Event Notification Report for July 31, 2023

AGREEMENT STATE REPORT - DAMAGED GAUGE HANDLE
The following information was provided by the South Carolina Department of Health and Environment (the Department) via email:
"On July 20, 2023, at 1507 EDT, the Department was notified by the licensee that while performing semi-annual shutter checks the licensee discovered that the handle on a Berthold LB7440D had broken off which prevented the shutter from being locked. The licensee cordoned off the area and was able to rotate the shutter to the closed and shielded position. The gauge is a Berthold Model LB7440D s/n FT314 and contains a 30 mCi Cesium-137 source. On July 21, 2023, BRH [Bureau of Radiological Health] on-call duty officer met licensee's RSO at 0800, to perform a visual inspection and radiation survey of the gauge. The highest radiation measured was 0.2 mR/hr. The licensee has contacted a licensed vendor to schedule the repair of the handle. "

DOSE TO AN EMBRYO

The following information is a summary of a phone call with the North Kansas City Hospital Radiation Safety Officer (RSO):

On May 10, 2023, a nuclear medicine tech administered 125.7 mCi of I-131 to a patient for the thyroid cancer ablation at North Kansas City Hospital. The patient had received a pregnancy test on May 8, 2023, which was negative.

On July 21, 2023, the hospital was notified that the patient was pregnant with an estimated fetal age of 7-10 weeks which would have had the patient pregnant at the time of administration, or shortly thereafter. This event is being reported because of the potential for a dose to the embryo.

At this time there are no known negative effects to the patient.

AGREEMENT STATE REPORT - MEDICAL EVENT (UNDERDOSE)

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

"On July 21, 2023, the licensee informed the Department of an underdose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable as per 10 CFR 35.3045(a)(1). It was determined that 76 percent of the prescribed dose to the target tissue was delivered for the above treatment.

"This is believed to have happened for possibly the following reasons: The spheres were attached to the bottom / interior portion of the septum and remained there even through 4 flushes of the system; There was clumping of spheres in the microcatheter connector, which did not clog the lines, that remained in the microcatheter connector.

"Possible reasons for these theories or reasons for the above theories are, there was no contamination in the room, or interior / exterior of box. The required alarming Rados personal dosimeter on the back of the box read zero as expected after the original 3 flushes. The authorized user (AU) had no indication from pushing the line that anything was wrong with the flow and in total 4 flushes went into the patient with no problem. All procedures and policies were followed, and this was directly observed by the Radiation Safety Officer (RSO) and the Boston Scientific Corporation, Incorporated (BSCI) company rep who was in the room.

"It was observed on the optional, additional, personal dosimeter that was used on the steel arm coming from the box, that the dose rate did not decrease as expected after the original first 3 flushes. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD 1007 EDT ON 7/25/2023 * * *

The source was 1.09 GBq of Yttrium 90 TheraSpheres (Lot # 2399334, vial # 8). The patient was prescribed 120 Gy, but it is calculated they received 91.4 Gy. The material was collected in the standard waste container. No one other that the patient received any dose.

Notified R1DO (Biickett) and NMSS Events Notification email group.

Pennsylvania Event Report ID Number: PA230019

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 - LOSS OF CONTROL (LOST THEN FOUND) OF RADIOACTIVE MATERIAL

The following is a synopsis of information received from Oregon Health Authority, Radiation Protection Services (RPS):

At 1845 PDT this evening a caller contacted the Oregon Emergency Response System (OERS) to report a yellow package with a radioactive placard that was found in a parking lot at their location.

RPS followed up on the OERS report (Incident Number: 2023-1825) and it appears that an employee from Weston Solutions, an EPA contractor, discovered a box with a Yellow II DOT label in the middle of a parking lot outside of their warehouse in Portland. The box appeared structurally sound and intact.

The caller had a survey meter on-site (a Ludlum 2241 with pancake probe) and measured approximately 11,000 cpm at 1 inch away from the package. The employee called 911 and the police notified the National Response Center and sent officers to respond.

The police inspected the package and discovered it belonged to Cardinal Health. Cardinal Health Nuclear Pharmacy, a licensee, shares a parking lot and occupies an adjacent warehouse to Weston Solutions. The police then hand-carried the box to the Cardinal Health building. A representative from Cardinal Health (police verified credentials) accepted the package and took it inside their facility.

RPS called Cardinal Health Nuclear Pharmacy Services and spoke with the on-call pharmacist / RSO of the facility. At the time of the call she was on-site at the pharmacy to investigate the situation after being contacted by the employee that accepted the package from the police.

The pharmacist / RSO explained that she had immediately leak tested the package and the readings were typical. The box was labeled as containing I-131. There was no sign of a breach or disturbance to the package. The package was then transported to a locked storage vestibule and the pharmacist / RSO then notified the courier of the misplaced material.

The courier used to transport the radionuclides to the nuclear pharmacy was PNW Trade Winds. RPS called and spoke with the lead courier to gather more information about the circumstances that could have led to losing the package.

The lead courier had spoken with the driver involved and their best guess is that while the driver was segregating packages for the different delivery locations at his vehicle, he must have dropped a box and it landed underneath the vehicle. All the material that was supposed to arrive at Cardinal Health was accounted for, so the driver was not aware of the missing package. The driver most likely would not have realized it was lost until performing a physical inventory at a subsequent location.

As far as timing, the lead courier explained that the driver had left Cardinal Health at approximately 1800 PDT and the package was discovered by Weston Solutions at 1820 PDT. When talking with the Weston Solutions employee, he had mentioned that they were in the parking lot area at 1745 PDT and did not see the package at that time, confirming the timeline. Therefore the material was in the parking lot for only about 20 minutes before it was discovered.

RPS Incident Number: 23-0035

FUEL ELEMENT INSPECTION FAILURE

The following information was provided by the licensee via email:

"This notification is being made per the requirements of technical specification 6.7.2

"During the facility's routine 2023 fuel inspection on July 27th, 2023, it was discovered that a stainless steel clad standard TRIGA 20/20 element did not pass its visual inspection. The visual inspection of the element, made via an underwater camera with approximately 2 times optical magnification, showed inward pitting and unusual discoloration in the cladding of the fueled section of the element. The elongation and transverse bend of the element were measured and were within tolerance per the facility's technical specifications. The cause of this pitting is unknown at this time. The element has been permanently retired from service and placed in an in-tank fuel storage rack. No unusual radiation readings were observed leading up to the inspection or during the inspection. Therefore, it is very likely that the integrity of the cladding has not been compromised and no fission products have escaped as a result of the pitting.

"Though not required by the facility's technical specifications, [McClellan Nuclear Research Center] (MNRC) staff is proceeding with the inspection of all adjacent fuel elements and all other standard elements that have not been inspected within the last year. This inspection corresponds to approximately 85% of all in-core elements. The expected completion date of this inspection is August 2nd. Detailed results of this inspection will be provided in an incident report to the NRC no later than August 10, 2023."

CONTROL ROOM ENVELOPE INOPERABLE

The following information was provided by the licensee via email:

"On July 30, 2023 at 1119 CDT, Waterford Steam Electric Station Unit 3 declared the control room envelope inoperable in accordance with technical specification (TS) 3.7.6.1 due to the control room envelope doors failing a door seal smoke test creating a breach in the control room envelope.

"Operations entered TS 3.7.6.1 Action b.

"Mitigating actions were implemented and tested satisfactorily by 1215 CDT.

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

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident, due to the control room envelope being inoperable.

"The NRC Resident Inspector has been notified."

MANUAL REACTOR TRIP DUE TO LOW MAIN TURBINE ELECTRO-HYDRAULIC CONTROL (EHC) OIL LEVEL

The following information was provided by the licensee via email:

"On July 30, 2023 at 1526 EDT, with unit 1 in mode 1 at 100 percent power, the reactor was manually tripped due to low main turbine electro-hydraulic control oil level. The trip was uncomplicated with all systems responding normally post-trip. Operations stabilized the plant in mode 3. Decay heat removal is being accomplished using the steam dumps in steam pressure mode to the main condenser. Emergency Feedwater actuated due to low-low steam generator level as expected.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident Inspector has been notified."