Event Notification Report for June 25, 2018

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERES

The following information was obtained from New York City Department of Health and Mental Hygiene, Office of Radiological Health via email:

"On June 25, 2018, a 65-year old male patient was treated with Y90 TheraSphere to the right side of the liver. The intended dose of administration was 64.8 mCi (2.4 GBq). Upon conclusion of the procedure, when the waste materials (delivery line, vial, gauze, etc.) was counted, it was found that 41.87 mCi (1.55 GBq) of Y90 TheraSphere was actually administered to the patient. In other words patient received 64.6% of intended dose. The Radiation Safety Office of Mount Sinai Hospital reported the incident to the New York City Department of Health and Mental Hygiene [NYCDOH] on 6/25/2018 at 1340 hrs. These findings were communicated to the patient and the referring physician within 24 hours. The licensee stated that no serious adverse events occurred and the patient will be followed up with Interventional Radiology as per protocol. The licensee indicated that the root cause analysis of the event is currently being performed and a detailed report of the event with corrective action will be sent to the NYCDOH within 15 days."

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.

OHIO AGREEMENT STATE REPORT - LOST IODINE-125 SEED

The following information was obtained from the state of Ohio via email:

"An I-125 seed, approximately 127 microCi, was retrieved from a breast seed localization patient on 6/20/18. A gamma probe was used during surgery to verify it was present in the tissue sample. After surgery the sample was x-rayed and surveyed to verify the seed was still present in the sample; the tissue was placed in a formalin tray and locked in a cabinet. Pathology dissected the tissue on 6/21/18 and did not find the seed. The licensee believes the seed was loosely attached to the tissue and was thrown away with the rest of the materials after it was x-rayed. The licensee performed surveys and did not locate the source. Due to the low activity of the source, it is not expected that the public dose limit would be exceeded."

Ohio NMED Report No.: OH180005

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

FITNESS-FOR-DUTY TEST POSITIVE FOR NON-LICENSED SUPERVISOR

At 1029 PDT on June 25, 2018, Pacific Gas and Electric determined a non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE UNABLE TO RETRACT

The following information was received via email.

"North Carolina (NC) Radioactive Materials Branch (RMB) is submitting the following reportable event: Radiography Camera Source Unable to Retract.

Reportable per: 10 CFR 30.50(b)(2) & 10 CFR 34.101(a)(2)
Event Date & Discovered Date: 6/25/18
Date Reported to RMB: 6/26/18
Location where event took place: Stoneville, NC
Reporting Licensee: Applied Technical Services [ATS]
NC License Number: 1510-1
Radiography Camera Manufacturer: QSA Global, Inc.
Radiography Camera Model #: Delta 880
Radiography Camera S/N: D5059
Source: Ir-192
Source Activity: 71.4 Ci
Source Manufacturer: QSA Global, Inc.
Source Model #: A424-9
Source S/N: 65909G

"While conducting radiography shots at a water tank construction site, ATS radiography crew experienced a source hang up. Radiographers initially believed the cause to be a crimped guide tube due to source not moving in either direction. While maintaining a 2 mR/hr boundary, additional personnel were dispatched to the work site by ATS with additional shielding material and [the] RSO [radiation safety officer] who is responsible for source retrievals. Lead blankets were placed on the guide tube and the RSO determined that the guide tube was not compromised, kinked, crimped or otherwise damaged. Probable cause was determined to be in the control assembly. RSO unthreaded the guide from the outlet adapter and exercised the controls with no effect. Guide tube was reconnected and RSO began to troubleshoot the connection side of the camera by removing the housing from the connection to observe the cable while again exercising the controls. Cable would flex but was observed to be either wedged or pinned at the connector. During this process, it was observed that since the cable would not flex on the outlet side of the camera it was determined that extreme force on the controls side would not result in the cable being disconnected from the pig tail. The housing was reattached, and extreme force was used on the controls to break the cable free and the source was returned to its secured and shielded position. The RSO observed the control assembly crank did have more movement than usual, and root cause was determined to be debris from a damaged bearing that had moved down the control cable housing and locked up the controls. This equipment had quarterly maintenance and weekly inspections conducted on it. [The] controls were shipped to QSA for repair or disposal. All personnel involved in the source retrieval received doses well within annual limits for radiation workers.

"RMB has concluded its investigation and consider this event Closed & Complete. No other agencies were informed of this event and no other generic issues identified."

NMED Event ID: 180329
NC Tracking ID: 180029

PART 21 NOTIFICATION - SELECTOR SWITCH SHORTED DUE TO INCORRECT HARDWARE

The following information is summarized and was obtained from Curtiss-Wright via fax:

"Curtiss-Wright was notified by Exelon Calvert Cliffs Plant that a Senasys selector switch P/N 910CMC-5240X (previously provided by Curtiss-Wright under Exelon purchase order 00630804), had failed a post-installation test. Calvert Cliffs sent the suspect switch to Exelon Powerlabs where the failure was found to have been caused by an assembly screw that was 1/8 inch too long, allowing it to cut into the coil of the switch, causing an electrical short. Correspondence between Exelon and the manufacturer determined that an inventory error had occurred.

"According to [Curtiss-Wright] records, only one customer and one plant received these defective switches. Exelon Generation's Calvert Cliffs received 5 switches on Exelon PO number 00630804 Rev. 2. Exelon Calvert Cliffs has been notified of this issue.

"Curtiss Wright's dedication plan will be revised to include a note to ensure no selector switches, for this part number, are manufactured with the November and December 2017 date codes.

"If you have any questions pertaining to this information, please contact Timothy Franchuk, Director of Quality Assurance, at 513-201-2176"

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the state of Colorado via email:

"A tritium exit sign, containing 7.09 Ci, was knocked off wall at the Boulder Rural Fire Dept. and assumed to have been discarded in the dumpster."

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