Event Notification Report for October 21, 2020

This material event contains a "Less than Cat 3" level of radioactive material.

EN Revision Imported Date : 10/14/2020

EN Revision Text: AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On October 12, 2020, the licensee notified the Agency that on October 10, 2020, one of its technicians completed a job at a temporary job site in Dallas, Texas, and drove to another temporary job site in Venus, Texas. Upon arriving, the technician found he did not have the Humboldt 5001 EZ moisture/density gauge in his truck. The gauge contained an 8 milliCurie cesium-137 and a 40 milliCurie americium-241/beryllium source. The technician believed he left the gauge at the Dallas site so he drove back to that site. The gauge was not there. The technician called his supervisor but never made contact. The technician called the company office and left a voicemail about the incident which was retrieved this morning. The licensee is notifying local law enforcement, contacting area pawn shops, and conducting its investigation. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9806

* * * UPDATE ON 10/13/2020 AT 1414 EDT FROM KAREN BLANCHARD TO OSSY FONT * * *

The following update was received from the Agency via email:

"The location where the event occurred is a temporary job site in the 7400 block of Hillcrest Road in Frisco, Texas. The gauge, a Humboldt 5001 EZ, contains 10 milliCuries of cesium-137 (not 8) and 40 milliCuries of americium-241/beryllium. The insertion rod was locked. The licensee has made a report to the Frisco police department. The licensee has thoroughly searched the construction site a second time and will be checking businesses around the site for possible video surveillance that may provide information. The Agency has informed the Frisco fire department/emergency management coordinator. Further information will be provided as it is obtained in accordance with SA-300."

Notified R4DO (Azua) and NMSS Events Notification, ILTAB, and CNSNS (Mexico) via email.

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

NON-AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

The following is a summary from a phone call with the licensee:

A patient at the Indiana University Health Methodist Hospital was prescribed 46.7 mCi of Y-90 Theraspheres to segments 5 and 8 of the liver, but received 54 percent (25.2 mCi) of the prescribed dose. The remaining 46 percent (21.5 mCi) was trapped in the catheter or the line. The patient and the physician were notified and a follow-up treatment has been scheduled for next week.


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.

MAXIMUM LICENSED POWER LEVEL EXCEEDED

"During the course of operations, a potential error in the power calibration of the PUR-1, License Number R-87, was discovered. This calibration error would result in a special report requirement as specified in [(Technical Specification)] TS 6.7.b.1.c.vi, which is that an observed inadequacy in the implementation of a procedural control such that this inadequacy could have caused the development of an unsafe condition with regards to reactor operations. By extension the miscalibration caused a true reactor power higher than the measured reactor power. As such, this likely resulted in the operation in violation of the limiting condition for operation as established in TS Section 3 Table I and operation with an actual safety system setting for a required system less conservative than the limiting safety system settings specified in the Technical Specifications. These reporting requirements are Part i. and ii. of TS 6.7.b.1.c. The calibration error implicates a violation of the maximum licensed power level of 12 kW. The Safety Limit was not exceeded at any point."

THERMAL EVENT RESULTING IN LOSS OF INTEGRITY OF LICENSED CONTAINER

At 1000 EDT on October 20, 2020, a thermal event occurred inside a hot cell at the Curium facility in Noblesville, Indiana. The thermal event did not result in a chemical or radioactive material release. Prior to the incident, technicians were processing materials containing strontium 82 and 85 (quantities are unknown at this time). The pressure created by the reaction caused the rear door of the hot cell to open approximately eight inches and was immediately shut by the technicians. There is no contamination outside of the hot cell and there were no injured or contaminated personnel. The vessel containing the strontium material was observed to be intact and the resultant fire was extinguished by the hot cell's suppression system. No offsite fire assistance was required. Personnel have not accessed the hot cell due to elevated dose rates. Dose rates outside of the hot cell are within the facility's normal limits and historical averages.