Event Notification Report for April 16, 2021

EN Revision Imported Date: 4/19/2021

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: 4/19/2021

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: 4/19/2021

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: 4/19/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED GREATER THAN PRESCRIBED

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

"A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021.

"Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose [that varied by] greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days.

"The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state."


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: 4/19/2021

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."