Event Notification Report for April 13, 2021

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE

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

"On April 1, 2021, at 1647 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 moisture density gauge containing an eight millicurie cesium-137 source and a 40 millicurie americium-241 source had been run over at a field site by a piece of equipment.

"The RSO stated the technician using the gauge stated that the cesium-137 source was in the fully shielded position when the event occurred. The RSO stated the technician was moving his equipment to a new test location at the site when the gauge was damaged. The RSO stated the gauge case was shattered and he was not sure how they would recover the gauge. He stated the gauge was reading 40 millirem per hour on contact near the cesium source. The RSO stated a barrier was establish around the gauge and the dose rate readings at the barrier were at background.

"The Agency advised the RSO to contact the manufacturer and request assistance in recovering the gauge. The RSO contacted the Agency a short time later and reported the manufacturer could not assist in the recovery. The RSO also stated that during his inspection of the gauge they discovered the cesium source was not in the fully shielded position. Also, it appeared that the source rod was no longer attached to the gauge housing. The RSO stated the source rod was bent so they could not retract the source into the shield.

"The licensee decided to recover the source by picking the source rod up from the end opposite of the source using channel locks and placing it in a thirty gallon can half full with sand and then covering the source with sand. The RSO reported the highest dose rate on the container after placing the source in the can and covering it with sand was 0.8 millirem per hour. The RSO contacted the Agency at 1828 CDT on April 1, 2021, and reported that the source was locked in their storage facility. The RSO stated they would work with the manufacturer to dispose of the gauge and sources. The RSO stated the gauge would be leak tested on April 2, 2021. The RSO stated the americium-241 source was not affected by the event. No individual received a significant exposure from the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9835

EN Revision Imported Date: 4/16/2021

EN Revision Text: PATIENT RECEIVES WRONG DOSE

The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:

On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.


* * * RETRACTION ON 4/5/21 AT 1519 EDT FROM BROOK STRAHLE TO BETHANY CECERE * * *

On further evaluation, this event did not meet reportability requirements.

Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by email)

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: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - FAILED SHUTTER HANDLE ON NUCLEAR GAUGE

"On April 5, 2021, the licensee reported that on April 4, 2021, the roll pin in the shutter handle on a Berthold Model 8010 density gauge containing 20 milliCuries of cesium-137 had failed and the shutter handle came off. The gauge had been mounted on a pipe near the well head on a well in La Salle County, Texas. The licensee is authorized to replace the roll pin so one of its trained technicians responded to the site and removed the gauge and repaired the roll pin. The technician found the shutter was closed when he surveyed prior to beginning work. The licensee also reported the technician found that the nuts had backed off of the bolts where the gauge was mounted to the pipe, so the gauge was not snug to the pipe. The licensee contacted Berthold to discuss effects of vibration as it pertains to this event (and potential effect for its other gauges mounted similarly) as well as the corrosion that was observed on roll pin(s). The licensee's determination was that there would not have been any exposures as a result of this event. The licensee will keep the gauge in storage until it can complete an evaluation of the gauge mounting location and the roll pin type for this and its other gauges. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.

"Device/Source Information:
"Berthold Model 8010 SN: 10455
"20 milliCurie cesium-137 source: SN: 0330/12 (Eckert-Zigler Model CS7.P02)"

Texas Incident Number: 9836

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - SEALED SOURCE MISSING IN TRANSIT

The following information was received from the Louisiana Department of Environmental Quality via email:

"A common carrier picked up a black overpack package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 at 1623 CDT on April 1, 2021.

"[The package] left Baton Rouge, LA via common carrier at 2003 CDT and arrived in Memphis, TN at 2319 CDT on April 1, 2021. [The package] was scanned internally at the common carrier's Memphis facility at 0230 CDT on April 2, 2021. That is the last record of this 54 pound package. The [package] destination was Acuren Inspection [located] at 2060 Afton Place in Farmington, NM 87401. (They have not received it.) "

Common Carrier Tracking Number: 9860 8682 9990

LA Incident Tracking Number: LA20210005

Notified: DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).

* * * UPDATE ON 4/7/2021 AT 1612 EDT FROM JAMES PATE TO JEFFREY WHITED * * *

The following is a summary of information received from the Louisiana Department of Environmental Quality via email:

The lost transportation package from QSA Global containing a Delta 880 Industrial Radiography camera (S/N D15673) containing 106 Curies (3922 GBQ) of Ir-192 was delivered to its intended licensee this morning.

Notified: R1DO (Werkheiser), IRMOC (Kennedy), NMSS (Rivera-Capella), INES (Milligan), ILTAB (Roundtree), NMSS Event Notifications (email), DHS SWO, DOE Operations Center, FEMA Operations Center, HHS Operations Center, CISA Central, USDA Operations Center, EPA Emergency Operations Center, FDA Emergency Operations Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), CWMD Watch Desk (email).

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

EN Revision Imported Date: 4/16/2021

EN Revision Text: AUTOMATIC ACTUATION OF GROUP I CONTAINMENT ISOLATION LOGIC

"At 2323 EST on 02/12/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group I containment isolation logic occurred during fluid flushing of turbine stop valves. The reason for the actuation was due to a maintenance activity resulting in turbine stop valve movement with no condenser vacuum which is a Group I isolation signal. Two Group I isolation valves, 2B31F019 and 2B31F020, reactor water sample valves, automatically isolated as designed when the system actuation signal was received. The other Group I valves had already been removed from service as part of the refueling outage schedule.

"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group I containment isolation system.

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

EN Revision Imported Date: 4/16/2021

EN Revision Text: AUTOMATIC ACTUATION OF GROUP 2 CONTAINMENT ISOLATION LOGIC

"At 2320 EST on 02/17/2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Group 2 containment isolation logic occurred on the inboard valves. The reason for the actuation was most likely due to air entrapment in reactor water level sensing lines following maintenance. Group 2 inboard isolation valves in the drywell floor and equipment drain system and the fission product monitor system automatically isolated as designed. As a corrective action, the variable leg and reference leg of the instrumentation were backfilled with water to ensure all air was removed from the line.

"This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the Group 2 containment isolation system.

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