Event Notification Report for October 27, 2023

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE

The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:

"This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this [configuration], the planning and delivery systems are not linked. [As a result,] staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted."

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 - DAMAGED TROXLER GAUGE

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

"At 1520 EDT on August 31, 2023 a troxler gauge containing a 9 mCi Cs-137 source and a 44 mCi Am-241 source was struck by a dump truck at a construction site in Clarksburg, Maryland. The gauge was licensed to, and being operated by, ECS Mid-Atlantic, LLC (MD-21-037-01). The display and source guide handle was damaged but the part of the gauge containing the sources was not. The sources' shielding was not damaged. The source rod was successfully retracted by the Radiation Safety Officer (RSO) and several surveys of the area were performed by the RSO confirming only background radiation levels. At the time, the gauge was returned to the licensee's storage facility and tested for source leakage. MDE was notified and requested that the gauge be tested for leakage and the RSO's dosimetry be read. Leak tests later showed no leakage of radioactive material and the RSO's dosimetry read a minimal dose. At this time, the gauge has been repaired by the manufacturer and returned to service.

AGREEMENT STATE REPORT - UNSHIELDED SOURCE

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

"On October 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that a 52 millicurie (current activity) strontium - 90 source could not be returned to the fully shielded position in a Novoste brachytherapy device. The source had been retracted from the patient, therefore the patient had received the prescribed dose. The therapist followed the licensee's emergency procedure and placed the device into a plastic box and took it to their hot lab. Once in the hot lab, they were able to fully retract the source. The device has been taken out of service. The RSO stated the vender has been notified of the event. No overexposures occurred due to this event."

Texas Incident Number: 10060
Texas NMED Number: TX230048

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 2159 on 10/24/2023, with Unit 3 in Mode 1 at 100 percent power, the reactor was automatically tripped due to an actuation signal into the Unit 3 reactor protection system protection rack during maintenance. The trip was uncomplicated with all systems responding normally post trip. Decay heat is being removed via auxiliary feed water system and the steam dump system. Unit 4 is not affected.

"This event is being reported pursuant to 10CFR50.72(b)(2)(iv)(B) and 10CFR50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified.

"The cause of the automatic reactor trip will be investigated by the licensee."