Event Notification Report for June 01, 2023

STOLEN NUCLEAR DENSITY GAUGE

The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email:

"On May 24, 2023, the Department was notified of a stolen nuclear density gauge. This event is reportable within 24-hours per 10 CFR 20.2201(a)(1)(i).

"On May 23, 2023, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge in it, was stolen earlier that day. Local, Regional, and State Police are aware of the incident and a bulletin has been issued. [The Department] has been in contact with the licensee and will update this event as soon as more information is provided.

"The Department will perform a reactive inspection."

Stolen gauge details:
Troxler Model Number: 3440
Serial Number: 33833
Sources: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries

* * * UPDATE ON 5/24/2023 AT 1340 EDT FROM JOHN CHIPPO TO IAN HOWARD * * *

The following information was provided by the Department via email:

"The vehicle has been recovered with the device still secure and intact in the trunk."

Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (email).

PA Event Report Number: PA230016

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 AND RECOVERED SOURCE

The following report was received via email by the Colorado Department of Health:

"On May 19, 2023, the RSO [Radiation Safety Officer] at Memorial Hospital, University of Colorado Health, reported a missing 1.2 mCi germanium-68 sealed source. The source was determined to be an internal quality control source of a PET/CT [Positron Emission Tomography/Computed Tomography] camera. The source was identified as missing during a routine 6-month inventory performed on April 21, 2023.

"The PET/CT camera was purchased by Siemens Medical Solutions USA, Inc. in December 2022. Siemens subcontracted the decommissioning of the camera to a 3rd party (Clinical Imaging Systems), however, they failed to remove the source prior to transporting/shipping the camera to a Clinical Imaging System's warehouse. The source has been removed from the camera and is currently secured in a locked room at the warehouse. Memorial Hospital has been working with Siemens to have a licensed service provider ship the source back to Memorial Hospital or directly to a licensed recipient for disposal."

Colorado Event Number: CO230013

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 - PATIENT UNDERDOSE

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

"On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation."

Event Report ID No.: CO230014

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.

EN Revision Imported Date: 6/1/2023

EN Revision Text: REACTOR TRIP

The following information was provided by the licensee via email:

"At 0446 EDT on 5/30/2023, with Millstone Power Station Unit 3 operating at approximately 100 percent reactor power, an automatic reactor trip occurred due to a turbine trip caused by electrical protection. The reactor trip was uncomplicated and decay heat is being removed via steam dumps to the condenser. All systems responded as expected to the trip.

"Auxiliary feedwater actuated automatically as expected following the trip due to low-low levels in the steam generators.

"There was no risk to the public. There was no impact to Millstone Unit 2.

"This event is being reported as a four hour report under 10CFR50.72(b)(2)(iv)(B) as a condition that resulted in actuation of the reactor protection system while the reactor was critical, and as an eight hour report under 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B) for actuation of the auxiliary feedwater system.

"The NRC Resident Inspector has been notified."