Event Notification Report for January 21, 2021

This material event contains a "Category 3" level of radioactive material.

AGREEMENT STATE REPORT - HDR SOURCE NOT FULLY SECURED IN TRANSPORT PIG

The following information was received from New Jersey Department of Environmental Protection (the Agency) via email:

"On January 11, 2021, the Agency was notified by the licensee that during a vendor source exchange of the center's radiation oncology Iridium-192 remote afterloader source (approximately 5.2 Curies at time of incident), the service engineer, noted the failure of the source to be fully secured in its transport pig bucket. This was discovered because the service technician's personal monitor and the in-room monitor both indicated the presence of radiation. The service technician promptly left the vault, closed the door, notified the physicist on site, and the room was secured from further entry.

"This engineer, another service engineer, the vendor RSO and source recovery team then worked to fully secure the source as per their source exchange procedure. The estimated doses received during the incident are 52.8 mrem and 39.9 mrem to the service engineers involved in securing the source. Their dosimeter readings will be available in the future. No patients or hospital staff were exposed. The vendor will supply the hospital with a full report on the incident, including possible cause."

Equipment/device involved, Isotope and activity, manufacturer, model and serial number, leak test results as applicable: Varian Medical Systems, VariSource ix HDR, serial number VS-321, Ir-192, 5.2 Ci (at time of incident), manufactured by Alpha Omega Services, model VS2000, serial number 02-01-2823-001-101420-11593-17.


New jersey Incident No.: N/A


Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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

EN Revision Imported Date: 1/14/2021

EN Revision Text: AGREEMENT STATE REPORT - TWO MISSING TRITIUM EXIT SIGNS

The following is a summary of a telephone notification from the Nebraska Division of Radioactive Materials (the Department):

The Department was notified by the Church of Jesus Christ Latter Day Saints (church) that they were replacing their Tritium exit signs with LED signs. When the Department compared the inventory lists they identified that two signs were missing from the list. The church is investigating, with the signs identified as missing at this time. The documentation indicates the two missing signs are Isolite brand with serial numbers A391989 and A391995. The original curie content was 11.5 curies of tritium each.

The Department will update this report when they receive more information.


* * * RETRACTION ON 1/13/2021 AT 1652 EST FROM DEB WILSON TO OSSY FONT * * *

The following retraction was received via telephone from the Department:

The two missing tritium exit signs were found.

Notified R4DO (O'Keefe) and NMSS Events Notification and ILTAB 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

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

AGREEMENT STATE REPORT - LOST SOURCE

The following was received from the Georgia Radioactive Materials Program, (the Program) via e-mail:

"The Program received a voicemail on January 11, 2021, from the Radiation Safety Officer (RSO) notifying us of missing radioactive material. The package, containing 500 microCi of P-32, was scheduled for delivery on December 14, 2020 to the licensee. Because of COVID, [common carrier] did not use electronic signatures and just documented that the package was received by the warehouse attendant, specifically by their name. However, the warehouse attendant who monitors incoming packages, stated the package was never received by him.

"The warehouse attendant is trained to stage packages containing radioactive material separate from the other incoming packages and to notify the Radiation Safety Office of the delivery. The licensee has searched through the warehouse in hopes of finding the package but has been unsuccessful. They have also contacted [the common carrier] on several occasions; however [the common carrier] claims the package was delivered. The licensee has informed [the common carrier], to begin again using electronic signatures at the time of delivery. The licensee is within the 30 day reporting requirement and will follow-up with a detailed report within the next day."

Georgia Incident Number: 34

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.

EN Revision Imported Date: 1/13/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN PORTABLE GAUGE

The following was received from the Arkansas Department of Health (the Department) via email:

"The Department received notification on January 12, 2021, from licensee Mid-Continent Laboratories, Inc., that a Troxler gauge model 3411-B [(S/N: 4794; Activity: Am-241 (44 mCi); Cs-137(9 mCi))] had been stolen from a licensee while at his residence.

"Upon review of the event, the Authorized User checked the portable gauge out of its permanent storage location at approximately 0600 CST to travel to Colorado for work. Before leaving, the Authorized User returned to his place of residence. While at his residence the chains securing the gauge to the truck were cut and the portable gauge was stolen from the vehicle.

"This event has been reported to Law Enforcement, in addition, Arkansas Department of Health inspectors are currently working with the Tennessee Department of Environment and Conservation, Division of Radiological Health, to investigate and report. [West Memphis, AR is on the border with Tennessee.] Arkansas Department of Health will be issuing a Press Release.

"The Arkansas Department of Health considers this investigation open pending receipt and review of any further information that may become available."

Arkansas Event Report ID No.: AR-2021-001

* * * UPDATE ON 01/13/2021 AT 1401 EST FROM CHRIS TALLEY TO OSSY FONT * * *

The following update was received from the Department via email:

"The Authorized User was allowed to store the gauge overnight in his vehicle at his place of residence. The theft occurred between 2130 CST, January 11, 2021 and 0730 CST, January 12, 2021. The Authorized User noticed the disappearance of the gauge while leaving his residence to go to work."

Notified R4DO (O'Keefe) and NMSS Events Notification and ILTAB 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

EN Revision Imported Date: 1/20/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - SHUTTER NOT FUNCTIONING CORRECTLY

The following is a summary of a call received from the licensee:

During routine maintenance, an inspector from Radiometric Services and Instruments found that the shutter for an AMC-19 gauge, s/n: 998110B, with a 100 microCi AM-241 source, would close slowly. This was not as expected. The inspector noted that the pneumatic system was over pressurized. The gauge is located on the Continuous Galvanizing Line and the shutter is open during normal operations.

The shutter can still be closed and a Geiger counter can be used to verify. There was no exposure to personnel.

* * * UPDATE ON 1/19/2021 AT 1731 EST FROM ROBIN BIRK TO JOANNA BRIDGE * * *

The following is a summary of a call and e-mail received from the licensee:

While testing the shutter today we were experiencing some continuing problems with the shutter mechanism at our Continuous Galvanizing Line. During maintenance, we discovered some error codes in the RSI software that indicated possible additional shutter problems. There was no potential for employee exposures. RSI will be back at the plant to address on 1/20/21.

Notified R3DO (Peterson) and NMSS Events (e-mail).

AGREEMENT STATE REPORT - UNDERDOSE OF GREATER THAN 20 PERCENT

The following was received from Massachusetts Radiation Control Program via email:

"The licensee reported by telephone on January 12, 2021 that it discovered on January 11, 2021 a radiopharmaceutical medical event involving the therapeutic administration of iodine-131 for treatment of thyroid cancer.

"The licensee reported that the administered dose was an underdose of greater than 20 percent and was a difference of greater than 50 rem to an organ, the thyroid, when compared with the prescribed dose, meeting the reporting requirements 105 CMR 120.594(A)(1)(a).

"One iodine-131 capsule instead of two iodine-131 capsules were administered. The prescribed total activity was 100 milliCuries and the administered total activity was 19.5 milliCuries. The second iodine-131 capsule that was not administered was accounted for and contained in its original glass vial.

"The licensee reported that the referring physician and the patient has been notified.

"The licensee reported that its staff had discussed the medical event and put into place competencies to prevent future recurrence and that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(A)(4).

"The Agency considers this event to be open."


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 - LEAKING SOURCE

The following was received from the Alabama Department of Public Health via email:

"On 1/13/2021, registrant Pace Analytical Services reported that a 15 mCi Ni-63 source (model: 82397-65506; s/n: U25815) in an ECD [(electron capture detector)] device (Agilent 7890B; s/n: CN14453150) was reported to be leaking with a routine wipe test. The device was transferred to Pace Analytical in Ormond Beach, Florida on or around 10/29/2020. The registrant reported that the device is currently with Agilent awaiting disposal."

Alabama Event: 21-02

AUTOMATIC REACTOR TRIP DUE TO TRIP OF MOTOR CONTROL CENTER

"On 1/20/2021 at 1822 EST, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a loss of Motor Control Center 2B2. The trip was uncomplicated with all systems responding normally post trip. Operations stabilized the plant in Mode 3. Auxiliary feed-water automatically actuated on the 2A Steam Generator post trip. Current decay heat removal is the 2B main feedwater pump to both steam generators and the Steam Bypass Control System to the main condenser.

"Unit 1 is not affected.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B).

"The NRC Resident Inspector has been notified."