Event Notification Report for October 30, 2020

CONCURRENT REPORT DUE TO NON-RADIATION WORKER INJURY

"A carpenter working in a clean area (not a radiological controlled area) injured his hand and required medical treatment.

"The nature of the hand injury requires reporting to the State of Washington Department of Labor and Industry. This concurrent report is being made in compliance with 10 CFR 70 Appendix A criteria c) which requires the reporting of any event or situation, related to health and safety for which notification to other government agencies has been or will be made."

The licensee also notified the NRC Region 2 office.

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

AGREEMENT STATE REPORT - MISSING LICENSED MATERIAL

The following information was received from the Commonwealth of Pennsylvania via email:

"On October 20, 2020 the licensee discovered a lost gadolinium-153 source. This source, Eckert and Ziegler Model NES8412, is an attenuation correction source in a SPECT camera. These sources are sold in pairs, and the serial numbers for the pair are R3-129 and R3-130. Only one is missing and it is unknown which it is currently. The licensee believes the sources were present in mid-June when the source holders were removed from the gamma camera in preparation for scrapping. The licensee is investigating to confirm that is true. The sources were nominally 250 mCi (+20%/-10%) each on March 1, 2019. The activity on June 15, 2020 was calculated to be 64 mCi, and on the date of discovery 44 mCi. The licensee has notified its facility and safety staff and is actively searching for the source. The DEP [Department of Environmental Protection] has been in contact with the licensee and will update this event as soon as more information is provided."

PA incident no.: PA200022

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 - EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following information was received from the State of Wisconsin, Department of Health Service (DHS) via email:

"On October 20, 2020, the licensee's high dose-rate remote afterloader experienced multiple abnormalities during the administration of a fraction to a patient. Prior to exposure, the device failed to retract its check cable when performing the pre-administration routine. Following the manufacturer's advice, the licensee restarted, and performed a system restore on the device. The routine was then re-initiated and went as expected, with the exception of "Status - Terminated" appearing on the console during the administration. All indications were that the fraction was delivered successfully to the patient. Following the fraction, no information was saved indicating that any fraction had been delivered. The licensee was able to replicate circumstances using radiographic film, and verified that while dose is being delivered as intended, no record is being retained by the software. The licensee worked with a manufacturer's service technician on October 21 to address the issue. They believe they have resolved the immediate hardware and software issues. The manufacturer will continue to follow up on the event. DHS will follow up with the licensee."

WI Incident No.: WI200007

This material event contains a "Category 2" level of radioactive material.

EN Revision Imported Date: 10/28/2020

EN Revision Text: AGREEMENT STATE REPORT - MISSING CATEGORY 2 MATERIAL

The following was received from the Commonwealth of Massachusetts (the Agency) via email:

"QSA Global reported via telephone at 1100 EDT on 10/22/2020 that a package shipped via common carrier on 10/9/2020, containing two Model A424-9 Ir-192 industrial radiography sealed sources within a Model 650L source changer, was reported as missing via telephone by common carrier at 0926 EDT on 10/22/2020. Common carrier trace already initiated and in progress, and tracking indicates last known package location was common carrier hub in Memphis, TN. This was a RQ UN2916, Yellow-II, Type B package with a Transport Index of 0.5 at time of shipment. Source changer SN 2238. Sources SN 11393M (65 Ci) and 11394M (33.1 Ci). This situation is an immediately reportable event per regulation. A search for the missing package by common carrier is ongoing. Agency currently considers this docket to still be OPEN"

Intended recipient is Gilligan Engineering Services, Prudhoe, Northumberland, Great Britain.


* * * UPDATE ON 10/27/2020 AT 1305 EDT FROM ANTHONY CARPENITO TO OSSY FONT * * *

The following update was received from the Agency via email:

"The licensee/shipper (QSA Global Inc.) on 10/23/20 reported to this Agency that the missing package was reported by the carrier as found in the carrier's Memphis, TN hub facility on 10/23/20. The package is being returned to the licensee/shipper for inspection.

"Agency expects this event docket to remain open until all details, including action docket numbers, are compiled, licensee's 30-day written report is received, and all relevant documentation is completed and reviewed."

Notified R1DO (Young) and NMSS Events Notification, NMSS Regional Coordinator (Rivera-Capella), and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

THROUGH-WALL LEAKAGE IDENTIFIED ON REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DURING TESTING

"At 1030 EDT on Thursday, October 29, 2020, during the performance of Peach Bottom Atomic Power Station leakage testing of the reactor pressure vessel and associated piping, a through-wall leak [non-isolable] was identified on an instrument line connected to the N16A nozzle.

"The reactor will be maintained shutdown until pipe repairs and testing are complete.

"The NRC resident inspector has been informed."