Event Notification Report for August 11, 2020

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

"The [Pennsylvania] Department [of Environmental Protection (DEP)] received notification from a licensee on August 12, 2020, of a medical event involving Yttrium-90 Sir-Spheres. The licensee believes a patient received only 47% of the prescribed dose. The prescribed dose was 1.44 GBq and the delivered dose is believed to be 0.67 GBq. Preliminary cause is believed to be a clotted catheter. The licensee continues to investigate the event. The patient and referring physician were informed following the procedure. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided."

PA NMED Event # PA2000016

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.

LOSS OF TECHNICAL SUPPORT CENTER VENTILATION SYSTEM

"At 1334 EDT on Tuesday August 11th, the Peach Bottom Atomic Power Station (PBAPS) Technical Support Center (TSC) Ventilation System lost power due to a trip of the Station Blackout (SBO) electric power supply breaker. The trip was due to a fault at the Conowingo Dam and Conowingo was not able to realign electric power to the SBO within an hour. Power restoration is complete and TSC Ventilation was restored at 1725 EDT.

"This report is being submitted pursuant to 10CFR 50.72(b)(3)(xiii) as a Major Loss of Emergency Preparedness Capabilities due to a reduction in the effectiveness of the Onsite Technical Support Center (TSC).

"The NRC Resident Inspector has been notified."

FIRE INVOLVING A CONTAINER POSSESSING LICENSED MATERIAL

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

"An incident took place while processing a liner with water filters and Dry Active Waste (DAW) in it during filter shredding operation in the Filter Shredding area of the Radioactive Material Solutions (RMS) Building on site. The container contained mixed fission and activation products with Co-60 as a primary contaminant. A fire was observed in the steel Final Form Container (FFC) liner through the remote observation. The size of the fire was limited to the container itself. The FFC is a steel liner where the material accumulates and is contained in preparation for sealing for disposal. The filter processing room was accessed via a hatch and a crane was used to seal the FFC. The fire suppression system was activated to cool down the FFC liner. The Oak Ridge Fire Department responded to the site. Since the fire was contained to the FFC liner, the Oak Ridge Fire Department did not enter the building. The area radiation and air effluent stack monitors did not alarm. Samples from air samplers are being analyzed for airborne material. Staff that remained in the building will undergo a bioassay to assess for potential uptake. A follow-up report will be submitted within 30 days."

TN Incident No.: TN-20-116

FITNESS-FOR-DUTY - LICENSED OPERATOR VIOLATED THE FFD POLICY

On August 11, 2020, at approximately 1432 MST, a licensed operator's test results were confirmed positive for use of a controlled substance following a random Fitness For Duty screening test. The individual's unescorted access has been terminated in accordance with station procedures.

The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - LOST I-125 SEED

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

"On September 9, 2020, the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 251 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.

"In this incident two seeds were placed into a patient on 8/10/2020 and removed on 8/11/2020. Removal of the seeds from the patient was confirmed by x-ray in the operating suite. The seeds were then sent to the Frozen Section Room for margin check then sent to the Grossing Room in Pathology. After slicing in the Grossing Room, the specimen was x-rayed again and only one seed was visualized. Pathology believed that the seed was in the Frozen Section Room and immediately searched and surveyed both the Frozen Section Room and the Grossing Room, then notified the RSO [radiation safety officer] when the seed was not found. The RSO and an assistant surveyed the OR suite, Frozen Section Room and Grossing Room. Trash from all three locations was surveyed and after three days radioactive waste was surveyed and examined but the seed was still not recovered.

"In the time between the incident and reporting to the Department, searches and surveys were performed in Surgery, Pathology, Radiation Safety and Environmental Service areas. In addition, trash, regulated medical waste, and radioactive waste were surveyed and inspected. The seed has not been recovered.

"Ultimate disposition of the source is unknown and it is possible that the source may still be recovered."

New York Event Report ID No.: NYDOH-20-04

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