Event Notification Report for July 06, 2022

EN Revision Imported Date: 7/6/2022

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

* * * UPDATE ON 7/5/22 AT 1711 FROM GARY FORSEE TO KERBY SCALES * * *

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

"This is an update to NMED incident EN55961 (Illinois incident number IL220022) where we reported an incident involving the potential for an occupational exposure exceeding 250 rad to the extremities. Agency staff completed a reactionary inspection and received the expedited dosimetry reports from the licensee. A time motion study conducted by Agency staff estimates the occupational exposure at no more than 19 rem to each hand and no more than a few hundred millirem whole body. The dosimetry reports were received and indicated the employee received 100 millirem whole body and an average of 1.2 rem to each hand. We do believe the extremity and whole body badges to be representative of the doses received. Neither our conservative calculations nor the processed dosimetry report indicate this will be an abnormal occurrence. We will update the NMED report and resubmit to INL tomorrow."

Notified R3DO (Lafranzo); NMSS Events Notification, Gretchen Rivera-Capella, and Robert Sun via email.

AGREEMENT STATE REPORT - LOST AND FOUND SOURCE

The following is a summary of a report received from Florida Bureau of Radiation Control (the Bureau) via email:

On February 24, 2022, at 0920 EST, the Vice-President of Imaging Physics at Landauer Medical Physics at the Cleveland Clinic Martin South Hospital called the Bureau to report a missing source. A 15 mCi Co-57 Med 3709 (s/n 2281-093, reference date February 1, 2022) source was ordered from Primestar to be delivered to the Nuclear Medicine (NM) Department. The order shipped January 12, 2022, at 1104 EST, and delivery was signed for, but the individual who signed for delivery did not remember seeing a radioactive box. The source was never received in NM. The South Hospital facility and all other NM departments checked for the source the week of the February 14 but were unable to locate it. The source was considered missing/lost by February 21, 2022.

The Bureau received an update on February 25, 2022, at 1647 EST. The Department Heads met to see how something could be received and not accounted for. The theory was that the person that signed for the package did not have the best handwriting, and the intraoffice label may have been misunderstood, sending it to nutrition instead of nuclear. A search of the nutrition storage shed at the South Hospital revealed the source. The shed is a secure, unoccupied space away from any staff, with limited access. This incident is considered closed.

Florida Incident Number: FL22-027

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"Representatives of Elmhurst Hospital (RML IL-01612-01) contacted the Agency at approximately 1230 CDT today, 6/29/22, to report a Y-90 Theraspheres administration that took place on 6/29/22 (approximately 1000 CDT) which resulted in 100 percent of the dose prescribed not being delivered. The pre and post surveys of the vial and delivery system were nearly identical, supporting the licensee's assertion that no microspheres were delivered. The patient was surveyed post-administration and was at background. While contamination was identified on the draping, it resulted from the disconnection of the delivery system when the administration was halted. No contamination was identified on the patient.

"Microspheres were observed clustered at the hub and none beyond. The licensee claims there were no kinks and the manufacturer's checklist was followed to include agitation/flushing. At this time, it is unclear if the patient and referring physician have been notified, but the licensee is aware of the requirement. The licensee is aware of the 15-day written report requirement. The AU [(Authorized User)] will be back in the office on Friday and understands the Agency will need additional information via a reactionary inspection. The Agency is scheduling a reactive inspection and this report will be updated as information becomes available."

Illinois Item Number: IL220023

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 - LOST SHIPMENT

The following was received from the California Department of Public Health Radiologic Health Branch (CDPH/RHB ) via email:

"On 06-29-2022, Mistras Group determined that their shipment containing radioactive materials was officially declared lost. This is not a NSTS [(National Source Tracking System)] level source.

"The RSO [(Radiation Safety Officer)] for Mistras Group Inc. notified CDPH/RHB that a QSA source changer, QSA model 650L, No. 201 containing a QSA Global, Inc. iridium-192 source, model A424-9 No. 683G (radioactivity content on 06-29-2022 was 4.5 curies) shipped on 06-16-2022 had not arrived at QSA Global, Burlington, MA in a timely manner. The [Common Carrier] tracking number indicates the package arrived at the [Common Carrier] hub in Memphis, TN on 06-17-2022, but was delayed with an expected delivery on 06-22-2022.

"On 06-20-2022, QSA Global notified Mistras Group that only two of their three shipments had been received.

"On 06-22-2022, the [Common Carrier] reported the package remained delayed.

"On 06-25-2022, a missing Dangerous Goods (DG) investigation was opened to trace the package. DG was provided a picture of the missing package.

"On 06-27-2022, the [Common Carrier] administrator notified Mistras Group that the package was not located in the hub of the [Common Carrier], Memphis, TN.

"On 6-28-2022, the [Common Carrier] DG personnel notified Mistras Group that the package was not found at LAX [(Los Angeles International Airport)]."

California 5010 Number: 062922

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

REACTOR MANUAL SCRAM DUE TO LOWERING REACTOR WATER LEVEL

The following information was received from the licensee via facsimile:

"On July 4, 2022 at 0104 CDT, with Unit 2 in Mode 1 at 100 percent power, a manual scram was inserted on U2 due to lowering reactor water level, which occurred following an unexpected closure of the 2A Feedwater Regulating Valve. Following the reactor scram, reactor water level decreased to approximately minus 16 inches, which resulted in an automatic Group II and Group III isolation (expected response). Following the scram, reactor water level rose to plus 75 inches resulting in a trip of all three Reactor Feedwater Pumps. At 0114 CDT, Reactor Water Level lowered to less than the Feedwater Pump High Level Trip setpoint and the 2C Reactor Feedwater Pump was restarted. Reactor Water Level control has been established in a normal band. The cause and details of the event are under investigation.

"The Unit 2 scram was not complicated. Operations responded using the Emergency Operating Procedure and stabilized the plant in mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"Unit 1 was unaffected by the event and remains at 100 percent power.

"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).

"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 licensee will notify the Illinois Emergency Management Agency.

BOTH TRAINS OF STANDBY GAS TREATMENT INOPERABLE

The following information was received from the licensee via email:

"At 0130 CDT on July 4 2022, it was discovered both trains of Standby Gas Treatment System were simultaneously inoperable due to failure to reach required flow rates. Both trains were capable of starting but failed to reach the required flow of 4000 SCFM. Secondary Containment differential pressure was not able to be maintained at greater than or equal to 0.25 inches of vacuum water gauge, causing Secondary Containment to also be inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C) and 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."