Event Notification Report for March 28, 2018

CONCURRENT REPORT DUE TO DAMAGED TRITIUM EXIT SIGN

"At approximately 1330 EDT, 3/28/2018, a report was sent to the State of North Carolina Department of Radiation Protection. The report is below:

"'Pursuant to 10A NCAC 15.0309, Global Nuclear Fuel Americas, LLC (GNF-A) is providing this report for discovery of a damaged self illuminated exit sign in the Fuel Manufacturing Operations (FMO) building.

On February 26, 2018, it was discovered that one tube out of the twelve originally installed tubes in a generally licensed exit sign was damaged. The sign was in storage and not being used at the time and there was no significant exposure as a result of the event.

The sign is believed to be a model number 101 or 201, originally containing a maximum of 25 Ci of tritium manufactured and distributed by:

Evenlite, Inc., 220 VFW Avenue.,Grasonville, MD 21638.

Arrangements were made to properly dispose of the sign. It was shipped offsite for recovery or disposal on March 23, 2018 to SRB Technologies (NC Radioactive Material License 034-0534-2).'

"This report to NRC is being made in accordance with 10 CFR 70 Appendix A (c) - Concurrent Reports (... notifications to other government agencies has been or will be made, shall be reported to the NRC Operations Center concurrent to the news release or other notification.)"

The Licensee has notified NRC Region 2.

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

NOTIFICATION OF A LOST THICKNESS GAUGE

The licensee determined today, 3/28/2018, that they had lost an Am-241 thickness gauge source. A few months ago the Am-241 thickness gauge source had been replaced with a non-radioactive thickness gauge source. The licensee had observed the Am-241 thickness gauge source at the plant after it was removed, but when they tried to locate it last week could not find it. They searched the site, including using a radiation detector to search with, and did not locate the Am-241 thickness gauge source.

The gauge is an NDC Technologies, probe Model 103, with an Am-241source. The device S/N is 12131, and the source S/N is 7199 LQ with an Assay date of 10/6/1998. No specific source strength was included in the data the licensee had, but they indicated the source strength was low. NDC Technologies license GL-657303-19 indicates the Am-241 source activity is 150 micro Ci.

The licensee stated that they are continuing to search for the Am-241 thickness gauge source, and they are preparing a written report. The licensee stated that they have revised their administrative policy for control of radioactive material and are scheduling retaining for their radiation safety officers.

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

MISSING I-125 SEED

On 3/27/2018, a patient was implanted with a 83 microCi I-125 seed marker in preparation for a breast tumor surgery. Following the surgery on 3/28/2018, at approximately 1500 EDT, the I-125 seed marker went missing. The operating room was surveyed, and the patient was imaged with no discovery of the I-125 seed marker.

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.p

NOTIFICATION OF A LOST TRITIUM EXIT SIGN

During an annual audit on 3/28/2018, the licensee determined that a self luminous exit sign was missing. Through interviews the licensee determined that an employee had removed the sign during a safety walkdown, because it did not appear to be working, and likely disposed of in the trash. Through a records review the licensee determined the safety walkdown was most likely on 11/1/2017.

The licensee information on the self luminous exit sign is that it was a Isolite model SLX60, serial number Y60813, manufactured in 11/2008 with an activity of 7.4 curies of H(3).

The licensee continues to investigate this event and has counseled the employee to follow the procedures for these signs. The licensee is planning to put out a general communication on these signs, and for the eventual removal of all the self luminous exit signs. The licensee is preparing a written report.

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 - BRACHYTHERAPY SOURCE DID NOT FULLY RETRACT

The following was received from the State of California via E-mail.

"The Regional RSO, Kaiser Permanente Medical Care Program, contacted LA County Radiation Management (LA County) on April 10, 2018 to report a Medical Event that occurred at the Kaiser Therapy Department on March 28, 2018 located in Los Angeles, CA. The event occurred during a HDR [High-Dose Rate] brachytherapy procedure in which the iridium-192 (Ir-192) source did not fully retract post-treatment and remained in the transfer guide tube about 5 cm from the cylinder-transfer guide tube connector. The source remained in this position between the patient's thighs for approximately 15 minutes resulting in the patient receiving about 300 cGy (300 rad) to the thighs. It was later determined that the source wire was bent near the source which is suspected to be the reason the source did not retract fully.

"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, especially concerning the delay in removing the source from the immediate vicinity of the patient, the delay in reporting the event to the RSO, as well as to better understand the reason the source wire did not fully retract. "

California 5010 Number: 041018 (5010#)


* * * UPDATE ON 7/30/2018 AT 1746 EDT FROM ANA CASAJE TO ANDREW WAUGH * * *

The following was excerpted from an E-mail received from the State of California:

Kaiser Permanente contacted LA County Radiation Management on April 24, 2018 to update this medical event based on new information submitted by their primary medical physicist and corroborated by other HDR personnel present during the incident. The patient's exposure time has been revised from 15 minutes to 5 minutes, and the calculated unintended dose was revised from 300 cGy to 100 cGy.

Notified R4DO (Gaddy) and NMSS (Bollock) and NMSS Events Notification group via email.

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.