious and invalid) enabling the discharge of installed fire suppression (CO2) into the space. Upon entry by the site fire brigade, it was determined that no smoke or fire existed and reported to the Shift Manager at 0930 EDT. All fire alarms were reset. Troubleshooting activities are in progress to determine the cause. A fire watch has been established and CO2 has been isolated. The required compensatory measures for the affected areas will remain in place until completion of the investigation, and CO2 suppression is restored to functional."

Notified R2DO (Miller), IR-MOC (Crouch), NRR-EO (Felts), DHS-SWO (email), FEMA Ops Center (email), CISA Central (email), FEMA NWC (email), CWMD Watch Desk (email), DHS NRCC THD Desk (email), and DHS Nuclear SSA (email).

AVERAGE POWER RANGE MONITORS DECLARED INOPERABLE

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

"On October 21, 2023, at 2048 EDT, reactor recirculation pump (RRP) 12 tripped. The cause for the trip is under investigation.

"Following the RRP trip, the average power range monitors (APRMs) flow bias trips were inoperable due to reverse flow through RRP 12. The APRMs were restored to operable on October 21, 2023, at 2058 EDT, when the RRP 12 discharge blocking valve was closed.

"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(v)(A) which states: "Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition."

"The NRC Resident Inspector has been notified."

SECONDARY CONTAINMENT MOMENTARILY INOPERABLE

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

"On October 22, 2023, at 1149 CDT, with the reactor at 100 percent core thermal power and steady state conditions, the Cooper Nuclear Station secondary containment differential pressure exceeded the Technical Specification (TS) Surveillance Requirement (SR) 3.6.4.1.1 limit of -0.25 inches water gauge. The condition existed for approximately 80 seconds until the reactor building ventilation system responded to restore differential pressure to normal. Investigations identified a hinged duct access hatch found open. The hatch was closed and latched, and ventilation system parameters were returned to normal. There were no radiological releases associated with this event.

"Declaring secondary containment inoperable as a result of not meeting TS SR 3.6.4.1.1 is reportable under 10 CFR 50.72(b)(3)(v)(C) and (D) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material and mitigate the consequences of an accident.

"The NRC Senior Resident Inspector has been informed."

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

At the time the licensee notified the NRC Headquarters Operations Officer, the cause of the hinged access duct being open had not been determined. This event has been added to the licensee's corrective action program.