Event Notification Report for October 22, 2020

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.

AGREEMENT STATE REPORT - TC-99M EXTERNAL CONTAMINATION

The following was received from Illinois Emergency Management Agency (the Agency) via email:

"During the afternoon of October 13, 2020, the Agency received a call from the RSO [(Radiation Safety Officer)] at Rush Oak Park Hospital, Inc. (IL-01676-01) to notify the Agency of a potential 24-hr notification requirement from an event which occurred at 0830 CDT, Friday, October 9, 2020. According to the RSO, a Nuclear Medicine Technologist (NMT) was administering a 27 mCi dose of Tc-99m to a patient when the vein "collapsed" which created pressure and sprayed a small quantity of Tc-99m back into the technicians face and eyes. The technician soon thereafter went to the E.R. [(emergency room)] and had her eyes rinsed out. At 1000 the same morning, the RSO met the NMT in the E.R. and took a near contact measurement of her face utilizing a Ludlum model 26 which identified a maximum 6,050 cpm on her forehead. The RSO stated that he could not identify any contamination elsewhere or within the wash water at the E.R. Having no other information, the RSO calculated that in consideration of an approximately 0.23 percent efficiency of the instrument, approximately 1.2 microCi of Tc-99m was on the skin of the NMT. The RSO also stated that he did a few worst case scenario calculations but didn't come close to reportable levels. The Agency concurs with the licensee's determinations. Furthermore, the patient was given most of the dose and still had a normal scan. No contamination was identified on the patient. The used syringe measured 1 mCi remaining following treatment and the accident. The RSO explained that he didn't think it was reportable but following a closer look at 32 IAC 340.1220(c)(3) thought he had better complete his due diligence and give us a call. Inspection and Enforcement supervisor to follow up with the licensee.

"The incident will be entered into NMED [(Nuclear Material Events Database)] and reported to the Headquarters Operations Officer within 24 hours of notification, as required.

"The licensee will be advised of the requirement to submit a written report within 30 days in accordance with 32 IAC 340.1230."

Item Number: IL200019

UPDATE TO ACCEPTANCE CRITERIA FOR ITAAC

"In accordance with 10 CFR 52.99(c)(2) as described in NEI 08-01, Industry Guideline for the ITAAC Closure Process Under 10 CFR Part 52, Vogtle Units 3 and 4 Construction is making this notification to the NRC for determining that Inspections, Tests, Analyses and Acceptance Criteria (ITAAC) 2.3.05.13a.ii (Index No. 344) for Unit 4 requires additional actions to restore the completed status. The ITAAC Closure Notifications for Unit 4 ITAAC 344 was submitted on July 22, 2020 (ML20204B029).

"On October 19, 2020, it was determined that maintenance activities for the Unit 4 Polar Crane auxiliary hoist holding brake used a different approach for Post Work Verification (PWV) than the original test described in the ICN [ITAAC Closure Notification] for ITAAC 344. The alternate PWV used a test method that is standard industry practice and in accordance with ASME B30.2 to demonstrate that the Acceptance Criteria was met.

"An ITAAC Post Closure Notification will be submitted in accordance with 10 CFR 52.99(c)(2) and NEI 08-01.

"The 10 CFR 52.99(c)(4) All lTAAC Complete Notification has not been submitted for VEGP [Vogtle Electric Generating Plant] 4. The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - MISSING DENSITY GAUGE

The following was received from the Colorado Department of Public Health and Environment (CDPHE) via email:

"[A Troxler 3440 (SN 23106) containing not more than 333 MBq (9 mCi) of cesium-137 and 1.63 GBq (44 mCi) of americium-241:beryllium; or 2.44 MBq (66 microCi) of californium-252] was reported missing after a licensee was unable to account for it during a routine inventory check. The material was noticed missing at approximately 1000 MDT on Wednesday, October 14, 2020. The event was reported to the CDPHE at approximately 1700 on October 14, 2020.

"No signs of a burglary at the facility are present. The last entry for the gauge in the utilization log is August 19, 2020. The licensee suspects that a former employee stole the gauge, the employee to last check-out the gauge was terminated on bad terms.

"The licensee is in the process of reporting the theft to the local police."


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 - LOST GAUGES

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

"General licensee, Blues City Brewery, reported the loss of 3 gauges after contractor work that involved the movement of the gauges. Blues City reported the loss. It is possible that the gauges could have made it into the local scrap metal stream. From the scrap metal facility, the load that might have included the gauges went to a shredding facility in Alabama. The State of Alabama Radiation Control has been notified in case gauges are discovered at the shredding facility. The gauge is below:

"Manufacturer Model SN Isotope Activity
"Industrial Dynamics CI-2GV/3 44 Am-241 300 mCi
"Industrial Dynamics CI-2GV/3 46 Am-241 300 mCi
"Industrial Dynamics FT-100 33 Am-241 100 mCi"

TN event number: TN-20-152

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 - UNPLANNED FIRE AND DOSE TO THE PUBLIC

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

"Energy Solutions experienced a fire in the gas furnace 'Drum Drying Operation' of the Liquid Volume Reduction Facility (LVRF) building, which is a sub building off of the Incinerator building located at the 1560 Bear Creek Road, [Oak Ridge, TN] facility. The drums being processed contained Energy Solutions secondary waste with the following listed source term associated with the containers: C-14 (0.5 mCi), Co-60 (2.2 mCi), Cs-137 (0.96 mCi), Fe-55 (2 mCi), H-3 (4 Ci), and Tc-99 (98 mCi).

"Estimated 0.03 mrem dose to the public as a result of the event."

TN event number: TN-20-155