Event Notification Report for August 24, 2023

EN Revision Imported Date: 8/24/2023

EN Revision Text: 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. "

* * * UPDATE FROM ANDREW ROXBURGH TO DONALD NORWOOD AT 1132 EDT ON 8/23/2023 * * *

The following information was provided by the Department via email:

On July 28, 2023, the licensed vendor was on site to repair the damaged shutter handle. The handle and shutter were replaced, and the gauge was placed back into service. This incident is considered closed.

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

EN Revision Imported Date: 8/24/2023

EN Revision Text: 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

* * * UPDATE FROM TOM PFAHLER TO DONALD NORWOOD AT1334 EDT ON 8/23/2023 * * *

The following information was received from RPS via email:

"This letter [from Cardinal Health to RPS] serves as the written report concerning an incident involving the loss of radioactive material as it relates to Oregon radioactive materials license ORE-90509, pursuant to OAR 333-102-0350(3)(b).

"On July 23, 2023 at 1845 PDT, a caller contacted the state emergency response system to report a package was discovered in their parking lot with a radioactive material label in Portland, OR. The package was labeled Cardinal Health. Cardinal Health's Portland nuclear pharmacy (ORE-90509) shares a parking lot with the location that reported the package. The police delivered the package to Cardinal Health, where it was then secured by a Cardinal Health employee. The package was inspected and wipe tested by the site radiation safety officer, with no contamination, damage, or breach found.

"The package contained 1 mCi worth of I-131 capsules that had been packaged for delivery to a separate Cardinal Health location in Seattle, WA. The package was transferred to PNW Trade Winds, a contract courier, upon receipt at the airport for transportation to Cardinal Health's Seattle location. PNW Trade Winds reported that the package was likely dropped when segregating packages for different delivery locations. The driver reportedly left the licensee at approximately 6:00 pm, the package was discovered at 1820 PDT. With this timeline the package was left unattended for approximately 20 minutes before it was discovered.

"In response to this event Cardinal Health has inquired with PNW Trade Winds to review the corrective actions taken on their part. PNW Trade Winds reported that the driver has reviewed their triple check policy and has been placed on three months' probation. During the first month of their probation they are required to call their manager at each stop to review the delivery and verify the remaining packages in the vehicle."

Notified R4DO (Dixon) and the NMSS Events Notification and ILTAB email groups.

AGREEMENT STATE REPORT - CONTAMINATION EVENT

The following information was received via email from the New Jersey Department (NJDEP) Bureau of Environmental Radiation:

"On 6/28/2023, NJDEP Bureau of Environmental Radiation (BER) was notified by its NRC Regional State Agreements Officer of an allegation made by a concerned citizen regarding a powder being sold by an online marketplace. The company address is in New Jersey. The citizen believed the powder contained Thorium-232 (Th-232). BER subsequently followed up with a site investigation and confirmed that Th-232 was present. The individual on-site stated that the powder had been mixed into paint, which was used to paint the walls in his basement and bathroom. The investigation is ongoing.

"On 7/8/2023, BER staff visited the seller's residence to perform an interview and contamination survey. The survey confirmed the presence of alpha and beta contamination in the residence. A sample of the powder was also collected and sent for gamma spectrometry analysis by a certified laboratory. Results of the analysis were received on 8/14/2023, and indicated concentrations of Th-232 as 14,800 pCi/g. On 8/15/2023, an estimate on the total activity present was made, and it was determined that this was a reportable event."

New Jersey Event Report Number: Not yet assigned

AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT

The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:

"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:

"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.

"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."

Illinois Event Number: IL230018

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 - TREATMENT TO WRONG SIDE OF ORGAN

The following report was received via email by the Ohio Bureau of Radiation Protection:

"On July 28, 2023, a patient was scheduled to receive treatment to the right lobe of the liver, however, imaging performed on August 16, 2023 showed the left lobe received the dose. Approximately 83 mCi of Y-90 was delivered, resulting in a dose of 130 cGy (130 Rad) to the wrong treatment site. The patient and referring physician were notified. Future treatment of the left lobe of the liver was planned, but not under this written directive."

Ohio Event Number: OH230009

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.

MANUAL REACTOR TRIP AND AUTOMATIC ACTUATION OF AUXILIARY FEEDWATER SYSTEM

The following information was provided by the licensee via email:

"At 1724 EDT, on August 22, 2023, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to a failure of the non-safety heater drain pump 'B' and the failure of the non-safety condensate pump 'A' to automatically or manually start. At 1735 EDT, a fire was identified on heater drain pump 'B' and was extinguished by the onsite fire brigade at 1807 EDT. Operations responded and stabilized the plant. The trip was not complex, with all safety systems responding normally post-trip. Decay heat is being removed by the main steam system to the main condenser using the steam dumps. There was no impact to Units 2, 3, or 4.

"An automatic actuation of the auxiliary feedwater system (AFW) also occurred, as expected, due to lo-lo steam generator levels resulting from the reactor trip. AFW is currently controlling all steam generator levels at their normal levels. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Due to the notification of another government agency, the Burke County Fire Department, this event is being reported as a four-hour, non-emergency notification under 10 CFR 50.72(b)(2)(xi). The Burke County Fire Department was not needed to extinguish the fire. This event is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the auxiliary feedwater system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."