Event Notification Report for July 17, 2020

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTERED TO PATIENT

The following was reported by the Florida Bureau of Radiation Control:

"On 7/17/2020 during ablative treatment with Y-90 TheraSpheres to the male patient, it was discovered that only a partial treatment was administered to the patient. 511.6 Gy was prescribed, 358.9 Gy was delivered, for a 70% delivery rate. The event was discovered during a routine check of waste activity. The Radiation Safety Officer (RSO) reports that from initial information from the tech, all procedures were followed. No abnormal events were noted during the procedure. The prescribing physician and patient have been notified. Clinical outcome is expected to be ok. The RSO will phone in more details on Monday as he was working remotely on Friday. A fifteen day letter will follow. Licensing and Technology will be tasked to investigate."

FL incident number: FL20-082

Notified RI and NMSS Events Notification.

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.

MANUAL REACTOR SCRAM DUE TO INCREASED HYDROGEN USAGE

"On July 17, 2020, at 1346 PDT with Diablo Canyon Power Plant Unit 2 operating at 100 percent power, the reactor was manually tripped in accordance with plant procedures due to increasing hydrogen usage in the Unit 2 main generator. The reactor trip was uncomplicated and the Auxiliary Feedwater system started as expected. The plant is stable in Mode 3.

"This notification is being made in accordance the requirements of 10 CFR 50.72(b)(2)(iv)(B) as a manual actuation of the reactor protection system and 10 CFR 50.72(b)(3)(iv)(A) as an automatic actuation of a specified safety system.

"The cause of the increased hydrogen usage is under investigation. There was no impact to the health and safety of the public or plant personnel.

"The Senior Resident Inspector has been notified."

AGREEMENT STATE REPORT - LOST TROXLER GAUGE

The following was received by the state of Maryland via email:

"On July 17, 2020 at 2115 EDT the Maryland Radiological Health Program was notified of a lost or stolen portable moisture density gauge. A technician for J. D. Hynes and Associates was at a job site at the University of Maryland Eastern Shore, 30610 College Backbone Road, Princess Anne Maryland. The technician completed the job and was preparing to store the gauge in the transportation case when he was distracted. He then drove the truck approximately 16 miles back to the office at 32185 Beaver Run Drive, Salisbury, MD 21804. The technician discovered the gauge was not in the case. The technician contacted his supervisor and the owner at 1730 EDT and then returned to the job site at approximately 1800 EDT to search for the gauge and discovered the site was locked. The project superintendent was contacted and a key for entry was obtained by the licensee supervisor. Both the licensee supervisor and technician entered the jobsite and searched for the missing gauge and did not locate it there. Then they searched along the travel route independently from each other to try and locate the missing gauge. Both employees searched until approximately 2100 EDT when it got too dark to see. The licensee contacted Wicomico County Police Department and Somerset County Police department and both county fire departments. The gauge was a Troxler 3400 series with 9 mCi Cs-137 and 44 mCi AmBe sources. The serial number is 75791. A reactive inspection will be conducted on Monday July 20, 2020."

* * * UPDATE ON 7/2/2020 AT 1724 EDT FROM ATNATIWOS MESHESHA TO THOMAS KENDZIA * * *

The following update was received via email:

"A portable density gauge was lost from the J.D. Hynes and Associates, Inc. on July 17, 2020 between approximately 14:45 EDT to 15:20 hours EDT. The gauge was identified as Troxler, model 3440P, serial number 75791 with nominal activities of 8 mCi of Cs-137 (on 1/7/2019) and 40 mCi of Am-241:Be (on 2/11/2019). The last leak test was performed on March 6, 2020. The gauge was lost while returning to office from the job-site.

"On July 17, 2020, at approximately 10:00 hours EDT, the density gauge was placed in the tailgate of a pick-up truck by the gauge operator after warm up and daily calibration, and waiting for the day's work at a building construction in the University of Maryland Eastern Shore Campus located at 30610 Collage Backbone Road; Princess Anne, Maryland 25813; in Somerset County. Work was suspended at about 14:45 hours EDT due to water leakages in the underground pipes. The gauge operator proceeded to drive back to the licensee's office located at 32185 Beaver Run Drive, Salisbury, MD 21804, in Wicomico County. After driving for about 25 minutes (about 18 miles) and arriving at the office parking lot the gauge operator realized that the gauge was not placed in its transportation case. The gauge was missing from the bed of the open tailgate of the pick-up truck.

"The event has been reported to the Maryland State Police, in Salisbury; the Incident Number is: 2020-00322775.

"Maryland Department of Environment, Radiological material Division will conduct a reactive investigation.

Notified R1DO (Carfang), NMSS Event Notifications (email) and ILTAB (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