Event Notification Report for April 23, 2019

AGREEMENT STATE REPORT - DOSE GREATER THAN PRESCRIBED DOSE

The following was sent by email from the Commonwealth of Massachusetts:

"The licensee reported on April 24, 2019 that it discovered on April 23, 2019 two High Dose-rate Remote Afterloader (HDR) medical events where tissue other than the treatment site received a dose exceeding the reporting requirements 105 CMR 120.594(A)(1)(c). One of the medical events occurred in March of 2019 and the other occurred in October of 2018.

"The licensee reported that a 5 cm offset from the target location resulted in dose to unintended tissue during each treatment.

"The licensee used a Varian Medical Systems, Inc. Model VariSource iX HDR containing iridium-192 to deliver the doses for both treatments. Each prescribed dose to each patient was 10 gray (1,000 rad) to the vaginal cavity across two fractions.

"Both events occurred as a result of an unintended area of each patient's vaginal cavity receiving a portion of the prescribed dose. The licensee reported that the cause of the events is a combination of a change in applicator size and incorrect parameters input into the device console. Some two years ago, the size of the vaginal applicator changed from 120 cm in length to 125 cm in length, but there were no issues until the two aforementioned events. From the administration documentation, the licensee determined that the technician erroneously entered 120 cm into the device console rather than 125 cm, effectively causing a 5 cm offset. As a result the lower 5 cm of each patient's vaginal cavity received more dose than intended. The exact number is yet unknown. The licensee will provide additional information in a written report.

"The licensee reported that the referring physician, who is the same for each patient, has been notified and that the referring physician intends to notify each patient.

"The Agency [Massachusetts Radiation Control Program] plans to perform a special inspection and considers this event to be open."

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.

FITNESS FOR DUTY REPORT - ALGORITHM USED FOR RANDOM TESTING EXCLUDED A POPULATION OF INDIVIDUALS

"On April 23, 2019, at 12:56 Central Time, South Texas Project Nuclear Operating Company (STPNOC) identified a programmatic failure, degradation, or discovered vulnerability of the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program."

The NRC Resident Inspector has been notified.

NEW YORK AGREEMENT STATE REPORT - PANORAMIC IRRADIATOR SOURCE FAILED TO RETRACT

The following information was received from the state of New York via facsimile:

"The New York State Department of Health (NYSDOH) was notified by [the radiation safety officer] (RSO) of Pall Hauppauge (C1935) that they had an incident where the source did not retract completely leaving the source partially exposed for a period of time.

"According to the RSO, he was notified on April 23, 2019, at approx. [0900 hrs. EDT] of a fault at Vault 4, and arrived approximately 15 minutes later and found that the source had gotten stuck very slightly above the down (safe) position when the cycle ended. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action.

"The RSO contacted Nordion to discuss the situation and he was able to free the source and get it into the safe position without any issue. The RSO then checked the radiation levels in the irradiator and found that they were normal. There was no risk of personnel or public exposure at any time during this incident, nor was there any risk of contamination.

"The root cause for the source getting stuck has not been yet determined. The RSO will be working with Nordion to assess the equipment and decide the course of action.

"DOH will continue to monitor this incident.

"Pall Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator."

NY Event Report ID No.: NY-19-06

TEMPORARY LOSS OF CONTROL ROOM ENVELOPE BOUNDARY

"At 0232 EDT on April 23, 2019, a Main Control Room (MCR) alarm was received for low control room positive pressure.

"At 0233 EDT, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10 Control Room Emergency Ventilation System (CREVS) was declared not met for both trains. Watts Bar Unit 1 entered Condition B. Watts Bar Unit 2 was not performing movement of irradiated fuel assemblies and did not meet the APPLICABILITY for CREVS per LCO 3.7.10.

"At 0233 EDT on April 23, 2019, the alarm cleared, CREVS was declared operable and LCO 3.7.10 Condition B was exited.

"The safety function of the CRE boundary is to ensure the in-leakage of unfiltered air into the CRE will not exceed the in-leakage assumed in the licensing basis analysis of Design Basis Accident (DBA) consequences to CRE occupants. From 0232 EDT to 0233 EDT, [Watts Bar Nuclear] WBN was unable to validate that CREVS could fulfill its required Safety Function.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."

WASHINGTON AGREEMENT STATE REPORT - LOST AND FOUND RADIOACTIVE MATERIAL

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

"Swedish Medical Center notified the state of Washington that a lead pig, containing 50 mCi (1.86 GBq) of Y-90 Sir-Spheres, was picked up for lead recycling. When the recycling company (Stericycle) came to collect all the lead pigs, a tech let the company into the waste room to collect the pigs not knowing that one of the pigs contained the Y-90 material left over from a treatment on Friday the 19th of April 2019. On April 23rd, the RSO [radiation safety officer] was reviewing the lead disposal paperwork and realized the material was sent out with the other lead pigs and notified the State. The RSO called the recycling company and was told the pigs were still in a drum and had not been processed. They will be returning the drum to the medical center on April 24th, 2019 and the RSO will notify the State when it arrives."

WA Event Report ID No.: WA-19-014

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)