Event Notification Report for November 11, 2020

AGREEMENT STATE REPORT - LOST PACKAGE CONTAINING RADIOACTIVE MATERIAL

The following was received via e-mail from the Illinois Emergency Management Agency (the Agency):

"A 6"x6"x6" excepted package containing approximately 86 mCi of Am-241 was reported missing in transit on November 11, 2020 by the licensee. The last known location was Bridgefield, Ohio at the [common carrier] terminal. The [common carrier] is still actively searching. While a reportable quantity under DOT and NRC, this does not represent a serious public exposure hazard. There is no indication of intentional theft or diversion at this time. This quantity of material would not be immediately useful for illicit purposes.

"The Agency was contacted on November 11, 2020, by the radiation safety officer for the licensee to advise that a package scheduled to arrive at their Downers Grove, IL facility on November 10, through November 11, had not arrived. The [common carrier] could not immediately locate the package. The package contained two special form model AMC-25 sealed sources containing approximately 43 mCi of Am-241 each. Source serial numbers were 4429CW and 4475CW. Both sources were contained in a 6"x6"x6" brown cardboard box. As it was an excepted package, it only bears UN2910 and does not have radioactive labels on the exterior. Should the package be opened, there is an aluminum 5"x5" round can filled with foam and two zip lock bags. Each bag contains a shielded source holder with the Am-241 capsules therein. The bags and the can are labeled with a trefoil and the words 'Radioactive Material'. Unshielded, the two sources would yield a combined exposure rate of about 15 mR/hour at one foot. This is not an immediate hazard to workers or members of the public that locate the package.

"The package is assigned tracking number 474-473-809-5 by the [common carrier]. The package left their Buffalo, NY terminal on November 5 after a trailer switch. It was reported as arriving at the common carrier's Bridgefield, OH terminal on November 6, and leaving November 7, on the same trailer. The package was bound for the [common carrier's] Bolingbrook, IL terminal but reportedly never arrived. The [common carrier] is actively searching and Illinois staff are in contact. Ohio Radiation program staff will be notified as well."

* * * UPDATE ON 11/11/2020 AT 2025 EDT FROM DANIEL SAMSON TO BRIAN P. SMITH * * *

The following update regarding the lost package en route from New York to Illinois was received via fax from the New York State Department of Health:

"A shipment of two 45 mCi sources of Am-241/Be was misplaced in transit between Tonawanda, NY and Bolingbrook, IL. The last known location was in Tonawanda, NY. The truck went through PA/OH/IN and arrived without the package in Illinois. More information will be forthcoming as it is discovered."

Notified R1DO (Carfang), R3DO (Cameron), NMSS Events Notification (email), ILTAB (email), CSNC Canada (fax)

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

NOTIFICATION OF STEAM GENERATOR TUBE DEGRADATION

"At 1311 EST on November 11, 2020, it was determined, after evaluation of the Watts Bar Nuclear Plant (WBN) Unit 2 Steam Generator (SG) tube eddy current test data collected during the on-going refueling outage, that the WBN Unit 2 Reactor Coolant System pressure boundary did not meet the performance criteria for SG tube structural integrity. Specifically, SG number 3 failed the condition monitoring assessment for conditional burst probability. WBN has completed tube plugging and additional corrective actions are in progress. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - MEDICAL REPORT - UNDERDOSE

The following was received from the State of Kentucky via email:

"The Kentucky Radiation Health Branch was notified by the Radiation Safety Officer of a medical event at Norton Hospital Interventional Radiology Downtown Campus, Louisville KY (RML No. 202-031-26). Deviation from Y-90 Therasphere treatment dose to a patient was immediately identified due to a leak between the administration kit and the microcatheter used in administration of the dose. The situation was remedied by tightening the connection at the junction, and no further loss of material was observed. Spillage was confined to patient drape and follow-up surveys for external contamination on the patient and staff present were conducted. The room and staff were subsequently cleared of any radioactive contamination. The patient dose assessment was estimated using the patient waste and the spill waste and it was determined that the delivered dose was 93 Gy which was 68 percent of the prescribed dose of 135 Gy. Initial root cause analysis indicated that the administration set received from the manufacturer was a different kit from the previous set, and a mismatch resulted in a leaky junction. The licensee has contacted the manufacturer (Boston Scientific BTG) to resolve this situation."

Kentucky Event Report ID No.: KY200006

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.