Event Notification Report for April 20, 2016

AGREEMENT STATE REPORT - POLONIUM 210 SOURCE MISPLACED

The following report was received via email:

"On April 20, 2016 an employee Thermo Fisher (Thermo Finnigan LLC-Round Rock, Texas) reported that an anti-static nozzle containing polonium 210 had been misplaced at his facility. The activity of the source was 10 mCi (serial number A2JY896). The source was inside the spray nozzle control which screws onto the spray gun used for electronic cleaning. During the process of collecting the nozzles to return to manufacture it was found that one was missing. A company wide search is in progress to find the missing source. More information will be sent as obtained from the licensee."

Texas Incident #: I 9390

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

UNANALYZED CONDITION DUE TO ESSENTIAL SERVICE WATER PRESSURE TRANSIENT

"Recent Operating Experience at Callaway has shown that the pressure transient experienced in the Essential Service Water (ESW) system during Engineered Safety Feature Actuation System (ESFAS) testing can result in gasket failure on the Control Room Air Conditioners rendering the units nonfunctional. Previously, this pressure transient was considered to be the result of the system alignment used to perform the surveillance test, which is not the same as the system lineup which would occur on an actual Loss of Offsite Power (LOOP) or Safety Injection Signal Design Basis Accident (DBA) event. However, on April 20th, 2016, Callaway received preliminary analysis results that predict the Control Room Air Conditioners would actually experience a greater pressure transient during a DBA than what is currently experienced during ESFAS testing. This condition could result in the Control Room Air Conditioners not being capable of performing their safety function following a DBA event, and challenge Control Room Habitability. Therefore, this condition meets the reporting criteria of 10 CFR 50.72(b)(3)(ii)(B).

"Based on current conditions (i.e., the plant is not in Power Operation), this condition does not present an immediate safety concern.

"The analysis of the pressure transient experienced by the ESW system during a postulated DBA event is preliminary and further evaluation of the analysis is ongoing.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - MISSING STATIC IONIZATION SOURCE

The following report was received from the State of Washington via email:

"On 4/21/2016, the Radiation Safety Officer at University of Washington reported by phone and by email that a Po-210 static ionization source was missing from a lab at the Southlake Union [SLU] Campus. The static ionization source had been placed in a cardboard box in preparation for shipment back to NRD [manufacturer]. Someone in the lab thought the box was empty and placed it in the recycling. This was discovered on Monday, and the lab had been searching for it for a couple of days before notifying the Radiation Safety Officer.

"The immediate report value for Po-210 is 100 microCi and the 30 day report value is 1 microCi.
Source information: Isotope: Po-210, Manufacturer: NRD, Model: P-2001, Initial Activity: 5 mCi (May 2015), Current Activity: approximately 1 mCi
Device information: Nuclespot - Static Eliminator, Manufacturer: NRD, Model: P-2042-1000, Serial Number: Not reported.

"The facilities personnel are currently trying to find out from [the recycling company] where the recycling is taken for processing. [The recycling company] picks up recycling from the SLU campus twice a week on Friday and Tuesday. University of Washington Principal Investigator lab informed NRD of the loss. Once their investigation is complete, UW will provide us [WA Office of Radiation Protection] with a written report as required by WAC 246-221-240(2).

"Incident Number: WA-16-018"

* * * UPDATE AT 1541 EDT ON 05/18/16 FROM ANINE GRUMBLES TO S. SANDIN * * *

The following information was received from the State of Washington via email:

"WA-16-018 Po-210 static ionization source missing from University of Washington

"Update and Closure

"University of Washington submitted their final report on the lost Po-210 static eliminator. University of Washington is a Broad Scope A Licensee.

"Their [University of Washington] Radiation Safety staff performed a thorough investigation and search for the source.

"There are a total of six possible routes the source may have taken; all of which end up overseas. Initially, three potential avenues were explored at Recology CleanScapes:

1. If source stayed inside the box with the paper - processed as corrugated cardboard and sent overseas for recycling processing
2. If paper came out of the box and source stayed with paper - processed as mixed paper and sent overseas for recycling process
3. If paper came out of box and source came out of the paper - source would have filtered out into glass recycling stream (includes metal), which is sent to Strategic Materials. The RSO contacted Strategic Materials and identified an additional three possible outcomes for the source, if it made it to the Strategic Materials facility.
4. All incoming material is first passed by a large magnet, if the source housing was ferrous enough the source would have been transferred to a metal recycler. The source model is believed to have an aluminum housing.
5. If the source was not pulled out by the magnet, it was either manually removed by a picker and thrown in the trash, or
6. The source was pulled out by an Eddy Current device and would be in one of the device collection bins. This also would have been thrown in the trash. Staff at both facilities were shown photos of the source and interviewed, and no one had seen or moved the source.

"Ultimately, it is believed that the source, thoroughly wrapped in in paper, in a corrugated box was processed and sent overseas in a bulk cardboard or mixed paper recycle bundle.

"The Registry of Radioactive Sealed Sources and Devices - Safety Evaluation of Device (Number: NY 502 D 108 G) for the P-2042 model indicates an maximum external exposure rate of 0.05 mR/hr on contact with the source. This is equivalent to background radiation levels. It should be noted that the principle emission of Po-210 is an alpha particle, so the exposure falls off rapidly with increasing distance from the source. Therefore, the exposure to any individual handling the source would be negligible. Since Po-210 is an alpha emitter, the highest risk would be to a person who ate the radioactive foil. However, this scenario is extremely unlikely due to the fact that the individual would have to first remove the foil from the housing, and then have a desire to eat the foil.

"Some new additions to the information:

Manufacturer: NRD Inc.
Device Type: Nuclespot - Static Eliminator
Device Model: P-2042-1000
Sealed Source Model Designation: P-2001
Serial Number: A2KG893
NRD Lease Number: 059345
Shipped to UW: 5/21/2015
Original Activity: 5 millicuries
Activity when lost: 1 millicurie

"This source is considered lost and unrecoverable. The assessed health and safety risk is very low. This incident is considered CLOSED."

Notified R4DO (Miller) and NMSS Events Notification 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

AGREEMENT STATE REPORT - NUCLEAR GAUGE STUCK SHUTTER

The following report was received from the North Carolina Department of Health and Human Services via email:

"The Agency [North Carolina Department of Health and Human Services] was notified of service contract reciprocity 0003-R Ronan to arrive at NC [North Carolina] Licensee Chemours in Fayetteville on 9/21/16. Ronan to work on a Ronan SA-1, Gauge SN:M1713, Cs-137, 20 mCi (decayed to approx 10 mCi) with a stuck shutter.

"[The North Carolina Radioactive Materials Branch Health Physicist] went to Chemours 0109-7 to conduct a reciprocity inspection, and conducted an investigation regarding [Chemours] failing to notify the Agency [North Carolina Department of Health and Human Services] of a stuck shutter on a radioactive gauge. The stuck shutter was identified during scheduled leak test and shutter testing by Chemours workers in June, 2016. This was confirmed with the RSO [Radiation Safety Officer].

"Shutter was in the open position. No members of the public or workers were at risk of exposure (due to facility design).

"Source: Cs-137
Activity: 0.020 Ci
Manufacturer: Ronan Engineering
Model Number: sa-1
Serial Number: m1713

"NC Item Number: NC160030"

AGREEMENT STATE REPORT - UNDERDOSE EXCEEDING 20 PERCENT OF THE PRESCRIBED DOSE

The following was received via email from the state of Illinois:

"During a routine inspection [by the State of Illinois] of Riverside Medical Center, IL-01242-01, conducted on January 29, and continued document review conducted February 5, 2019, inspectors identified an apparent under dose to a patient receiving I-125 seed prostate therapy. The event occurred in April of 2016. Of the six patient records reviewed (all 2016), one post operational dosimetry report indicated a D90 of 120.7 Gy, resulting in a 24.5 percent variance from the prescribed dose of 160 Gy. Two of the patient records did not have a post operational dosimetry report and inspection findings indicate the licensee does not have written procedures for prostate seed therapies which ensure the administrations are in accordance with the written directive. As a result of the lack of procedures, the determination of a 20 percent variation from the prescribed dose is being compared against the D90 value following prior recorded NMED [Nuclear Materials Events Database] events and NRC guidance. The licensee has been notified and will submit a written report within 15 days.

"The licensee is not actively engaged in brachytherapy and the authorized user is no longer with the licensee. Agency enforcement action will ensure either procedures are established or modality authorization is removed. Pending appropriate address of the patient's treatment and root cause by the licensee, a reactive inspection is not being conducted in accordance with Management Directive 8.10, Section III(A)(3). This report will be updated as additional details become available."

Item Number: IL190007

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.