Event Notification Report for April 06, 2023

AGREEMENT STATE REPORT - STUCK SHUTTER

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

"On March 29, 2023, the licensee reported to the Agency that on March 28, 2023, one of its technicians was performing routine shutter checks, and the shutter on one of their Vega SHF-2 gauges, containing a 50 millicurie cesium-137 source, was stuck in the open position. Open is the normal operating position for the gauge. The gauge is mounted 10-12 feet above the ground on the side of a tank with no direct access so there is no risk of exposure to individuals The licensee will contact a service company to make repairs. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No.: 10002

Texas NMED No.: TX230013

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following report was received from the Washington State Department of Health [WA State] via email:

"WA State received a licensee report of a stuck radiography source incident at 1606 [PDT] on March 28, 2023. The incident took place at the licensee's facility in Tacoma. The source guide tube was crimped, preventing the source drive cable from retracting into the device's shielded enclosure. A two milli-Roentgen per hour, radiation boundary was established, and the facility operations location/entrance was secured. No overexposures or spread of contamination occurred due to the event. Source retrieval/recovery actions have been completed. WA State was notified that the source was fully retracted into the shielded exposure device today, March 29, 2023, at 0430 [PDT]."

WA Incident No.: WA-23-006

AGREEMENT STATE REPORT - DOSE ABOVE PRESCRIBED DOSE

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

"On 3/29/2023 at 1353 EDT, the Radiation Safety Officer (RSO) at Tufts Medical Center reported a medical event, misadministration, to the MA Radiation Control Program.

"On 3/28/2023 at 2230 EDT, the licensee discovered that a patient was administered, on the same date shortly before the discovery, a therapeutic activity of 37.9 mCi of Y-90 microspheres to the right lobe of the liver instead of the intended total of 11 mCi in a two-step successive administration per written directive. The patient and the referring physician have been notified.

"It was reported by the RSO that the administering physician determined that there will be no adverse effect to the patient as a result of the event. The cause of the event has initially attributed to human error by the administering technologist. The error was the improper application of a dose calibrator correction factor for the administration of Y-90 microspheres. A correction factor of 10 was not applied as per procedure. As a result, the technologist drew an activity of 60.3 mCi into the vial instead of 6.03 mCi as per the written directive for the first dose in an intended two step successive administration up to 11 mCi. The actual stasis administration was 37.9 mCi, which is the portion actually delivered to the right lobe of the liver via the delivery apparatus resulting in overloading. No further administrations to the patient occurred.

"At 1538 EDT on 3/29/2023, the Tufts RSO was contacted to discuss the facility's immediate corrective action. MA RCP recommended that the technologist responsible for the event not be allowed to perform any further therapeutic or diagnostic procedures at this time due to their failure to follow procedures (written directive). The Tufts RSO agreed. It was also agreed that he would contact the administering physician and forward the request for the dose conversion from mCi to rads or Grays to the target tumor.
Tufts will provide any additional immediate corrective actions and the delivered dose estimate to the Radiation Control Program in a preliminary summary report on 3/30/2023."

MA Event Number: TBD

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/STOLEN TRITIUM EXIT SIGN

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

"On March 29, 2023, RHB was notified by the Manager of Regal Manchester Cinemas 16 number 1820 via email that a second tritium exit sign was stolen from the movie theater hallway leading towards auditorium number 8. It appeared that it was pulled out forcefully from the wall. Please note that the first exit sign was stolen on March 8, 2023 (see EN56399). The facility has not provided RHB with the model, serial number, or quantity for the exit signs."

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 - LOST SOURCE

The following information was provided by the Colorado Department of Public Health and Environment via email:

A customer shipped a package containing an AirSentry II-IMS unit with a 10 mCi nickel-63 source to Particle Measuring Systems. On February 16, 2023, the customer emailed that the package should have arrived. Particle Measuring Systems contacted the common carrier, whose tracking system showed the package was delivered on February 7, 2023. The site conducted an extensive search but could not locate the package. The Radiation Safety Officer was informed on March 1, 2023, that the package was lost. The Colorado Radioactive Materials Unit was subsequently notified of this event on March 10, 2023."

Colorado Event Number: CO 230009

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

OFFSITE NOTIFICATION

The following information was provided by the licensee via email:

"At 1915 EDT, Susquehanna Nuclear Control Room was notified of a reportable oil release from a spare transformer outside of its secondary containment of an unknown quantity. Oil staining was observed on the ground outside of the designed containment vault stored on the grounds of Susquehanna Nuclear. The quantity and duration of the oil leak is unknown and thus poses a potential pollution risk to groundwater. Spill response measures are in-progress and as of 1500 on 4/4/2023 a field walkdown reported no visible oil outside of the containment vault. The spill event is reportable under Pennsylvania Department of Environmental Protection (PADEP) Clean Streams Law (PACSL) per PA Code 91.33 and 25 PA code 92a.41. This notification is being written to notify the US Nuclear Regulatory Commission within 4 hours of determination of a required report to another government agency per 10 CFR 50.72(b)(2)(xi)."

The NRC Resident Inspector has been notified.

MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 0651 EDT on April 5, 2023, with Unit 1 in mode 1 at 85 percent power, the reactor was manually tripped due to loss of main feedwater pump 'C'. The trip was not complex, with all systems responding normally post-trip. Main feedwater pump 'B' had previously been removed from service in preparation for a planned shutdown as a part of refueling outage RF27.

"Operations responded and stabilized the plant. Decay heat is being removed by the emergency feedwater system.

"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) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) resulting from valid actuation of the reactor protection and emergency feedwater systems.

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

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The licensee continues to investigate the loss of main feedwater pump 'C'.

The licensee notified the NRC Resident Inspector.