Event Notification Report for May 26, 2023

AGREEMENT STATE REPORT - FAILED SHUTTER

The following information is a summary provided by the Illinois Emergency Management Agency via email:

During a routine inspection on May 17, 2023 at Flexsys America, L.P. in Sauget, IL, an inspector identified a February 2022 equipment failure involving a fixed gauge that resulted in a stuck-open condition of the shutter (300mCi Cs-137 sealed source, model A-2102, serial number 3654CP). This incident was reportable to ONS-RAM within 24 hours under 32 Ill. Adm. Code 340.1220(c)(2). No personnel exposures occurred as a result. Corrective action was taken with repairs to the mechanism performed by the manufacturer and the gauge was returned to operable condition. The initial reporting requirement was not met by the licensee and will be addressed through inspection correspondence. This matter was reported to the NRC within the required timeframe.

Illinois report number: IL230010

AGREEMENT STATE REPORT - CONTAMINATED WORKER

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

"On May 18, 2023, The University of Texas MD Anderson Cancer Center (the licensee) reported to this Department that they had discovered a technician and package with contamination of around 12,000 dpm [disintegrations per minute]. The licensee's technician picked up the bag (package) with their bare hands. They then did a wipe test of the bag and found that it was contaminated. They also discovered that both their hands were contaminated. They washed repeatedly which reduced the contamination on their hands but did not eliminate it. The licensee believes that the remaining contamination has been absorbed into their skin and that it is no longer removable. The technician has gone home with instructions to continue wearing gloves. The technician is pregnant, and the licensee plans to perform a thyroid check tomorrow.

"The bag had elevated readings at the handle, but the contamination seemed to mostly be at the top right of the bag where the zipper handle was located. The licensee has not found contamination in any other areas of their facility. The licensee used a well counter to try to determine the isotope and believes it is either 5 microcuries of technetium-99m or 2 microcuries of iodine-123. A comparison of activities of the following day will determine which isotope it is since there is a significant difference in half-lives. The container with the ordered 10 millicuries of iodine-123, which was inside the bag, was wiped and found to not be contaminated.

"The nuclear pharmacy that supplied the bag and material inside the bag did wipe tests of the driver's hands, the steering wheel, pedals, the rack the bag would sit on, and the hand truck that the package would have been placed on. They did not find any radiation above background. They also performed wipes and surveys within their facility and again did not find any contamination.

"The worker who prepared the material at the pharmacy in the morning only drew iodine-123 for this single package. All other iodine-123 packages were pre-prepared. The pharmacy sent around 45 packages out in the morning to many medical facilities. None have reported contamination. The truck only carries packages from this single pharmacy.

"The Department has asked both facilities to continue to look for contamination and has recommended that the technician wear cotton gloves inside of the other gloves to hopefully get the hands to sweat the material out into the cotton."

Texas incident number: 10020.

AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)

The following information was received from the Pennsylvania Department of Radiation Protection via email:

"On March 28, 2023, a patient was treated with a permanent Cs-131 implant with a prescribed dose of 60 Gy. On April 11, 2023, the patient presented with a serious medical condition which necessitated the immediate removal of the implant. The seeds were all accounted for and placed into storage for decay to background. The actual dose delivered is calculated to be 37 Gy. The referring physician and the patient have been informed."

Event Report Identification Number: PA230015

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 - LEAKING SOURCE

The information below was provided by the Georgia Department of Natural Resources via email:

"During a routine sealed source inventory check, Cardiac Consultants of Central Georgia, LLC, license GA 1629-1 discovered that one of their Cs-137 vials (S/N 1615-4-2) appeared to display signs of moisture within. This source's current activity is 0.15078 mCi. A wipe test was then performed. Results of the wipe test confirmed that this source was leaking. The area surrounding the source was surveyed and wipe tested as well. No sign of contamination was discovered. The leaking source has been contained and is secured in the licensee's hot lab in an appropriate shielded container. The licensee waits for a hazardous waste disposal quote before properly disposing. This incident occurred on May 11, 2023, and the licensee reported to the State on May 15, 2023. The State is waiting for the licensee to provide a copy of leak test results for the source of concern and confirmation of source disposal."
GA Incident Number: 65

AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)

The following was received from the Colorado Department of Public Health and Environment via email:

"On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation."

Colorado Event Report Number: CO230012

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 - PACKAGE EXCEEDED RADIATION LIMITS

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

"A telephone call received by the Agency from the [Radiation Safety Officer] RSO of Invicro, LLC, at 1054 EDT on 5/19/2023. A package was received on 5/19/2023 at approximately 1000 EDT at the licensee's site that exceeded the dose rate limit of 200 mrem/hr on the external surface of the package. The radionuclide was fluorine-18 (F-18) in liquid form enclosed in a glass vial. The assayed dose was 499 mCi at 0930 at PETNET Solutions, Inc. in Woburn, MA, the distributor of the F-18.

"The package was labeled Yellow II and the maximum surface dose rate should therefore not exceed 50 mrem/hour for a Yellow II labeled package. The package upon shipment was measured by the shipper to have a surface dose rate of 7 mrem/hour and a transport index (TI) of 0.4.

"The licensee reported that 5 wipe samples were taken on the external surface of the package with no resultant removable contamination observed. It was reported that the glass vial contained approximately 350 mCi of F-18 at the time the package was opened. The external dose rates on all external surfaces continued to exceed 200 mR/hr, even with the vial removed from the package.

"Surveys of areas where the package was opened, and where the vial was transported, are undergoing. The vial is currently stored in a hot cell. The external package is being stored in a shielded location. Personnel are being surveyed for contamination. At this time there is no indication of external contamination of the shipping package.

"The Agency, Invicro LLC, and PETNET Solutions, Inc. are in communication working the details of the scenario and potential personnel exposer.

"The Massachusetts Radiation Control Program considers this to be an open reportable event."

PART 21 - DEFECT IDENTIFIED IN EMERGENCY DIESEL GENERATOR GOVERNOR

The following is a synopsis of information provided by the Engine Systems, Inc (ESI) via fax:

Component Description: Woodward Governor, Part No. 9903-722, Serial No. 18847017

Problem Description: An EGB-35P governor/actuator (governor) installed on a customer's emergency diesel generator failed soon after installation. Investigation revealed a piece of foreign material, a loose buffer plug, inside the governor that caused the failure. Since the governor is used to maintain fuel rack position of the diesel engine, failure of the governor would prevent the emergency diesel generator from performing its safety-related function during an event.

Affected Plants: Brunswick Nuclear Plant

Corrective Actions for Brunswick Nuclear Plant: No action required. The affected governor has been returned to ESI.

Corrective Actions for ESI: The governor will be refurbished under ESI's 10 CFR 50 Appendix B program and certified for continued use at Brunswick Nuclear Plant. To prevent reoccurrence, ESI will revise the dedication requirements to enhance existing foreign material inspection practices to include a visual inspection where the buffer plug was located within the governor. The revisions are expected to be complete within 30 days but in all cases prior to future shipments.

FITNESS-FOR-DUTY REPORT

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

"On May 24th, 2023, at approximately 0710 MDT, a non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The individual's plant access has been terminated in accordance with station procedures.

"The NRC Resident Inspector has been notified."

UNANALYZED CONDITION OF EMERGENCY DIESEL GENERATOR

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

"At 1345 EDT on May 25, 2023, it was determined that a fire barrier for area 737-A1B was not installed, and would render the 2A Emergency Diesel Generator (EDG) not operable in the event of a fire on the Unit 2 side of elevation 737 in the Auxiliary Building. The 2A EDG is the credited power source for fire safe shutdown for a fire located in this area. Without the credited source of power, this places WBN U2 [Watts Bar Nuclear Unit 2] in an unanalyzed condition. A fire watch has been established in the area until the issue is resolved. Therefore, this event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."