Event Notification Report for May 19, 2023

AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed 27.72 mCi but was delivered 17.38 mCi, a percent dose delivered of approximately 63 percent. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona incident number: 23-008

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 - STUCK SHUTTER

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:

"The licensee [Bethune Nonwovens, Inc., d/b/a Suominen Nonwovens] notified the Department in writing on April 21, 2023, that a generally licensed fixed gauging device had a failed shutter which had been repaired by the manufacturer on April 3, 2023. The licensee discovered that the event occurred on March 31, 2023, and reported that upon discovery of the stuck shutter, that the manufacturer arrived on site on the same day and placed the device out of service until repaired. The event involved a Mahlo fixed gauging device (model number: 11-200933, serial number 11-011985-AH-5783), which housed an Isotope Product Laboratories, krypton-85 sealed source (model number KAC.D3, serial number: AH-5783), with an activity of 9.62 GBq (260 mCi). The licensee reported that the cause of this equipment failure was attributed to corrosion around the shutter assembly.

"On May 2, 2023, a Department inspector was dispatched to the facility to conduct an on-site investigation. All dose measurements were consistent with the Sealed Source Device Registry certificate for the device. Based on the resulting dose rate surveys conducted by the Department and the manufacturer, interviews with licensee representatives, and the removal of the device from service at the time that the failure was discovered, it does not appear that any radiation exposure to workers, or any other individual members of the public has occurred.

"This event is considered closed."

Internal ID number: SC230009

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

"On May 16, 2023, it was determined that a licensed operator violated the station's FFD policy. The employee's unescorted access at South Texas has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC resident inspector has been notified."

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

On May 17, 2023, at 0649 PDT, it was determined that a prohibited item had been found inside the protected area.

The NRC Resident Inspector has been notified.

CONCURRENT REPORT - FIRE DOOR MALFUNCTION

The following information was provided by the licensee via email:

"At approximately 0940 EDT on May 18th, the New Hanover County Deputy Fire Marshal was notified that the fire door of the dry conversion process (DCP) elevator shaft malfunctioned and was in the open position. The DCP elevator is located on the south wall of the DCP which is a credited fire barrier. A fire watch was initiated and maintained until the elevator door was closed at approximately 1030 EDT. The elevator was restored to full operation at approximately 1330 EDT on May 18th. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The NRC region will be notified.