Event Notification Report for March 23, 2021

EN Revision Imported Date: 3/16/2021

EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSED WORKER

The following was reported by the state of Oklahoma via email:

"Globe X-ray Services, Inc., a radiography company, reported via phone this morning that a technician's dosimeter received a 5.3 rem dose. The dose was reported on the January dosimetry report and the licensee learned about it yesterday.

"The licensee is currently working with Landauer [badge supplier] to have the badge processed further, and is investigating the exposure.

"No additional information is known at this time, we will provide updates as additional information becomes available."

Oklahoma event Number: Not Assigned

* * * UPDATE ON MARCH 15, 2021, FROM ELIZABETH McCASKILL TO THOMAS HERRITY * * *

The following update was received form the state of Oklahoma via email:

"The badge reading was: 5132 mrem DDE, 5192 mrem LDE and 5192 mrem SDE.

"The RSO stated that they believe the Landauer dosimeter received the dose on January 22, 2021.

"The RSO interviewed the radiographer and it is believed that the Landauer dosimeter was in a jacket pocket in the shooting area during exposures.

"The alarming ratemeter and pocket dosimeter readings were not elevated for January 22, 2021.

"The licensee has contacted Landauer and are awaiting imaging results to determine if the exposure was static."

Notified R4DO (Kellar), and NMSS Events Notification via email.

EN Revision Imported Date: 3/16/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE

The following was received via an email from the state of Pennsylvania:

"The Department [PA Bureau of Radiation Protection] received notification from a licensee on March 12, 2021 of medical event involving yttrium-90 TheraSphere [TM]. The licensee believes a patient received only 2 milliCurie of the 63.7 milliCurie prescribed dose. The connection piece between the Therasphere [TM] apparatus and the patient catheter failed when the injection started. All contamination was contained with absorbent pads that were located below the connection. The room, staff and patient were extensively surveyed and not found to be contaminated. The patient and the prescribing physician have been informed. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA210002

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.

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

EN Revision Imported Date: 3/16/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED

The following was received from the state of New York:

"A sealed source (BEST Model 2300) containing iodine -125 with an activity (actual) of 1.79 megabecquerel (48.28 microCurie) on the date of clinical use was implanted into the patient as part of a seed localization procedure on January 8, 2021 and verified by x-ray image as to its location. The patient reported for surgery on January 11, 2021, but the seed could not be located by intra operative radiation probe, portable radiation instrumentation or x-ray. After surveys and discussions with staff and the patient, it is presumed that the seed washed down the drain or removed in household trash while at the patient's home.

"Two scenarios are used to estimate a dose to a member of the public from the lost seed.
"1) Seed washed down the drain evening prior to reporting for surgery. The estimated dose to the public is less than1 millirem.
"2) Seed displaced in home the day prior to reporting for surgery. The estimated deep dose equivalent to an individual from the sealed source based on the activity of the seed before the date of surgery until the date of survey in the residence is approximately 3 mrem. The seed final disposition is presumed removed with household trash.

"Surveys were conducted with the appropriate radiation instrumentation on the patient, in the procedure room, in the implant facility, and at the patient's home.

"Procedures or measures that have been or will be, adopted to ensure against a recurrence of the loss or theft of licensed or registered sources of radiation. Patient education material is updated. Patients instructed to not remove SteriStrip following radioactive seed localization implantation."

New York Event Report ID: NYDOH-21-01

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 DENSITY GAUGES

The following was report received from the state of Texas via email:

"On December 30, 2020, the licensee reported that during an in-depth audit it had been unable to locate two ThermoFisher model 5192 densitometers, each containing 200 milliCuries of cesium-137. The licensee had records showing it possessed them at one of its facilities more than two years ago, but it could neither physically locate them nor find any records showing their disposition. The licensee has continued its investigation but still has not determined the location or disposition of the devices. Serial Numbers for the two devices are B7713 and B7850. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident # I-9831.

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

AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE

The following was received via an email from the state of North Carolina:

"Licensee reported that on March 11, 2021, a medical event occurred where the dose difference [from Iodine 131 is greater than 20 percent from the prescribed dosage]. The prescribed dosage (by written directive) was 949 milliCuries; but the administered dose is estimated at this time to be about 507 milliCuries, which is 53% of the prescribed dose. The cause was a leaking tube from the infusion system. The bone marrow dose needed by the patient was considered sufficient, so there was no negative impact to the patient. An investigation by the North Carolina Radioactive Materials Branch is ongoing at this time.

"The radiopharmaceutical administered was Iomab-B (Iodine-131)."

North Carolina Tracking Number: 210003.

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.

MANUAL REACTOR TRIP DUE TO LOWERING STEAM GENERATOR LEVEL

"At 2216 EDT on 3/21/2021, Calvert Cliffs Unit 2 was manually tripped from 37 percent power due to lowering level in the 21 Steam Generator. All systems responded per design. Main Feedwater was secured and Auxiliary Feedwater was manually initiated. The Site Senior Resident has been notified."

The cause of the lowering level in the 21 Steam Generator is under investigation.

OFFSITE TRANSPORT OF POTENTIALLY CONTAMINATED PERSON

"At 1005 EDT on 3/22/2021, the control room was notified of a personal medical event in the Radiologically Controlled Area.

"An ambulance entered Susquehanna plant property at 1019 and exited at 1028 to transport the individual to a local hospital. Ambulance did not enter the Protected Area.

"The individual was considered potentially contaminated since a complete frisk could not be performed prior to transport. Following transportation to a local hospital, Radiation Protection (RP) technicians confirmed the individual and ambulance were not contaminated.

"This event is reportable under 10CFR50.72(b)(3)(xii).

"An Event of Potential Public Interest (EPPI) was made to the Pennsylvania Emergency Management Agency (PEMA) due to an emergency vehicle accessing plant property."

The NRC Resident Inspector was notified.

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

NON-AGREEMENT STATE REPORT LOST SOURCES IN TRANSIT

The following is a summary of a report received via phone:

On February 25, 2021, the licensee did not receive a shipment of three Cs-137 Brachytherapy sources with an aggregate quantity of 42.9 mCi (activities: 8.8 mCi, 8.7 mCi, and 25.4 mCi). The licensee reached out to the common carrier, who stated that it was still at their Memphis, TN distribution center and delayed due to the ice storm. The licensee has contacted the common carrier a number of times, with the last one taking place on March 18, 2021. The common carrier states they are still looking for the shipment package.


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