Event Notification Report for March 31, 2020

TECHNICAL SPECIFICATION NON-COMPLIANCE

The following is a summary of information received from the University of Utah Reactor Facility via email:

At 1217 MDT, on 3/31/2020, during a test of reactor systems, operators discovered that the safety control rod would not drop as expected after magnet power was secured. The safety control rod was manually driven from the 100 percent to 98 percent withdraw position, where it then dropped on its own to the fully inserted position. The reactor was shutdown during safety control rod testing, with the shim and regulating rod fully inserted. As a result, the licensee was not in compliance with Technical Specification 3.2.1.2, which requires the scram time to not exceed two seconds. The reactor will remain shutdown until the rod is inspected and repaired.

The licensee notified the NRR Project Manager (Yin).

NOTIFICATION OF A NON-EMERGENCY UNUSUAL EVENT DUE TO A SEISMIC EVENT

The following is a summary of information received from the Washington State University Reactor Facility via phone conversation:

At 1655 PDT on March 31, 2020, the licensee declared a Notification of Unusual Event due to seismic activity felt from an earthquake originating in southern Idaho. Operators felt the seismic activity and entered their emergency planning procedures to inspect for any damages to the reactor facility. There were no injured personnel and the reactor was shutdown at the time of the earthquake. Initial assessments revealed no damages or effects to the reactor or to the facility. Additional walk downs are in progress.

The licensee notified the NRR Project Manager (Hardesty).

NOTIFICATION OF A NON-EMERGENCY UNUSUAL EVENT DUE TO A SEISMIC EVENT

The following is a summary of information received from the Idaho State University Reactor Facility via phone conversation:

At 1750 MDT on March 31, 2020, the licensee declared a Notification of Unusual Event due to seismic activity felt from an earthquake originating in southern Idaho. The facility was closed due to the suspension of all campus activities set forth by the pandemic response. The reactor was shutdown at the time of the earthquake and is being constantly monitored by the campus public safety office. Inspections of the facility will be performed.

The licensee notified the NRR Project Manager (Yin).

* * * UPDATE ON 4/3/20 AT 1532 EDT FROM MARY LOU DUNZIK-GOUGAR TO ANDREW WAUGH * * *

The licensee has finished conducting visual inspections and monitoring activity levels throughout the facility. All indications came back normal. The licensee also verified the seismic indicator was still in its proper position.

Notified NRR PM (Yin) and NPR (Reed).

AGREEMENT STATE REPORT - LOSS OF IODINE-125 SEED

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

"An Iodine-125 seed [assayed at 69 microCuries on March 24, 2020 (Best Model 10172-11, Double wall titanium encapsulated, Serial Number: 49802A20)] used for breast lesion localization was shipped within a tissue specimen from Piedmont Fayette Hospital to Piedmont Atlanta and then lost into the ordinary solid waste stream, rather than being recovered and placed in decay-in-storage at Piedmont Fayette, as is the standard procedure.

"The seed was implanted in a patient with a breast lesion at Piedmont Fayette on March 24, 2020. The lesion containing the seed was successfully removed in surgery and sent to the pathology lab on March 30, 2020. The presence of the seed in the specimen was verified in pathology by Neoprobe measurement. There was no pathology physician assistant present that day and the pathologist was not notified. A lab staff member arranged for all specimens to be shipped to Piedmont Atlanta. The specimens, including the one containing the seed, were shipped by MedSpeed courier service that same day. At the Atlanta campus, the specimen with the seed was processed by the normal procedure on April 1, 2020. The histotechnologist there removed what he thought was a marker or a clip and discarded it in the regular waste bin. The waste containing the seed was removed from the Atlanta campus [in a bag of solid waste] and transported to the [Pine Ridge Regional Landfill] by the waste disposal company's normal procedure on or around April 2, 2020.

"[The Radiation Safety Officer (RSO)] was notified by phone on April 3, 2020 and searches of all relevant areas at Piedmont Atlanta were performed by staff using a GM survey meter with pancake probe as well as with a Sodium Iodide scintillator probe that day. No evidence of radiation or the seed was found in any location.

"The proper course of action that should have been taken in order to prevent this situation is as follows: The pathologist at Fayette should have been notified that there was a specimen with a radioactive seed. The pathologist would have removed the seed and the pathology staff would have contacted Nuclear Medicine to retrieve the seed and place it in decay-in-storage. Seeds should not leave the Fayette Campus.

"In [the RSO's] estimation, it is unlikely that any occupationally exposed worker or member of the public received any significant exposure or exceeded any dose limit.

"All staff in pathology have been educated on the circumstances that led to this incident. The procedure has been updated to clarify what actions should be taken if a specimen with a seed arrives in pathology when no pathology physician assistant is present. Knowledge of this procedure has been added to the competency checklist for pathology employees."

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