Event Notification Report for September 19, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
09/16/2022 - 09/19/2022

Agreement State
Event Number: 56099
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream   State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Adam Koziol
Notification Date: 09/09/2022
Notification Time: 12:25 [ET]
Event Date: 08/23/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOSS OF I-125 BRACHYTHERAPY SEED

The following information was provided by Illinois Emergency Management Agency (The Agency/IEMA) via email:

"The Agency received a phone and email report from Bard Brachytherapy [licensee] on September 2, 2022 indicating the loss of a single I-125 brachytherapy seed, accounting for a maximum estimated activity of 0.75 millicurie. The licensee's investigation leads them to believe the seed remains within their Illinois facility and the loss of accountability is a function of either operator or documentation error. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. Agency inspectors are conducting a reactionary inspection the week of September 12, 2022 for this incident and the loss reported September 1, 2022. While not representing a significant public safety concern, the quantity requires reporting to the US NRC HOO [Nuclear Regulatory Commission Headquarters Operations Officer] within 30 days.

"DETAILS: On August 23, 2022, staff at Brad Brachytherapy in Carol Stream, IL notified their manager of a missing brachytherapy seed. An investigation was opened and the counts compared against orders processed from this lot. Surveys were conducted of the workstations, the lab and the dumpster; yielding no identification of the seed. Reviews of paperwork, inventory records and orders also failed to indicate the location of the source. No customers have reported the receipt of an extra source. While the licensee believes the loss can be attributed to operator or documentation error; no root cause or corrective action was provided. An IEMA inspection team will seek this information in the reactionary inspection."

Illinois Incident Number: IL220032.

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
Event Number: 56100
Rep Org: Texas Dept of State Health Services
Licensee: Albemarle Catalysts LP
Region: 4
City: Pasadena   State: TX
County:
License #: G 01743
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Adam Koziol
Notification Date: 09/09/2022
Notification Time: 13:15 [ET]
Event Date: 09/09/2022
Event Time: 00:00 [CDT]
Last Update Date: 09/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the Texas Department of State Health Services (The Agency) via email:

"On September 9, 2022, the Agency was notified by the licensee that on this day the shutter on a Vega SH-F1 gauge containing a 60 millicurie (original activity) cesium - 137 source failed to close during routine testing. Open is the normal operating position of this gauge. The licensee will contact the manufacture to repair the shutter. No individual received additional exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9955


Agreement State
Event Number: 56103
Rep Org: Louisiana Radiation Protection Div
Licensee: GIT Services, LLC
Region: 4
City: Baton Rouge   State: LA
County:
License #: LA-12907-L01, Amendment 26, AI# 188034
Agreement: Y
Docket:
NRC Notified By: Russell Clark
HQ OPS Officer: Ernest West
Notification Date: 09/12/2022
Notification Time: 17:33 [ET]
Event Date: 09/10/2022
Event Time: 14:25 [CDT]
Last Update Date: 09/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE

The following information was received by email from the state of Louisiana Department of Environmental Quality:

"On September 10, 2022 at approximately 1445 [CDT], a source hang out incident occurred while an industrial radiography crew was working at Cembell Industries, Inc., a steel fabrication facility located in St. Charles Parish, Louisiana.

"The radiography crew was working on ground level in the main fabrication shop of the facility. After approximately five seven-minute exposures to a 48-inch outer diameter schedule 40 steel pipe, using a 4-HVL panoramic collimator, the crew was suddenly unable to crank in the source after repeated retraction attempts. The crew took apart the pistol grip on their crank out controls and observed a broken drive cable. The crank out controls were manufactured by Industrial Radiography Maintenance and Supply (IRMS), device serial number, 22JA15867. The crew then pulled the remaining free end of the drive cable continuous with the source assembly and succeeded in pulling the source completely into the shielded position within the crew's Model 880D exposure device. Approximately three feet of the drive cable on the near end had broken off.

"The crew's exposure device automatic lock was observed to function properly upon shielding the source. Crew members read their direct-reading pocket dosimeters and noted cumulative daily exposures of 62 mR and 68 mR. After briefing their RSO on the successful source retraction, the crew utilized a backup set of crank out controls and completed the temporary job. In an abundance of caution, the RSO of the crew collected the crew's Landauer body badges and [sent] the badges to Landauer for rush processing.

"No rust, corrosion or birdcaging was observed by the manufacturer, IRMS, upon physical inspection of the crank out controls and drive cable pieces. The root cause investigation by the manufacturer is still ongoing to determine what caused extreme tension in the cable, which contributed to its breakage. The RSO stated he believed the distal end of the cable had become snared in a crimped copper fitting, which was attached to conduit on one end and to a swivel on the pistol grip at the other. The IRMS crank out controls were approximately 45 feet in length and all components were manufactured by IRMS. The crew's source guide tube was in good physical condition and was approximately six feet in length.

"Note: because the crew's pocket dosimeters did not go off scale and the crew members did not approach the high radiation area at any time during expedient retraction operations in which the source was re-shielded, the above incident is being treated as a source retraction rather than a source retrieval. The RSO stated the source was fixed during the incident approximately one to two inches in front of the exposure device outlet nipple, which provided non-negligible shielding throughout the incident.

"The radiography exposure device was a QSA Model 880 Delta, device serial number, D13936. The source, Model A-424-9, was a sealed source of Ir-192 with 97.2 Ci of activity. The source serial number was 53444M."

Louisiana Event Report ID Number: LA20220008


Agreement State
Event Number: 56104
Rep Org: California Radiation Control Prgm
Licensee: Cedars Sinai Medical Center
Region: 4
City: Los Angeles   State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: Joji Ortego
HQ OPS Officer: Ernest West
Notification Date: 09/12/2022
Notification Time: 06:26 [ET]
Event Date: 09/12/2022
Event Time: 00:00 [PDT]
Last Update Date: 09/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 MICROSPHERES

The following was submitted by the California Department of Public Health by email:

"On Sept. 12, 2022, the RSO of Cedars Sinai Medical Center (CSMC) contacted Los Angeles County Public Health, Radiation Management (LA County) to report a medical event that ocurred at CSMC.

"During administraton of Y-90 Theraspheres to a patient, the Y-90 spheres were stuck in the microcatheter and the Authorized User (AU) was unable to administer the full dosage. The dosage drawn in the syringe was approximately 1.77 GBq (48 mCi) but only 1.05 GBq (28 mCi) was administered, a residual dosage of 40.7 percent [not administered]. Additionally, the prescribed dose to the target organ, liver, was 124 Gy (12,400 rad). The liver received a dose of approximately 71 Gy (7,100 rad), a difference of 5.3 Gy (5,300 rad).

"The RSO has initiated an investigation and the AU will be providing a detailed report."

California Reference Number: 091222

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.


Power Reactor
Event Number: 56112
Facility: Farley
Region: 2     State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Steven Leighty
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 09/17/2022
Notification Time: 13:06 [ET]
Event Date: 09/16/2022
Event Time: 22:57 [CDT]
Last Update Date: 09/17/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 80 Power Operation 80 Power Operation
Event Text
FITNESS FOR DUTY (FFD) REPORT
The following information was provided by the Southern Nuclear Company via email:

"At 2257 EDT on 09/16/2022, it was determined that there was a programmatic vulnerability of the Fleet FFD program. Specifically, it was determined that some individuals were not placed into the follow-up pool for additional screening when required by the program. All identified personnel were in the random FFD pool, and were subject to the behavioral observation program.

"This is reportable in accordance with 10CFR26.719(b)(4) for all Units and 10CFR26.417(b)(1) for Vogtle Units 3&4.

"The NRC Resident Inspectors have been notified."

See EN#s 56113, 56114, and 56115.


Power Reactor
Event Number: 56113
Facility: Hatch
Region: 2     State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Steven Leighty
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 09/17/2022
Notification Time: 13:06 [ET]
Event Date: 09/16/2022
Event Time: 22:57 [EDT]
Last Update Date: 09/17/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation
Event Text
FITNESS FOR DUTY (FFD) REPORT
The following information was provided by the Southern Nuclear Company via email:

"At 2257 EDT on 09/16/2022, it was determined that there was a programmatic vulnerability of the Fleet FFD program. Specifically, it was determined that some individuals were not placed into the follow-up pool for additional screening when required by the program. All identified personnel were in the random FFD pool, and were subject to the behavioral observation program.

"This is reportable in accordance with 10CFR26.719(b)(4) for all Units and 10CFR26.417(b)(1) for Vogtle Units 3 and 4.

"The NRC Resident Inspectors have been notified."

See EN#s 56112, 56114, and 56115.


Power Reactor
Event Number: 56114
Facility: Vogtle
Region: 2     State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Steven Leighty
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 09/17/2022
Notification Time: 13:06 [ET]
Event Date: 09/16/2022
Event Time: 22:57 [EDT]
Last Update Date: 09/17/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation
Event Text
FITNESS FOR DUTY (FFD) REPORT
The following information was provided by Southern Nuclear Company via email:

"At 2257 EDT on 09/16/2022, it was determined that there was a programmatic vulnerability of the Fleet FFD program.
Specifically, it was determined that some individuals were not placed into the follow-up pool for additional screening when required by the program. All identified personnel were in the random FFD pool, and were subject to the behavioral observation program.

"This is reportable in accordance with 10CFR26.719(b)(4) for all Units and 10CFR26.417(b)(1) for Vogtle Units 3 and 4.

"The NRC Resident Inspectors have been notified."

See EN#s 56112, 56113, and 56115.


Power Reactor
Event Number: 56115
Facility: Vogtle
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Steven Leighty
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 09/17/2022
Notification Time: 13:06 [ET]
Event Date: 09/16/2022
Event Time: 22:57 [EDT]
Last Update Date: 09/17/2022
Emergency Class: Non Emergency
10 CFR Section:
26.417(b)(1) - FFD Prog Failure (Construction)
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Defueled 0 Defueled
4 N N 0 Under Construction 0 Under Construction
Event Text
FITNESS FOR DUTY (FFD) REPORT
The following information was provided by the Southern Nuclear Company via email:

"At 2257 EDT on 09/16/2022, it was determined that there was a programmatic vulnerability of the Fleet FFD program. Specifically, it was determined that some individuals were not placed into the follow-up pool for additional screening when required by the program. All identified personnel were in the random FFD pool, and were subject to the behavioral observation program.

"This is reportable in accordance with 10CFR26.719(b)(4) for all Units and 10CFR26.417(b)(1) for Vogtle Units 3 and 4.

"The NRC Resident Inspectors have been notified."

See EN#s 56112, 56113, and 56114.