Event Notification Report for July 01, 2022

AGREEMENT STATE REPORT - CONTAMINATION OF THE HOT LAB

The following was received from the state of Kentucky, Radiation Health Branch via email:

"Kentucky [Radiation Health Branch] RHB was notified on 6/23/222 by a representative from University Of Kentucky Medical Broadscope, of a contamination event. Early in the afternoon of 6/22/2022 while preparing the assay, a 150 mCi liquid I-131 NaI dose, the vial cracked (the vial head and septum separated from the main body while the [Certified Nuclear Medical Technician] CNMT was attempting to remove excess packing material with forceps) and there was a subsequent spill and contamination event of the Nuclear Medicine hot lab. The area was controlled immediately, additional contamination controls put in place and cleanup efforts initiated.

"No significant personal (skin) contamination occurred.

"Preliminary assessment on 6/22 did not indicate gross iodine uptake in any affected staff.

"24-Hour thyroid bioassay results were negative for detected iodine uptake in the thyroid for staff present during the spill, but will be repeated at 48h.

"Decontamination efforts are ongoing."

EN Revision Imported Date: 6/27/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING LICENSED MATERIAL

The following was received from the state of South Carolina via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone on 11/18/2019 that two Ba-133 sources (Isotope Product Laboratories Model PHI-133 GFS series, serial numbers XX-621 and XX-622) contained in a Marconi Medical Systems BEACON non-uniform attenuation correction device (Model N211xxx series source housing) attached to a Marconi Axis camera were lost and could not be found. According to the licensee's report, on 04/18/2017 the camera was de-installed by a vendor and shipped to a scrap metal dealer in North Carolina. The estimated activity at deinstallation on 04/18/17 was 2.4 mCi total. Details of the event were provided to the North Carolina Agreement State Program on 12/18/2019.

"This event was entered into NMED in 2019, the NMED reference number 200018."



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

EN Revision Imported Date: 6/27/2022

EN Revision Text: AGREEMENT STATE REPORT - TREATMENT SEEDS RELEASED TO PUBLIC SEWER

The following was received from the State of South Carolina via email:

"On March 10, 2021, the inspector received a telephone message recorded at 7:30 a.m. [EST] from McLeod Regional Medical Center (Lic No. 139) to report an incident that occurred at their facility. The chief medical physicist at the hospital, called to report that at approximately 1:30 p.m., a member of the Day Hospital nursing staff flushed three implant seeds down the toilet into the sanitary sewer. The inspector called to get additional information about the incident.

"On March 9, 2021, at approximately noon, a patient had prostate seed implantation to act as a boost to the external beam treatment. Following the implantation, the patient passed three Theragenics Model 200 Pd-103 seeds with activity of 1.3 milli-Curie each (3.9 milli-Curie total).

"On March 12, 2021, the inspector travelled to McLeod Regional Medical Center to talk to the Chief Medical Physicist, Radiation Safety Officer, and other staff to find out additional information about the incident. During the review, the inspector was informed that a nurse did as she was instructed about straining the patient's urine but did not know the next steps once the implant seeds were filtered out. The nurse stated that she was told by another unnamed nurse that they could be flushed. This goes against the procedures that state that a member of health physics is to be informed, and will pick up the seeds once strained. Nursing is supposed to use the available seed recovery kits when a situation like this occurs. Because the toilets flow directly into the public sewer system, the seeds were irretrievable. Additionally, the licensee has procedures in place that state that a urologist will be present to perform a cystoscopy upon the conclusion of the implantation to ensure that there are no seeds in the bladder. This was not performed on the patient before his release to the Day Hospital staff.

"Both health physics and nursing explained that there has been a high turnover in nursing and that the training should be performed more frequently to ensure compliance from the staff. They are changing the policy to increase the training from annual to at least quarterly to address communication, training, and turnover issues. Day Surgery management stated that they plan to retrain monthly."

NMED #210164


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

EN Revision Imported Date: 6/27/2022

EN Revision Text: AGREEMENT STATE REPORT - OCCUPATIONAL OVEREXPOSURE

The following was received from Illinois Emergency Management Agency (the Agency) via email:

"The Agency was notified on 6/24/2022, that an employee at Decatur Memorial Hospital handled a vial of F-18 and may have received an extremity dose in excess of 2.5 Gy (250 rad). The exposure reportedly occurred on Monday, June 20, and was not reported timely. Agency staff will perform a reactionary inspection at 0600 CDT, Monday, June 27, when licensee staff are back on site.

"Agency inspectors were contacted via email by the RSO [(Radiation Safety Officer)] designee for Decatur Memorial Hospital (RML, IL-02444-01) on 6/22/2022, to advise an operator grabbed a reaction vessel vial containing 10 mCi of F-18 FDG [(fluorodeoxyglucose)] for roughly 20 seconds in order to save a production run. NOTE: The reported activity was updated on 6/24/2022, to 10 Ci. Reportedly, the employee was training a new operator and noticed during synthesis, the reaction vessel wasn't placed in the heating apparatus and synthesis would fail. He opened up the mini cells and placed the vessel into the correct spot with his gloved hand. At that time, both Agency and licensee staff estimated the exposure to the hand to be in the range of several hundred millirem to possibly over the 50 rem occupational limit. The licensee was instructed to expedite processing of the employee's extremity and whole-body badges and conduct a time-motion study to determine if occupational limits had been exceeded. During a phone discussion with the licensee on 6/24/2022, the license corrected previously provided information and stated the production vial contained 10 Ci of F-18. Agency staff immediately made a second call to the licensee's on-duty pharmacist to confirm. At 10 Ci, Agency staff estimate the operator's actions may have caused or threatens to cause a shallow dose equivalent to the extremities of 2.5 Gy (250 rad) or more. This is based on a 20 second contact time with a vial containing 10 Ci of F-18 and using a 1cm distance. Clarification will be obtained on 6/27/2022, during a reactionary inspection to perform a time motion study. The Agency is awaiting the dosimetry results."

Illinois Item Number: IL220022

INVALID SPECIFIED SYSTEM ACTUATION

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

"This non-emergency notification is being made pursuant to the provisions of 10 CFR 50.73(a)(1) to report the occurrence of an invalid automatic actuation satisfying the reporting criterion of 10 CFR 50.73(a)(2)(iv)(A), specifically for the actuation of one train of the Essential Service Water (ESW) system that occurred on May 1, 2022.

"On May 1, 2022, with the plant shut down and the core offloaded, control room personnel were performing a fast power transfer from Engineered Safety Feature (ESF) transformer XNB02 to ESF transformer XNB01. In anticipation of this activity, the `B' load shedder and emergency load sequencer (LSELS) had been removed from service. Also, at the time, a portion of the `A' ESW train was isolated to support performance of a local leak rate test (LLRT) of a containment isolation valve in the affected portion of `A' ESW train piping. Service Water was supplying cooling water flow to `A' train loads (in lieu of ESW cooling water). When the power transfer was performed, an unexpected automatic start of the `A' ESW pump, along with some associated, automatic valve repositioning, occurred.

"The actuation occurred due to inadvertent satisfaction of automatic start logic for the ESW pump. The logic is intended to detect loss of ESW flow when the opposite train LSELS isolates Service Water during an undervoltage condition on a safety bus. The flow transmitter involved in the actuation is situated in a portion of the ESW piping that was isolated for the LLRT. The low-flow signal from the transmitter was consequently not reflective of low cooling water flow to plant loads in light of the fact that cooling water flow was being supplied to plant loads and the transmitter was locally isolated. In regard to the ESW train actuation, therefore, although the undervoltage signal was considered a valid signal due to the voltage drop caused by the fast transfer activity, the low-flow signal from the noted transmitter was considered to be invalid.

"For this invalid actuation, it was concluded that the actuation was not part of a pre-planned sequence, that the affected system was not properly removed from service during the occurrence, and that the safety function had not already been performed relative to the occurrence.

"[The] NRC Resident Inspector has been notified and an email of this report has been sent to hoo.hoc@nrc.gov."

EN Revision Imported Date: 7/1/2022

EN Revision Text: MANUAL SCRAM DUE TO LOSS OF TRANSFORMER

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

"At 1445 [CDT] on June 30, 2022, with Grand Gulf Nuclear Station in Mode 1 and at 100 percent power, the reactor was manually scrammed due to the loss of balance of plant (BOP) transformer 23. All control rods fully inserted into the core and all systems responded appropriately.

"Reactor level is being maintained with condensate and feedwater. Reactor pressure is being maintained with turbine bypass valves. The cause of the loss of BOP transformer 23 is under investigation at this time.

"Standby Service Water 'A' and 'B' were manually initiated to supply cooling to Control Room A/C, ESF switchgear room coolers, and plant auxiliary loads.

"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B) as an event or condition that resulted in actuation of the Reactor Protection System and 10 CFR 50.72(b)(3)(iv)(A) due to the actuation of Standby Service Water.

"The NRC Senior Resident Inspector was notified."