Event Notification Report for February 21, 2019

MOBILE DIAGNOSTIC TRUCK INVOLVED IN FATAL TRANSPORTATION ACCIDENT

The Avera McKennan Hospital mobile diagnostic truck was in an accident where the truck went off the road, the cab and box detached, and the driver was killed. The truck contained various used sources and medical materials used in nuclear diagnostic medicine. The sources, although ejected from the truck, were found nearby in their respective transport boxes with the exception of the Tc-99 used syringes (sharps). Surveys and wipe tests show no contamination. The sealed sources will be leak checked. The transport box for the Co-60 source was damaged with a small hole. Radiation readings are slightly higher in the proximity of the hole. All the recovered sources are in storage at the hospital. The sharps container was empty with the sharps strewn along the snow bank alongside the road. Residual materials may be within the sharps. Cleanup of the material is underway but may be delayed until the snow melts.

The accident occurred on I-29, north of Sioux Falls, between the Baltic and Dell Rapids exits. The truck was headed north. The South Dakota Highway Patrol responded to the scene.

Notified South Dakota Health Agency, DOT Crisis Management Center, DOE Ops Center, and DHS SWO.

AGREEMENT STATE REPORT - EQUIPMENT FAILURE DURING MEDICAL TREATMENT

The following report was received from the Pennsylvania Bureau of Radiation Protection (PA DEP) via facsimile:

"As a result of a Departmental [PA DEP] inspection the licensee reported an equipment failure event that occurred on February 21, 2019. The equipment was a Varian GammaMed Plus, Serial #641017, containing 6.518 Ci of lr-192. A patient was receiving her last of three fractions of treatment with total treatment time for this fraction being 222.6 seconds divided through a total of eight positions. Twenty-five seconds into treatment the unit issued an inactive source error and retracted the source. The physicist entered the room to confirm that the source was retracted. The manufacturer was called. At the manufacturer's recommendation, the console key was powered off, then back on, and the
remaining treatment was initiated to continue with the untreated area. This time at 25.8 seconds into the treatment the same error occurred. The remaining treatment plan was saved into the planning
computer, and the patient had the applicator removed and was sent home. Varian sent a field service representative who successfully replaced the Geiger-Muller board and functionality was verified. The patient was then rescheduled. The continued treatment on February 25, 2019 accurately reflected the partial treatment and was appropriately scaled to reflect the source decay from the previous treatment. The final portion of the treatment was delivered without incident. There was no harm or overexposure to the patient. The patient was informed at the time. The attending physician has not been notified."

Event Report ID No.: PA190018

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.

IROFS SURVEILLANCE PERIODICITY ERROR

"It was discovered that the calculation which determines the periodicity for performing the IROFSC22 [Item Relied On For Safety] surveillance contains an error. IROFSC22 is a mass balance enrichment control.

"It is unclear if the calculation error causes the surveillance periodicity to fall outside of the minimum time to achieve a safe mass. UUSA [Urenco USA] has since changed the IROFS surveillance to a more frequent periodicity which has been determined to be sufficient.

"Although no event has occurred and the IROFS remain sufficient to meet the performance requirements of 10CFR70.61, as a conservative measure, UUSA is reporting this condition due to the facility being in a state that is different from that analyzed in the Integrated Safety Analysis and in accordance with 10 CFR 70 Appendix A(b)(1)

"The plant is in a safe condition."

The licensee will notify NRC Region 2 (Lopez).

AGREEMENT STATE REPORT - POTENTIAL RADIOGRAPHER OVEREXPOSURE

"The Chief RSO for TechCorr USA, LLC contacted the Radiation Control Bureau of the State of New Mexico after he received a report from Landauer IAC that showed an employee had received in excess of 1000 Rads.

"TechCorr is an industrial radiography company licensed in New Mexico. Based on the activity of the camera, the badge would have had to be exposed for 4 hours to get a dose reading of greater than 1000 Rads. After an interview with the employee, TechCorr has decided to send the employee to the hospital and have a blood sample drawn.

"The film badge of the crew member who worked with the individual with the high film badge reading only showed around 200 mrem dose on his badge.
A more complete investigation will follow"

State Item Number: NM190001

NI-63 SOURCE LOST DURING SHIPMENT

The following was received from the licensee via e-mail:

"On 21 February 2019 the Aberdeen Proving Ground Garrison Radiation Safety Officer (RSO) notified [the Combat Capabilities Development Command Chemical Biological Center RSO] of a lost [commercial carrier shipment] containing multiple Chemical Agent Monitor (CAM) detectors. Shipment, dated November 26, 2018.

"On November 26, 2018, the Garrison RSO shipped a package containing multiple chemical detectors with radioactive sources. One CAM, serial # 11769, containing 10 mCi of Ni-63 which is owned by the Chemical Biological Center under NRC license 19-10306-01, was included in the package.

"The shipment was going to Pine Bluff, Arkansas for final waste disposal.

"The Garrison RSO stated that a search for the packaged had been conducted at two [commercial carrier] locations, one in Maryland and one at the Pine Bluff final destination location with no package being found."

This event is related to NRC Event Number 53884.

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