Event Notification Report for November 25, 2020

This material event contains a "Less than Cat 3" level of radioactive material.

AGREEMENT STATE REPORT - SOURCE SENT TO RECYCLING CENTER, THEN RECOVERED AND RETURNED

The following was received from the state of North Carolina, Radioactive Materials Branch (RMB):

"Licensee reports that a laminating device containing a Kr-85 source was inadvertently disposed through their recycling service on 10/1 and was discovered missing on 11/4. On 11/5, working with the licensee, RMB was able to trace the disposal of the device to a recycling yard in York, SC. Licensee arranged with an authorized service provider that was able to assess the device for leakage/contamination and arrange for transport to return to vendor. No evidence of leakage or contamination was found, and the device was packaged and removed from the recycling yard on 11/6. South Carolina DHEC [Department of Health and Environmental Control] was made aware of this incident on 11/5.

"Device Manufacturer: INDEV, Model: 015030-2, Serial: 2289-4

"Source Manufacturer: INDEV, Model: 127-2, Isotope: Kr-85, Serial: KV-412, Activity: 500 mCi

"Cause: The licensee identified the cause as human error/process error.

"Corrective Action(s): Re-training of personnel, Methods & Procedure reviews and revising existing procedures."

NC event number: 200022

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

EN Revision Imported Date: 11/24/2020

EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE

"During normal plant start up on Limerick Unit 1, reactor pressure was raised above 200 psig prior to unisolating the Unit 1 high pressure coolant injection system (HPCI) which remained inoperable. Per TS 3.5.1, HPCI is required to be operable in Mode 2 above 200 psig. HPCI has since been restored to operable."

The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN

The following was received from the Iowa Bureau of Radiological Health via email:

"A maintenance technician at the 3M facility in Knoxville, Iowa discovered that a Thermo Fisher Scientific model SULP-77A fixed gauging device containing 661 milliCuries of krypton-85 had a shutter that was stuck open and would not close. This discovery occurred when the production line was shutdown for routine maintenance. The RSO [Radiation Safety Officer] and backup RSO were notified and the gauge was isolated with caution tape to prevent personnel from getting close to the device. 3M maintenance personnel are authorized to perform shutter repair under the supervision of the RSO or backup RSO by Iowa radioactive materials license number 0042-1-63-FG. The licensee will provide a written follow-up report once repairs have been completed and the cause of the failure identified."

Iowa Event Number IA200004

EN Revision Imported Date: 11/24/2020

EN Revision Text: BOTH TRAINS OF MAIN CONTROL ROOM VENTILATION AND AIR CONDITIONING SYSTEMS INOPERABLE

"At 1918 CST on 11/16/2020, it was discovered both required trains of the Main Control Room Ventilation and Air Conditioning systems were simultaneously inoperable. Due to these inoperabilities, the systems were in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v).

"Subsequent post-maintenance testing demonstrated that the Division 1 Main Control Room Ventilation system was available at the time of the event and was restored to operable status at 2036 CST on 11/16/2020.

"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.

EN Revision Imported Date: 11/24/2020

EN Revision Text: DAMAGED SOURCE RACK

The following was received from the licensee via email:

"Nordion personnel initiated cobalt reloading and source racks' cables replacement activities on November 18, 2020. Irradiator source rack No. 1 was emptied in order to proceed with the source rack cable replacement process. When the rack was lifted from the pool, it was noticed that multiple bars (cross taps) had welding points broken or separated from the rack main structure. All of the radioactive materials are kept stored in safe position inside the pool.

"Two Nordion technicians are providing the guidance and recommendations for the damage observed. As an immediate correction, re-welding has been initiated for all broken weldings and non-damage welding points for both source racks bars (cross taps).

"A report will be provided by Nordion personnel describing the findings, immediate corrective action implemented and long-term recommendations."

The licensee notified NRC Region I.