Event Notification Report for April 15, 2021

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT (INCORRECT DOSE LOCATION)

The following report was received from the state of North Dakota Department of Environmental Quality via email:

"Received a phone call at 1600 [CST] on Thursday March 18 that a PET/CT patient was injected with 10 milliCuries of Fluorine-18 and it was found that all of the injected Fluorine-18 had infiltrated in the arm of the patient [rather than being dispersed throughout the body]. Patient's arm was imaged by PET scanner to confirm dose was in fact infiltrated in the arm. Dose calculations are being performed by licensee to determine the dose to the patient's skin. "

ND NMED Event # ND210001

* * * RETRACTION ON 14 APRIL 2021 AT 1522 EDT FROM BROOKE OLSON TO JOANNA BRIDGE * * *
The following is a summary of a phone conversation with Brooke Olson from the North Dakota Department of Environmental Quality:

After calculations were performed, it was determined that the event did not meet the reporting requirements of a medical event and is being retracted.

Notified: R4DO (Pick) and NMSS (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 SATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was contacted on 4/6/21 by the Radiation Safety Officer (RSO) for Howell Asphalt Company to report a damaged Troxler Gauge. The incident occurred at approximately 1500 CDT at a temporary job site on Locust Street in Centralia, IL.

"The RSO for Howell Asphalt Company called to report that a Troxler 3440 gauge was run over by a vehicle and was stuck under a car. Reportedly, the driver of the vehicle dismissed the barriers and entered the construction zone. Emergency response personnel arrived on site to isolate and assist in moving the vehicle off the gauge. At the time of the accident, the gauge was in use for backscatter measurements and therefore, all sources were in the shielded position. The RSO responded to the site and reported that both the Cs-137 and the Am-241 sources appeared to be shielded and that only the gauge housing was damaged.

"At 1555 CDT, the RSO called to provide an update. The RSO reported that both sources were undamaged and had been retrieved. The RSO has secured the gauge and is returning it to the Effingham office for disposal through Troxler. The gauge will be transported in its Troxler case which was undamaged. Source and gauge serial numbers are pending and the report will be updated once available. Agency staff will continue to track this matter pending receipt of leak tests and confirmation of disposal"

Illinois Incident Number: IL210007

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On April 7, 2021, the licensee reported that a significant amount of Y-90 Theraspheres leaked out of the connection between the tubing and the catheter during a therapeutic procedure in which 24 mCi (a prescribed dose of 200 Gy) was to be delivered to the liver. The liquid was observed dripping out of the connection between the patient catheter and tubing onto the towels and drapings. The dose to skin of patient and worker cleaning up is not known because of the apparently large amount of contaminated towels and such. The [Radiation Safety Officer] RSO will attempt to address this and the cause in the coming days as the activity decreases. The RSO reports that both the patient and patient's physician were notified within 24 hours. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I-9837

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 - STUCK GAUGE SHUTTER

The following was received from the New Hampshire Radiological Health Section via email:

"[In January 2017], during routine maintenance of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close by ordinary means. A manual shutter handle within the actuation assembly was used to attempt to close the shutter, but the linkage was binding and causing the shutter to remain open. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure resulted.

"The cause was determined by the service technician as a binding solenoid spool. The spool bushing was reamed out and the shutter linkage was lubricated, which allowed the solenoid spool to resume moving freely as designed."

Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage

The New Hampshire Radiological Health Section considers this event closed.

Report ID #: #NH17-0003

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS

The following was received from the New Hampshire Radiological Health Section via email:

"[In April 2017], a generally-licensed static eliminator was lost during a routine replacement of a series of 30 static eliminators. The devices are leased from NRD Corporation and are affixed to assembly line machines. Annually, they are removed from service and returned to NRD Corporation. The missing device was last in use during a production run on 3/10/17 between 1500 EDT and 2400 EDT. Device exchange occurred during the 2nd shift after the line was shut down. The missing device was noticed during the subsequent 1st shift when supervision performed accountability. A facility search and employee interviews were conducted. Roll-off containers servicing the 'household' and 'recyclables' waste streams were searched without success, likely because the roll-offs contained a significant amount of waste that impeded the search for the relatively small device. The device was still missing after 30 days. The licensee concluded the device was inadvertently disposed in the 'household' waste stream, which is taken to a waste-to-energy incinerator."

Device Details: Polonium-210, 10 mCi (0.37 GBq); NRD Corporation, Model P-2021-8000 static eliminator, s/n A2KN339

The New Hampshire Radiological Health Section considers this event closed.

Report ID #: #NH17-0004

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: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received from the New Hampshire Radiological Health Section via email:

"[In January 2018], during routine semi-annual leak testing of a generally licensed fill-level gauge, it was discovered that the gauge shutter would not close completely by ordinary means and the red 'Source ON' status indicator lamp remained continuously lit. A manual shutter handle within the actuation assembly was used to close the shutter. While doing so, a green wire was noted as brushing against the shutter linkage and impeding its operation. The gauge was already out of service for maintenance, and remained so until the shutter mechanism was repaired. No personnel exposure.

"The cause was determined by the service technician as a wire interfering with the path of the shutter linkage, preventing full closer of the shutter. The wire was moved out of the way, allowing the shutter to move along its full path as designed."

Gauge Details: Americium-241, 300mCi (11.1 GBq) sealed source; Industrial Dynamics Model 19567; s/n 156LX; no detectable leakage

The New Hampshire Radiological Health Section considers this event closed.

Report ID #: #NH18-0001

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - REMOVABLE CONTAMINATION EXCEEDS LIMITS

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

"NSSI of Houston, Texas violated 49 CFR 173.443(b) and will be suspended from further shipments. Contamination was found on shipment packages. No contamination was found outside of the conveyance. No staff were contaminated, or internal dose assigned. WA State licensee corrected the shipment to allow the conveyance to proceed. NSSI's shipping privileges may be reinstated upon submittal of a root case analysis to the department and a successful point-of-origin inspection performed by the department.

"On February 24, 2021 NSSI/Recovery Services, Inc. of Houston Texas shipped 38 drums containing liquid tritium, LSA II, Exclusive Use, closed conveyance. Twenty-one drums were destined for Perma-Fix Northwest (PFNW) in Richland Washington for processing, and the additional 17 drums were to proceed to Perma-Fix DSSI, in Kingston, Tennessee.

"The truck arrived at PFNW on March 1, 2021. PFNW received and offloaded 21 of the drums. Prior to releasing the truck to continue to DSSI, PFNW conducted surveys of the truck and trailer. On March 3, 2021 the PFNW Radiation Safety Officer notified the WA State Department of Health (Department) that tritium contamination was found inside the trailer (survey results were not provided). PFNW did not find contamination outside of the trailer. PFNW notified and surveyed the driver; no contamination was found on the driver.

"After discussions with PFNW, it was determined that PFNW would ensure that the shipment was in compliance by offloading the 17 drums in order to inspect, decontaminate and, if necessary, over-pack the 17 drums prior to putting the conveyance on the road [to Kingston, TN] . PFNW offloaded, inspected, and overpacked the 17 drums, then loaded them on a new trailer. PFNW stated that the bungs on a few on the drums required tightening. The shipment was received at DSSI in Tennessee without incident.

"The Department requested survey results. After receipt and review of the survey results, the Department determined that 6 of the drums destined for DSSI, 1 drum offloaded at PFNW, and areas of the trailer floorboards were in excess of DOT's external contamination limits, 49 CFR 173.443(b). Results ranged from 2,902 - 973,124 [disintegrations per minute per square centimeter] (dpm/cm^2) (taking in account the 10 percent wipe efficiency); the 49 CFR 173.443(b) contamination limit is 2,400 dpm/cm^2 at any time during transit of an exclusive-use shipment. The contaminated trailer is currently at PFNW where the contaminated floorboards will be removed and disposed. Bioassays of the four participating PFNW staff were performed; no PFNW staff were assigned internal dose or were contaminated.

"NSSI violated 49 CFR 173.443(b), and will be suspended from further shipments to PFNW. Suspension tracked under WMS-DOT-21-01"

Washington Incident No.: WMS-INC-21-01

EN Revision Imported Date: 4/16/2021

EN Revision Text: LOST THEN FOUND SOURCE MATERIAL

The following is a summary of information received from the U.S. Navy via phone and email:

On March 5, 2021, the it was discovered that IBIS units (400 micro Ci total) had not been properly removed from 4 helicopter blades that were sent for recycling. The IBIS units were discovered when the detectors alarmed at the recycling facility in Bedford, IN. The blades were redirected to the Army Joint Munitions Command Morris Consolidation facility in Rock Island, IL for proper disposal.

Based on the shipping paperwork, the helicopter blades that contained the four IBIS were received at the recycling facility on 11/17/2020, and were picked up from the facility on 3/16/2021.

The highest reading was 0.7 mR/hr on contact without the cover installed for one blade. For the 3 other blades in their casing, needle deflection was observed, but had no appreciable dose rate.

It is not likely that personnel spent an appreciable amount of time in the vicinity of the helicopter blades.

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: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - SOURCE LOST DURING SHIPMENT

The follow was received from the Wisconsin Department of Health Services (Wisconsin DHS) via email:

"On April 8, 2021, the licensee's [Radiation Safety Officer] RSO reported a missing QSA global model 880 D exposure device containing a 28.9 Ci selenium-75 source. The package was shipped Monday April 5, 2021 via [the common carrier] from Neenah, WI to another Acuren location in Kingsport, TN. The package was shipped `overnight' with the intent to be delivered on Tuesday April 6, 2021. The package was reported delayed by [the common carrier] at Memphis, TN facility during the week. Then package arrived on Thursday April 8, 2021, damaged and without the shipped contents. Package weight information gathered as [the common carrier] handled the packaged indicates that the package contents were separated before final delivery, the exact location is unknown at the time of this report.

"The licensee is in contact with [the common carrier] and device manufacture QSA to locate the device and source. Wisconsin DHS will monitor efforts to locate the device and coordinated with other jurisdictions as necessary."

Event Report No.: WI210002

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

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

EN Revision Imported Date: 4/16/2021

EN Revision Text: INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

"This 60-day optional telephone notification is being made in lieu of an LER submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 1507 EDT on February 17, 2021, during performance of isolation logic periodic testing associated with Primary Containment Isolation System Groups 2 and 6, an invalid actuation of Group 6 Primary Containment Isolation Valves (PCIVs) (i.e., Containment Atmospheric Control/Monitoring and Post Accident Sampling isolation valves) occurred. The Group 6 isolation signal resulted from the reactor building ventilation radiation monitor `B' Channel exceeding the setpoint value. This condition likely resulted from the radiation monitor electronics being impacted by humidity levels, which exceeded the instrument design requirements that developed in the area over time as a result of the Unit 2 reactor building ventilation being secured per the test procedure. The `A' Channel, located in the same plenum, remained steady and below the setpoint value through the entire event. This, along with readings made by a Radiation Protection Technician, confirmed that there was no actual high radiation condition in the reactor building exhaust. Upon returning Unit 2 reactor building ventilation to service, the `B' Channel readings returned to be consistent with the `A' Channel.

"The PCIVs functioned successfully and the actuation was complete. The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.

"This event did not result in any adverse impact to the health and safety of the public.

"The NRC Resident Inspector was notified."