Event Notification Report for April 09, 2020

AGREEMENT STATE REPORT - STUCK SHUTTER

The following is a summary received from the state of Mississippi via phone:

The licensee notified the state that during a routine check of an Ohmart gauge (s/n: 1169GK), the shutter would not close. The gauge contains a 10 mCi Cs-137 source (source holder: SHF-1). It is located over a chemical bin and the normal shutter position is open, so there is no additional exposure to employees. An authorized company is scheduled to remove and replace the gauge with an identical model.

AGREEMENT STATE REPORT - LOST GAUGE

The following is a summary received from the state of California via email:

On 04/09/20, the California Office of Emergency Services (OES) contacted the Radiologic Health Branch (RHB) to report a notification made by a California licensee regarding a lost hydro probe. The gauge involved is a CPN Model 503DR, S/N H380104084 hydro probe containing 50 mCi of Am-241. The report stated that the field user placed the probe into its case without securing its latches and locks and drove off to the next field site. It is believed that the probe had fallen out of the truck somewhere on Crows Landing Road between Carpenter Road and Ehrlich Road. The RSO [Radiation Safety Officer] had notified the California Highway Patrol (CHP) and the local Fire Department of the incident. Repeated attempts made by the RSO, his staff and CHP to locate the gauge were unsuccessful. The RSO will be posting a reward on social media for the safe return of the gauge. The RHB will be following up on this investigation.

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

ABNORMAL OCCURRENCE

"On 4/9/20, at 1432 CDT, the University of Missouri-Columbia Research Reactor (MURR) was shut down due to the failure of the geared rotary limit switch assembly to move with corresponding regulating blade drive mechanism movement. This email is a required notification per MURR Technical Specification (TS) 6.6.c(1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, had occurred. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.f states, 'The reactor shall not be operated unless the following rod run-in functions are operable.' Specifically, the rod run-in function that occurs when regulating blade position is less than or equal to 10 percent withdrawn was not operable as required by TS 3.2.f.8.

"The regulating blade drive mechanism was repaired, post-maintenance operability testing was conducted satisfactorily, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on 4/9/20. Currently, MURR is at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3)."

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO REACTOR COOLANT SYSTEM PRESSURE BOUNDARY LEAKAGE

"On April 9, 2020 at 0100 EDT, while performing a containment walkdown due to a small increased Reactor Coolant System (RCS) unidentified leakage, a leak was identified on the 'A' Reactor Coolant Pump (RCP) seal injection piping. The source of the leakage cannot be isolated and is considered RCS pressure boundary leakage. At that time, Condition B of Technical Specification (TS) LCO 3.4.13, 'RCS Operational Leakage' was entered due to pressure boundary leakage. TS 3.4.4 'RCS Loops - Mode 1 and 2' and Technical Requirement (TR) 3.4.6 'ASME Code Class 1, 2, and 3 Components' are also applicable. Unit 2 is projected to be taken to Mode 5 for repairs.

"This event is reportable in accordance with 10 CFR 50.72(b)(2) for 'Initiation of plant shutdown required by Technical Specifications' and 10 CFR 50.72(b)(3)(ii)(A) for 'Any event or condition that results in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded.'"

The licensee notified the NRC Resident Inspector. There is no effect on Unit 1

AGREEMENT STATE REPORT - DOSE NOT DELIVERED TO THE CORRECT LOCATION DURING BRACHYTHERAPY TREATMENT

The following was received from the state of Texas via email and by telephone:

"On April 10, 2020, the licensee reported to the Agency [Texas Department of State Health Services] that it had an event on April 9, 2020, involving a Novoste device in which the source train had not advanced to the designated treatment site during two attempts to deliver intravascular brachytherapy to a patient. It was unclear if the source train had actually entered the patient and the Agency requested confirmation and more information. On April 14, 2020, the licensee reported back to the Agency confirming that the source train had stopped moving after it had entered the patient. During the first attempt, the source train of 16 Strontium-90 sources in the Novoste device failed to go to the expected treatment position and instead got stuck in the beta-rail catheter proximally to the treatment area for 6 minutes 54 seconds. The device was checked and a second attempt was made during which the source got stuck in the beta-rail catheter proximally to the desired treatment area for 3 minutes 41 seconds. The source train was stuck at different positions in the catheter for the two attempts and each time the physicians worked with the catheter to try and get the source train to move to the treatment site. Doses calculated for each of the locations: first location = 26.2 Gy at 2 mm; second location = 14.2 Gy at 2 mm. The licensee was able to fully retract the source into the device each time. The vendor is expected onsite next week to check the device and investigate the cause. The licensee has suspended this particular treatment program indefinitely pending identification of cause.

"Device Information:
Novoste device SN: 89670
Source train SN: ZA925
Active source train length: 40 mm
Number of Sr-90 sources: 16
Total activity: 2 GBq calibrated on 8/16/2002

"Treatment Information:
Vessel description: RCA
Vessel diameter: 4 mm
Lesion length: 30 mm
Radiation dose: 23 Gy
Dwell time: 5 minutes and 57 seconds

"Dose to staff was negligible since the source train was inside the patient. Effects to the patient, if any, as a result of this event were not reported with this initial information. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9760


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.