Event Notification Report for March 12, 2021

AGREEMENT STATE REPORT - LOST P-32 SHIPMENT

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

"On February 3, 2021, the University of Iowa received a package from [the common carrier] that was labeled as one of the standing orders of 1 millicurie P-32 dCTP for the Pathology Lab at UIHC [(University of Iowa Health Care)]. The outer label was correct and the packing slip inside was correct, however the contents of the package was actually a prescription of Enbrel intended for an individual in Illinois.
Further, the contents had obviously been repacked. It arrived in a large [common carrier] box, much bigger than required for the P-32 order or the Enbrel. Also, the top of the original package that held the P-32 had been torn off and affixed to the replacement box in an adhesive pouch. The licensee contacted both [the common carrier] and the pharmaceutical company that shipped the Enbrel. [The common carrier] returned to retrieve the Enbrel but haven't heard anything about the location of the original P-32 order. Perkin Elmer sent a replacement shipment of P-32 to the licensee. On February 10, 2021, [the common carrier] sent an email to the licensee notifying them that the original shipment of P-32 has not been located and they were closing the case. On March 4, 2021, the Iowa Department of Public Health contacted the University of Iowa Radiation Safety Officer (RSO) and was informed by the RSO that the original shipment of P-32 is still missing. The activity of the P-32 as of March 4, 2021 is approximately 244 microcuries."

Item Number: IA210001


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

NON-AGREEMENT STATE REPORT - EXTERNALLY CONTAMINATED PACKAGE

The following was received from the Veterans Health Administration (VHA) via E-mail:

"Per 10 CFR 20.1906(d), VHA National Health Physics Program is reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. The package was received Friday, March 5, 2021, at 1032 CST at the Robert J. Dole VA Medical Center in Wichita, Kansas. This facility operates as a satellite location of the VA St. Louis Health Care System which holds permit number 24-00144-05 under the VHA master materials license.

"The package was checked-in and surveyed upon receipt around 1032 CST. Three wipe tests performed on the external surface of the package indicated a removable contamination level that exceeded the regulatory limit of 240 dpm/cm2 for beta-gamma emitters (reported as 13,000 - 45,000 dpm/300 cm2 not corrected for wipe efficiency).

"The package contained two unit doses of F-18. Analysis of the wipe test confirmed a 511 keV peak associated with positron emission tomography (PET) material. Two wipe tests of the interior of the delivery package resulted in levels below background. The patient dosages inside the package were not impacted and were able to be used.

"The dosage was shipped from Cardinal Health out of 410 S. Emporia St., Wichita, Kansas, which was also the delivery carrier. The facility Nuclear Medicine Technologist (NMT) immediately notified the delivery carrier by phone about the contaminated package at 1040 CST. The radiopharmacy notified the facility at 1100 CST that the driver and transport vehicle had been surveyed with no contamination noted.

"This package is the last delivery of the day. Because of the short half-life of F-18, the package will remain on the delivery rack for decay and will be returned to the Radiopharmacy on Monday. The NMT will perform extensive end of the day wipe tests in the hot lab to ensure contamination has not spread.

"VHA National Health Physics Program, who manages the master materials license, was notified of the incident around 1130 CST."

NON-AGREEMENT STATE - DAMAGED SOIL DENSITY GAUGE

The following is a summary from an e-mail received by the licensee:

On March 4, 2021 at 1435 [CST], a tracked earthmover ran over a Humboldt 5001EZ soil density gauge at the main dam of the Sweetwater Mine Tailings Storage Facility. After the accident occurred, the licensee secured the area and had the equipment operator stop and stay outside a fifteen foot diameter area until it was confirmed no contamination was present. The contractor contacted the Facility safety officer and the technician immediately contacted the manufacturer and took steps to assure there was no risk of contamination. The top of the source rod, handle, and index rod were broken off but it was confirmed the remainder of the source rod was intact. The source rod was raised to the safe position with the bottom port shutter shield closed and in-place. Since the source rod locking mechanism was broken, measures were taken to secure the Cesium containing source rod in the safe position. The Americium source cylinder was examined and confirmed to be without damage. The device was placed in its locked travel case. The manufacturer confirmed with these conditions there should be no risk of contamination.

The licensee notified via telephone the NRC Operations Center at 1516 [CST] to provide a verbal report. The licensee also followed up with the NRC Region 3 point of contact. A survey and leak test was performed which confirmed the sources to be shielded and with no loose contamination. The readings obtained were noted to be in compliance with the manufacturer's specifications. The gauge is out of service in locked storage pending shipment to the manufacturer.

NOTIFICATION OF ENVIRONMENTAL REPORT TO ANOTHER GOVERNMENT AGENCY

"On March 10, 2021, Exelon reported an unpermitted release of a radionuclide (i.e., tritium) into the groundwater within the site boundary at Quad Cities Nuclear Power Station to the Illinois Environmental Protection Agency (IEPA) and the Illinois Emergency Management Agency (IEMA) in accordance with Illinois state regulations. There has been no detection of the release beyond the site boundary. The suspected source for the increased groundwater tritium levels is an onsite water storage tank or pipe; however, an investigation is in progress and the exact cause and source is not yet known. The increase in groundwater tritium concentration does not exceed any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency.

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