Event Notification Report for January 25, 2023

EN Revision Imported Date: 1/25/2023

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO EXTREMITY

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"Licensee reported employee weekly finger ring exposure exceeding 50 rem (67.569 rem for wear period, 7/4/22-7/10/22) a situation reportable within 24 hours per 105 CMR 120.282 (B) (1) (c). The other finger ring dosimeter worn by the subject employee received 31.509 rem exposure for same wear period. Exact cause of exposure not yet known. Licensee investigation ongoing. Licensee, a radiopharmaceutical manufacturer/distributer, stated that subject employee does perform work involved with F-18 radiopharmaceutical manufacturing operations.

"The Agency considers this matter still open."

MA Event Number: 20-5102

* * * UPDATE ON 1/24/23 AT 1054 EST FROM BOB LOCKE TO ADAM KOZIOL * * *

"On August 17, 2022, An Agency investigation was performed at the PETNET facility. The inspector determined that the root cause of the event was insufficient training of staff. The licensee submitted sufficient corrective actions to prevent recurrence. The Massachusetts Radiation Control Program considers this incident closed."

Notified R1DO (DeFrancisco) and NMSS (email).

EN Revision Imported Date: 1/25/2023

EN Revision Text: AGREEMENT STATE REPORT - Ra-226 DISC FOUND IN SCRAP LOAD

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via email:

"On 11/1/2022, Schnitzer Steel [Docket 23-5219] in Everett, MA notified the Agency that portal monitors detected radioactive contamination in a scrap load that originated from Spiegel Scrap Metal in Brockton. A handheld meter measurement showed 0.03 mR/hr on the driver's side of the truck. DOT [Department of Transportation] exemption form MA-MA 22-28 was created to transport the load back to Spiegel Scrap Metal.

"On 11/3/2022, Atlantic Nuclear surveyed the contents of the scrap load and discovered a disc containing Ra-226. A handheld meter measured 1.5 mR/hr on contact. The estimated activity of the gauge is 2 microCuries. Spiegel is contracting Chase Environmental to dispose of the item.

"The reporting requirement is within 30 days and is of 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

* * * UPDATE ON 1/24/23 AT 1055 EST FROM BOB LOCKE TO ADAM KOZIOL * * *

"The disc had no identifying markings such as manufacturer name, model number and serial number. The Ra-226 disc is currently in storage at the Spiegel facility scheduled for eventual transfer to a licensed disposal service. Probable inadvertent disposal by unknown person or persons at an unknown time in the past."

Notified R1DO (DeFrancisco) and NMSS (email).

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"The Department identified a possible medical event involving Y-90 Sir-Spheres during a routine inspection. A patient was prescribed an activity of 0.05 GBq (1.45 mCi) but was delivered 0.02 GBq (0.53 mCi), a percent dose delivered of 36.55 percent. The procedure date was 9/30/2022. The Department has requested additional information and continues to investigate the event."

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 - UNABLE TO RETRACT SOURCE INTO FULLY RETRACTED POSITION

The following report was received via email from the Texas Department of State Services [the Agency]:

"On January 18, 2023, the Agency was notified by the licensee that one of its radiography crews [working in Midland, TX] was unable to retract a 99.0 curie iridium - 192 [Ir-192] source into the fully retracted and locked position in a QSA 880D exposure device. The licensee stated they were able to retract the source into the exposure device, but it would not lock in the fully retracted position. An individual on the license approved to recover sources went to the site to retract the source. The licensee contacted the manufacturer who was able to provide instructions to the field team on how to return the source to the locked position. The licensee reported no overexposure occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No: I-9981
Texas NMED No.: TX230002

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following is a summary of information provided by the Oregon Health Authority, Radiation Protection Services via email and phone:

The licensee reported a damaged Troxler 3430 portable moisture density gauge. The gauge's cover was found to be cracked in multiple places, including the electronic pad. The source is in the shielded position and readings around the gauge indicate that the shielding is intact. It is unclear how the gauge became damaged but was found near a vibrating plate compactor.

The gauge will be shipped to the manufacturer for repair once a leak test has been performed.

Dose readings at 3 feet from source: 0.12-0.16 mR/hr
Gauge source: 8 mCi Cs-137, 40 mCi Am-241:Be
Oregon Emergency Response System Incident Number: 2023-0140

EN Revision Imported Date: 1/25/2023

EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE

The following information was provided by the licensee via email:

"At 0121 CST on 01/24/2023, it was discovered that the Unit 1 High Pressure Coolant Injection System (HPCI) was inoperable; therefore, the condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), as an 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 mitigate the consequences of an accident.

"1-FCV-073-0006B, HPCI Steam Line Condensate Outboard Drain Valve, failed closed during normal plant configuration. This valve is normally open. The HPCI steam line is not being drained with the valve in the current position.

"The Unit 1 Nuclear Unit Senior Operator entered Unit 1 Technical Specifications LCO 3.5.1 Condition C with required actions C.1 to immediately verify by administrative means that the Reactor Core Isolation Cooling (RCIC) system is operable and C.2 to restore HPCI to operable status in 14 days. RCIC has been verified operable by administrative means.

"There was no impact to the safety of the public or plant personnel. The NRC Resident Inspector has been notified."