Event Notification Report for May 24, 2023

EN Revision Imported Date: 5/24/2023

EN Revision Text: AGREEMENT STATE REPORT - STOLEN EXPOSURE DEVICE

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

"On March 9, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a Source Production and Engineering Company (SPEC) 150 exposure device containing a 121 curie iridium-192 source was stolen from one of the company's trucks. The radiography crew stated they left their job site to get some food at around midnight and stopped at a fast-food restaurant. They went into the restaurant to eat. The radiographers stated they failed to set the alarm on the dark room. They also stated they had left the key for the exposure device transport box in the dark room. The radiographers completed their meals and went back to the job site.

"When they went to get the exposure device they found it was missing. The radiographers contacted the RSO and a search was conducted for the device. It was not found. The RSO reviewed security footage at the location the radiographers were working and confirmed the exposure device was not on the tailgate of the truck. They reviewed security footage at the fast-food restaurant, but the cameras were not pointed in the right direction to see the truck. The RSO stated there is a restaurant across the street from where they believe the exposure device was stolen that has security cameras. They will go there when it opens to see if the theft was captured by their cameras. The RSO stated that personnel will be sent back to the area where they believe the theft occurred for additional searches. The RSO stated they have sent people out to contact local pawn shops and scrap dealers and notify them of the theft and provide their contact information. Local law enforcement have been notified of the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: I-10000

Notified DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), and NuclearSSA (email).

* * * UPDATE ON 03/11/23 AT 0652 EST FROM ART TUCKER TO KERBY SCALES * * *

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

"On March 9, 2023, at 1935 [EST], the Agency's radiation safety officer and an incident investigator arrived in the area where the exposure device was reported stolen. They searched the area using the Agency's [Radiation Solution Inc] (RSI) RS-700 mobile radiation monitoring system. They did not find the missing device or source. They intend to meet with the licensee's RSO this morning and search a broader area."

Notified R4DO (Gepford), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Ulses), INES Coordinator (Smith), CNSNS (Mexico) via email.


* * * UPDATE ON 03/11/23 AT 1929 EST FROM ART TUCKER TO OSSY FONT * * *

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

"The Agency personnel have completed their search in the Houston area and are returning to Austin. They did not locate the missing exposure device. The licensee will continue looking for the device."

Notified R4DO (Gepford), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Ulses), INES Coordinator (Smith), CNSNS (Mexico) via email.

* * * UPDATE ON 03/16/23 AT 1730 EST FROM ART TUCKER TO BILL GOTT * * *

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

"On March 15, 2023, the Agency conducted interviews with the licensee and individuals involved in the event. Using the licensee's GPS records, it was determined that the theft occurred between 2314 and 2355 CST the night of March 8, 2023."

Notified R4DO (Kellar), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Crouch), INES Coordinator (Smith), CNSNS (Mexico) via email.

* * * UPDATE ON 05/23/23 AT 1108 EDT FROM ART TUCKER TO BRIAN SMITH * * *

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

"On May 23, 2023, the Agency received a phone call from an apartment manager in Houston, Texas. The manager stated that he was cleaning an apartment when he found the exposure device on the balcony of the apartment. The manager provided the serial number of the device which matched the number of the stolen device. The Agency contacted the licensee who drove to the location and recovered the device. The licensee reported that the source was still fully shielded and that dose rates on the device were normal. The Agency notified the Federal Bureau of Investigation (FBI) Special Agent who has been involved with this event that the device had been located and recovered. The licensee reported that it had been in phone contact with the FBI agent. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Vossmar), NMSS (Rivera), NMSS Events Notification (email), ILTAB (MacDonald), IRMOC (Grant), INES Coordinator (Smith), CNSNS (Mexico) via email, DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), and Nuclear SSA (email).

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf*

EN Revision Imported Date: 5/24/2023

EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was provided by the Maryland Department of the Environment (MDE) via email:

On 04/14/2023 at 0951 [EDT], the MDE discovered an unsigned, undated report from the University of Maryland Medical Center, Baltimore, MD, that a medical misadministration had occurred on 02/28/2023. [After] contacting a health physicist and the Radiation Safety Officer (RSO) [at the University of Maryland], they confirmed that the event had actually occurred. A dose of 104.73 mCi of Ludotadipep [Lu-177] was being administered to a patient as part of a phase 1 clinical trial to treat metastasis. During the procedure, catheter infiltration (catheter movement) occurred resulting in a significant portion of the dose remaining in the upper left arm. The study sponsor was informed. Subsequent gamma scans showed that within 24 to 48 hours the dose had migrated to the intended treatment site. MDE is following up with the RSO and medical staff to confirm that the actual dose delivered to the treatment site was within 20 percent of the dose prescribed in the written directive. The University of Maryland staff has determined that an unintended dose estimated at 157 Rem had been delivered to the upper arm tissue. As of 04/14/2023, no ill effects have been observed, and the patient has been scheduled to resume subsequent treatment. This event is being reported under 10CFR 35.3045 (a)(1)(ii) B `. a dose that exceeds 50 Rem to an organ or tissue from administration of a radioactive drug containing byproduct material by the wrong route of administration'."

* * * RETRACTION ON 5/23/23 AT 1501 EDT FROM PAUL KOVACH TO BILL GOTT * * *

The following information was provided by the Maryland Department of the Environment (MDE) via email:

"[The MDE] has been informed that the NRC medical team has reviewed this event notification and determined that this is not a reportable event under 10 CFR 35.3045. The medical team determined that, although not explicitly named as such, this event notification describes an extravasation. Extravasations are currently exempted from medical event reporting due to Commission policy, however this may change in the near future. Please note that the NRC does not consider extravasations as 'wrong route of administration,' as stated in 10 CFR 35.3045(a)(1)(ii)(B).

"On May 19, 2023, the patient's physician at [University of Maryland Baltimore] (UMB) confirmed to [the MDE] that this event can be considered as an extravasation."

Notified R1DO (Jackson), NMSS (Rivera), and NMSS Events Notification via email.

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.

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

A non-licensed contract supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

TECHNICAL SPECIFICATION VIOLATION

The following information was provided by the University of Missouri-Columbia Research Reactor (MURR) via phone and email:

"During a normal reactor start up on 5/23/2023, while still approaching criticality, reactor power peaked slightly above 100 kW with a single control blade 1.4 inches below the other three control blades. This is a violation of Technical Specification (TS) 3.2.b which states that above 100 kW, the reactor shall be operated so that the maximum distance between the highest and lowest shim blade shall not exceed 1 inch.

"As part of a normal reactor startup, three control blades were at 23 inches and the core was approaching criticality. As the fourth control blade was being pulled to the bank height, the Lead Senior Reactor Operator stated power was approaching 100 kW, alerting the Reactor Operator to the TS of no more than a one-inch height differential between control blades. Reactor power slowly increased. The Reactor Operator stopped shimming out on Control Blade 'A' and shimmed the other three rods inward individually to stop the power rise. He continued to then pull Control Blade 'A' out while leveling power by shimming the other three rods in. The control room continued the startup. No other issues occurred during the approach to full power (10 MW).

"After the startup, the Lead Senior Reactor Operator raised a concern that it was possible power peaked slightly above 100 kW with Control Blade 'A' at 1.4 inches below the other three control blades. Strip charts confirmed power peaked at 103.5 kW during this time. Total duration in this unapproved control blade configuration was less than one minute.

"The Reactor Manager was informed of the problem, and he informed the Interim Facility Director. MURR Licensee Event Report (LER) 13-03 discusses a similar event. Calculations performed for that event show that a control blade can differ by as much as 4 inches from the bank with no adverse effects to the core. MURR reactor operations were continued.

"MURR will follow up with an LER to address this issue."

NOTIFICATION TO ANOTHER GOVERNMENT AGENCY

The following information was provided by the licensee via phone and fax:

"On 5/22/23, Xcel Energy performed a notification to the state of Minnesota Duty Officer, in accordance with Minnesota Statute 115.061, regarding 300-600 gallons of pumped ground water that overflowed from a holding tank and returned to the ground area from which it was pumped. The groundwater being pumped is related to recovery activities associated with the event reported on November 22, 2022 (EN 56236). This notification is being made solely as a four-hour, non-emergency report for notification to other government agency. An update is being provided to the Monticello community and published on Xcel Energy's website. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of public or plant personnel. The NRC Resident Inspector has been notified."