Event Notification Report for June 23, 2022

AGREEMENT STATE REPORT - LOST THEN FOUND I-125 SEED

The following information was received via E-mail:

"On 6/14/22, one Theragenics, I-125 brachytherapy seed (0.501 mCi) from the inventory was discovered missing. It was one of 10 spare seeds used for a patient prostate implant should they be needed. The inventory of concern was that required for a patient who was implanted with 88 seeds using 16 needles as planned. He did not need any of the spare seeds for his implant.

"In accord with our standard procedure, five of the 10 spare seeds were prepared in spare needles by one of our radiation oncology dosimetrists, one seed per needle, on Monday, 06/13/22. All prepared needles and loose seeds remained in the hot lab (SP 22244) until the patient's surgery. This means that five loose I-125 seeds should have remained in their transport vial in the hot lab (SP 2244) adjacent to the surgery room (SP 2245). However, when preparing to return the five spare needle prepared seeds to the transport vial, post patient implant, it was evident that there were only four rather than the expected five loose seeds in the vial. I surveyed the hot lab (SP 2244) but could not locate the missing seed in the hot lab or its surrounding area. The five spare needle prepared seeds were returned to the transport vial for a total of nine seeds rather than the inventory of 10. This vial was taken to the radiation oncology hot lab safe. Several surveys were performed of the Surgery Pavilion area (SP 2244) but the seed was not found.

"On 6/15/2022, the missing I-125 seed (0.501 mCi) was found and returned with the other loose seeds to the 'Medak' vial now located in the radiation oncology hot lab. On an inspired guess, the dosimetrist returned to the SP 2244 hot lab in the prostate pavilion and in a high cupboard searched a steel container used for sterilizing all 10 loose seeds before creating the five spare needles. This is where the missing seed was found.

"As corrective actions, the unused seeds will be visually counted and the checklist updated to include this process."

Washington Incident Number: WA-22-015

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 - STOLEN PORTABLE NUCLEAR GAUGE

The following information was received from the State of Nevada via email:

"At approximately 1350 PDT, the RSO/CEO for IQC Southwest LLC, 00-11-0745-01 notified the Nevada Radiation Control Program (NRCP) that a Portable Nuclear Gauge (PNG) had been stolen from a work site located near the intersection of Sierra Vista and Paradise Road working off of Paradise Road in Las Vegas, Nevada. In addition, Las Vegas Metro Police Department was on scene and taking a report during the Radiation Safety Officers (RSO) notification call to the NRCP.

"The RSO stated that they had video of the theft as it occurred. An unknown (possibly transient) individual walked through the work site, picked up the gauge and walked off, appearing to hide the gauge with his body while the Authorized User (AU) was getting material from his vehicle. The source rod was not locked when the gauge was taken.

"The gauge was a Troxler model 4640-B with a 9 mCi Cs-137 source.

"An incident inspection will be performed June 16, 2022 by the NRCP."

Nevada Item Number: NV220006

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 - HDR AFTERLOADER MOTOR FAILURE RESULTS IN ABORTED TREATMENT

The following information was received via E-mail:

"The following is preliminary information, and will be updated as the State of Washington learns more about this event:

"A mechanical incident occurred with the HDR (high dose rate) afterloader unit, and a treatment had to be aborted. It appears that a motor in the afterloader failed. The manufacturer's representative removed the active and dummy wires and is in the process of making the necessary repairs. There does not appear to be any radioactive material contamination in the system. No staff or patients received any excess dose. Plans are to exchange the source and complete all of the needed QA checks so that patient treatments may resume.

"The equipment involved was a Varian HDR remote afterloader, Model VariSource iX, Serial Number 600501, containing less than 11 curies of Iridium-192."

Washington Incident Number: WA-22-016

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the Minnesota Department of Health (MDH) via email:

"We (MDH) received an initial report on 6/15/22 at 1515 CDT of a reportable medical event. The event occurred at the University of Minnesota, license number 1049, in Minneapolis on 6/14/22. The event involved a treatment with Y-90 SirSpheres where 2.2 GBq was ordered but a 5.1 GBq unit dose was delivered and administered. The licensee is working through dose calculations. No additional details are available at this time. Follow up information will be sent when it becomes available."

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 - LOSS OF TWO TRITIUM EXIT SIGNS

The following is a synopsis of information received via E-mail:

Upon inventory inspection, Frenchman Valley discovered that two tritium exit signs that had been in their possession had been replaced. The property was then thoroughly searched twice and the signs were not located. The whereabouts of the signs are unknown and no replacement records were found.

The signs were manufactured by Isolite. Both signs were model SLX60. The serial numbers were 12-01067 and 12-01068 with each sign containing 8 Curies of tritium.

Nebraska Item Number: NE220002


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 - SOURCE DETACHED FROM PORTABLE GAUGE

The following information was received via E-mail:

"During the morning of 6/16/22, a portable gauge user noticed that the tub and the radioactive source were detached from the gauge cable and stuck approximately 5 ft. underground when the user was trying to retrieve the tub and the source back to the gauge. The portable gauge is a CPN model 503, serial number 50543, containing 50 mCi of americium-241:beryllium. The sealed source is not compromised.

"This event occurred in Kersey, Colorado."

Colorado Event Report ID No.: CO220017

OFFSITE AGENCY NOTIFICATION DUE TO CHEMICAL LEAK

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

"At 1547 EDT on June 21, 2022, it was determined that Beaver Valley Power Station Unit No. 1 experienced a reportable chemical leak. Approximately 261 gallons of a Sodium Hypochlorite/Sodium Bromine mixture reached the ground and approximately 130.5 gallons (of the 261 gallons) progressed to the Ohio River (via storm drain). The source of the leakage has been isolated and absorbent material has been placed to contain the leakage. Following confirmation of this leakage, notifications were made to the following offsite agencies starting at 1615 EDT:

"National Response Center (Incident Report # 1339391)
"Pennsylvania Department Of Environmental Protection
"Beaver County Emergency Management

"This condition is being reported as a four-hour, non-emergency notification per 10CFR50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 6/22/2022

EN Revision Text: CONTROL ROOM VENTILATION AND CONTROL AREA CHILLED WATER SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"At 2240 on 06/21/2022, it was discovered that both required trains of Control Room Ventilation and Control Area Chilled Water System were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(v)(d).

"There was no impact on the health and safety of the public or plant personnel.

"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 'B' train was restored at 2315.

LOSS OF AN ITEM RELIED ON FOR SAFETY

The following information was provided by the licensee via email:

"The plant is in a safe condition.

"On June 21, 2022, while performing a routine management observation, an employee noticed that only a single individual was performing the administrative actions required to implement both [items relied on for safety] IROFS 50b and IROFS 50c. These IROFS are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61. Since only one individual was performing the administrative action, the independence of the IROFS was not being maintained and the performance requirement of 10 CFR 70.61 was not being met. At the time of the event, there were not any heavy vehicles that threatened damage to equipment.

"[Urenco USA] (UUSA) is reporting this event per 10 CFR 70. Appendix A(b)(2).

"All work that requires utilizing person(s) to control the proximity of vehicles to equipment that could release UF6 has been stopped. This issue has been entered in UUSA's corrective action program as EV 152996."

The licensee will notify the NRC Regional inspector.