Event Notification Report for December 03, 2020

EN Revision Imported Date: 12/3/2020

EN Revision Text: AGREEMENT STATE REPORT - GREATER THAN INTENDED DOSE TO LIVER LOBE

The following was received via email from the California Radiation Control Program:

"On October 16, 2020, the [Radiation Safety Officer] RSO of Stanford University emailed [the Radiation Health Branch] RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi). The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi). So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation."

California 5010 Number: 101620


* * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1816 EST ON 12/2/2020 * * *

The following information was received via E-mail:

"The authorized user prescribed 31.57 mCi (1.17GBq) Y-90 to the right lobe of the liver and 13.22 mCi (0.49GBq) to the left lobe of the liver.

"The higher dosage, 31.57 mCi (1.17GBq) Y-90 was delivered to the left lobe of the liver.

"The prescribed dosage of 13.22 mCi (0.49GBq) would result in a dose to the left lobe of 7,000 rad (70Gy), however the delivered dose was 17,500 rad (175 Gy).

"This is 10,500 rad (105 Gy) above the prescribed dose."

Notified R4DO (Gepford) and via E-mail, NMSS (Williams) and the NMSS Events Notification E-mail Group.

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: 12/3/2020

EN Revision Text: IODINE-125 SEED INADVERTENTLY LEFT IN PATIENT

The following is a summary of a call with the licensee:

On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion.

On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork.

An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more.

The patient was informed and no effects are expected.

The licensee will notify the NRC Region 3 Office.


* * * RETRACTION FROM EVAN BOOTE TO DONALD NORWOOD AT 1620 EST ON 12/2/2020 * * *

The following information was received via E-mail:

"Following review of the images and discussion of this case with surgery [personnel], the linear metallic foreign body previously reported as a 'seed' has a high probability of being a vascular surgical clip."

Notified R3DO (Dickson) and NMSS Events Notification E-mail group.

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 - DOSED INCORRECT ORGAN

The following information was received from the state of New York via fax:

"A medical licensee reported on 11/23/2020 that a Y90 microsphere procedure performed on Friday 11/20/2020 was later discovered to have had the catheter connected to the gallbladder instead of the liver as prescribed in the written directive. More information will be forthcoming but preliminary information shows that the microspheres were Sirtex SIR-Spheres."

New York Incident Number: NYDOH-20-07.


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 - STUCK SHUTTER

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

"Marathon Petroleum Company contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on November 24, 2020, concerning a stuck shutter. The fixed gauge is stuck open and determined on November 23, 2020 to be in this condition. The fixed gauge is an Ohmart/Vega Model Number SHGL-2, s/n for housing and source is 9853 CN. The source is Cs-137 with an activity of 5000 mR (185 GBq). There were no radiation exposures. A technician from BBP will be out at the facility on December 1, 2020 for repair."

Louisiana Incident No.: LA20200009

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

AGREEMENT STATE REPORT - LOSS TRITIUM EXIT SIGNS

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

"On November 24, 2020, the Agency was contacted by the radiation safety officer (RSO) of a Texas licensee reporting that two self-luminescent tritium exit signs were not able to be located. The signs are Sealed Source Inc. Isolite signs each containing 7.5 curies (original activity) of tritium manufactured in April of 2015. The RSO stated that the area they were in had some work done and that he believes the signs may have been thrown into construction dumpsters after being replaced. The signs were first discovered missing on November 11, 2020. The RSO has been actively searching for the signs but as of today he has determined that they are no longer at the facility. The RSO stated that he will attempt to determine the final disposition of the construction dumpsters believed to have contained the devices. Additional information will be provided as it is received."


Texas Incident Number: 9814

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

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

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER MALFUNCTION

The following information was received from State of New Jersey via email:

"The licensee reported on 11/24/20 that during a 6-month shutter check, one Cs-137 (50 mCi) fixed gauge shutter was found to be not closing completely. The gauge manufacturer was contacted and came on site to fix the shutter. Leak tests were taken before and after and found to be under 0.005 æCi. More information will be provided by the licensee."

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

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

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the state of Massachusetts via email:

"MA RCP [Radiation Control Program] Officer received notification from the licensee Radiation Safety Officer (RSO) that one of their portable gauges was damaged by construction equipment at a temporary job site of the licensee.

"The portable gauge is a Troxler Electronics Laboratories Model 3400 Series moisture-density gauge containing up to 9 milliCurie of Cesium-137 in one sealed source and up to 44 milliCurie of Americium-241 in another sealed source.

"The RSO reported that they were in route to the site with a survey instrument and that, based on information received by his technician at the site, the damage is expected to be minor. The RSO indicated the portable gauge was in use at the time of the incident. The gauge and rod were pushed into the sand when the damage occurred. The RSO indicated his technician told him the shielding was intact, however, the source and shielding separated from the plastic portion of the gauge. He also indicated the source was able to be retracted into the gauge's shielding. Additionally, RCP dispatched personnel to the site to perform surveys and evaluation of the gauge.

"RCP staff evaluated NRC reporting requirements. Equipment was secured on-site. No loose contamination identified and maximum dose rate was 20 mR per hour at contact on the shielded source holder. No personnel exposure and there was no immediate threat to public health. No additional emergency response was required. RCP personnel assisted in boxing the damaged gauge and the licensee will return the gauge securely to their office and will then arrange for transport back to the manufacturer. RCP will follow up with additional information."

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

VALID ACTUATION OF AN EMERGENCY DIESEL GENERATOR

"At 0923 EST on December 3, 2020, with Unit 1 in Mode 1 at 100 percent power, an actuation of the Emergency AC Electrical Power System (Emergency Diesel Generator 1A) occurred during normal plant operations. The reason for Emergency Diesel Generator 1A auto start was due to Class 1E 4KV Bus 11 feeder breaker opening.

"The Emergency Diesel Generator 1A automatically started as designed when the loss of voltage signal on 4KV Bus 11 was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Emergency AC Electrical Power System.

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

The cause of the 4KV Bus 11 Feeder Breaker opening is unknown at the present time and is under investigation.