Event Notification Report for October 20, 2020

AGREEMENT STATE REPORT - A NON-LICENSED INDIVIDUAL PARTICIPATED IN MEDICAL TREATMENT

The following event was received from the Florida Bureau of Radiation Control (BRC, ERCM) via email:

"The incident was reported by [the medical physicist (MP)], who is standing in for local physics administrator who is on vacation. A 50 year old female was being treated with Ir-192 High Dose Rate (HDR). The Authorized Radiation Therapist and Physician were in the room along with [an acting MP with a] temporary license TMP-1. The supervising MP was remote. The supervising MP told the facility that the acting MP was on the license as an AMP [(Authorized MP)], which is why the AMP was in the room. The AMP was actually not on the license. After treatment was complete, the error about the AMP not being on the license was discovered, and the report to the Florida BRC was made. The treatment plan was confirmed before treatment by the AMP. Treatment was delivered as prescribed. Per ERCM: The AMP's license is null and void and TMP-1 is expired."

Florida Incident Number: FL20-116.

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

AGREEMENT STATE REPORT - LOST THEN FOUND MOISTURE / DENSITY GAUGE

The following is a synopsis of information received via phone and facsimile:

The Department (Nebraska Department of Health and Human Services, Office of Radiological Health) was notified around 0815 CDT on October 9, 2020, by the Nebraska State Patrol, of a lost, and subsequently recovered, nuclear gauge. The gauge was a Troxler 3400 series moisture density gauge containing a 9 mCi Cs-137 source and a 44 mCi Am-241/Be source.

During the afternoon of October 8, 2020, the gauge was on the tailgate of a pickup truck. The gauge user entered the vehicle before securing the gauge package. The user was distracted and began driving away. The gauge fell out of the back of the vehicle. An employee from the Nebraska Department of Transportation (NDOT) found the lost gauge near Norfolk, NE. The NDOT employee notified the Nebraska State Patrol and the gauge manufacturer, Troxler. Using the serial number of the gauge, Troxler was able to determine the gauge belonged to Olsson Associates. Olsson Associates was notified of the recovered gauge, and the gauge user retrieved the gauge. The estimated time between the loss of control and recovery is estimated to be one hour.

During the evening of October 8, 2020, the corporate Radiation Safety Officer (RSO) for Olsson Associates was notified of the incident. He did not report the event to the Department. A representative of the Department spoke with him at 1030 CDT on October 9, 2020. The RSO then provided a brief account of the incident to the Department representative.

The RSO noted that the gauge package appeared to be undamaged. The gauge itself did not appear damaged. The gauge was surveyed to confirm the presence of the source, and a leak test will be performed immediately.


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

AGREEMENT STATE REPORT - MISSING IODINE-125 SEED

The following information was received via facsimile:

"On April 29, 2020, the Department [New York State Department of Health, Bureau of Environmental Radiation Protection] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 220 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.

"In this incident, two seeds were placed into a patient on 4/10/2020 and removed on 4/14/2020. One of the two seeds was lost by the attending surgeon. An extensive survey of the patient was performed to verify that the seed was not in the patient and the Nuclear Medicine Department was notified. A survey of the operating room (OR) suite was conducted and the seed was not recovered. The Radiation Safety Office was notified, another survey of the OR was performed, again the seed was not recovered. The patient also had a lymphoscintigraphy with Tc-99m so the surgical trash that was still in the room was sequestered. After three days, the trash was surveyed and examined but the seed was not recovered.

"Searches and surveys were performed in surgery, pathology, radiation safety and environmental service areas. Trash and regulated medical waste were also surveyed and inspected.

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

New York State Event Report ID No.: NYDOH - 20-05

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

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA STUCK HAND-CRANK ASSEMBLY

The following information was received via E-mail:

"ND Testing Inc. made a 24-hour report to the Radiologic Health Branch that on October 8, 2020, at 1256 PDT a hand-crank assembly became stuck/seized and would not allow the source to travel forward or backwards at a temporary job site. The team of two experienced radiographers contacted their Radiation Safety Officer (RSO) for assistance and secured the area around their QSA Global 880 exposure device.

"The RSO arrived onsite at 1445 EDT with extra lead shielding and survey meters. He and the radiographers were able to place lead blankets and some solid lead blocks over the guidetube containing the Ir-192 source, open the crank assembly to remove some metal shavings and close the assembly. This allowed them to secure the Ir-192 source after approximately 2 hours at 1645 EDT. The highest individual dose received was 195 mrem by one of the radiographers.

"The Ir-192 source was a QSA Global model A424-9, with an activity of 67.1 Ci of Ir-192."

California 5010 Number: 100920

EN Revision Imported Date : 10/14/2020

EN Revision Text: AGREEMENT STATE REPORT - LOST MOISTURE DENSITY GAUGE

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On October 12, 2020, the licensee notified the Agency that on October 10, 2020, one of its technicians completed a job at a temporary job site in Dallas, Texas, and drove to another temporary job site in Venus, Texas. Upon arriving, the technician found he did not have the Humboldt 5001 EZ moisture/density gauge in his truck. The gauge contained an 8 milliCurie cesium-137 and a 40 milliCurie americium-241/beryllium source. The technician believed he left the gauge at the Dallas site so he drove back to that site. The gauge was not there. The technician called his supervisor but never made contact. The technician called the company office and left a voicemail about the incident which was retrieved this morning. The licensee is notifying local law enforcement, contacting area pawn shops, and conducting its investigation. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9806

* * * UPDATE ON 10/13/2020 AT 1414 EDT FROM KAREN BLANCHARD TO OSSY FONT * * *

The following update was received from the Agency via email:

"The location where the event occurred is a temporary job site in the 7400 block of Hillcrest Road in Frisco, Texas. The gauge, a Humboldt 5001 EZ, contains 10 milliCuries of cesium-137 (not 8) and 40 milliCuries of americium-241/beryllium. The insertion rod was locked. The licensee has made a report to the Frisco police department. The licensee has thoroughly searched the construction site a second time and will be checking businesses around the site for possible video surveillance that may provide information. The Agency has informed the Frisco fire department/emergency management coordinator. Further information will be provided as it is obtained in accordance with SA-300."

Notified R4DO (Azua) and NMSS Events Notification, ILTAB, and CNSNS (Mexico) via 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

CONTROL ROOM ENVELOPE INOPERABLE

"On October 18, 2020 at 2313 CDT, Arkansas Nuclear One (ANO) discovered that 2VRA-1B (2VSF-9 outside air damper reserve bottle) was below 600 psig. This condition caused the control room envelope to be inoperable in accordance with OP-2104.007 Attachment L. ANO Unit 1 entered TS 3.7.9 Condition B for inoperable control room boundary. ANO Unit 2 entered TS 3.7.6.1 Action D for inoperable control room boundary. A procedurally controlled temporary modification was implemented to install a blank flange on the 2VSF-9 outside air damper. Both Units declared the control room boundary operable at 2358 CDT. The associated control room emergency recirculation fan remains inoperable with the blank flange installed. This is a 7-day shutdown-LCO for both units.

"The licensee informed the NRC Resident Inspector."

NON-AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

The following is a summary from a phone call with the licensee:

A patient at the Indiana University Health Methodist Hospital was prescribed 46.7 mCi of Y-90 Theraspheres to segments 5 and 8 of the liver, but received 54 percent (25.2 mCi) of the prescribed dose. The remaining 46 percent (21.5 mCi) was trapped in the catheter or the line. The patient and the physician were notified and a follow-up treatment has been scheduled for next week.


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.

MAXIMUM LICENSED POWER LEVEL EXCEEDED

"During the course of operations, a potential error in the power calibration of the PUR-1, License Number R-87, was discovered. This calibration error would result in a special report requirement as specified in [(Technical Specification)] TS 6.7.b.1.c.vi, which is that an observed inadequacy in the implementation of a procedural control such that this inadequacy could have caused the development of an unsafe condition with regards to reactor operations. By extension the miscalibration caused a true reactor power higher than the measured reactor power. As such, this likely resulted in the operation in violation of the limiting condition for operation as established in TS Section 3 Table I and operation with an actual safety system setting for a required system less conservative than the limiting safety system settings specified in the Technical Specifications. These reporting requirements are Part i. and ii. of TS 6.7.b.1.c. The calibration error implicates a violation of the maximum licensed power level of 12 kW. The Safety Limit was not exceeded at any point."

THERMAL EVENT RESULTING IN LOSS OF INTEGRITY OF LICENSED CONTAINER

At 1000 EDT on October 20, 2020, a thermal event occurred inside a hot cell at the Curium facility in Noblesville, Indiana. The thermal event did not result in a chemical or radioactive material release. Prior to the incident, technicians were processing materials containing strontium 82 and 85 (quantities are unknown at this time). The pressure created by the reaction caused the rear door of the hot cell to open approximately eight inches and was immediately shut by the technicians. There is no contamination outside of the hot cell and there were no injured or contaminated personnel. The vessel containing the strontium material was observed to be intact and the resultant fire was extinguished by the hot cell's suppression system. No offsite fire assistance was required. Personnel have not accessed the hot cell due to elevated dose rates. Dose rates outside of the hot cell are within the facility's normal limits and historical averages.