Event Notification Report for May 06, 2021

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

EN Revision Imported Date: 5/6/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The State of Colorado reported that a Tritium exit sign at the Centura Health-Saint Francis Health Services, which was not able to be located during a change of ownership in June 2020, has been declared lost. The sign contains 10 Ci of Tritium.

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: 5/6/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE UNABLE TO RETRACT

The following was received via e-mail from the Rhode Island Dept. of Health, Radiation Control Agency:

"A licensee, Electric Boat Corporation, reported the inability to retract a 1.62 TBq (43.8 Ci) Co-60 source (QSA Global, Inc. Model A424-14, S/N 81346G) into the radiography exposure device (QSA Global, Inc. Model Sentry 330, S/N P30106) on March 7, 2021, at Electric Boat's Quonset Point Facility. At approximately 0120 [EDT], the [source] was [extended] without any issue.

"At the completion of the exposure, the radiographer attempted to retract the source into the exposure device, and attempted to re-expose the source to verify that the auto-locking mechanism on the Sentry 330 exposure device had engaged. At this time, the radiographer noted that the auto-lock did not engage and that dose rates indicated by his ND-2000A survey instrument at the reel (remote control) remained at approximately 10 mrem/hr. The radiographer then attempted to expose and retract the source to engage the locking mechanism 2 additional times without success.

"At approximately 0156 [EDT], the RSO [(Radiation Safety Officer)] was notified of the inability to retract a Cobalt-60 source into its exposure device. The RSO was able to observe the set up with an inspection mirror from the opposite side of the large part being inspected and determined that the guide tube had become disconnected from the collimator, exposing 10-12 feet of drive cable on the deck, and the source pigtail had become stuck in the collimator.

"After creating and briefing retrieval and contingency plans, source retrieval evolution began at 0640 [EDT]. The RSO Delegate secured the source pigtail in the collimator with a 6 ft long remote handling tool to prevent the source from leaving the collimator prematurely while the RSO stepped out from behind the lead shield with another 6 ft long remote handling tool to move the guide tube from the deck back up to the collimator. While the RSO was straightening out the guide tube and drive cable, a radiography supervisor was slowly retracting the drive cable at the reel to remove the 10-12 ft of drive cable slack on the deck while the RSO communicated via radio. Once the drive cable slack was removed and the RSO guided the guide tube back up to the collimator and tension on the source pigtail was released, the RSO Delegate released control of the source and it was immediately retracted by the radiography supervisor into the exposure device. The source was confirmed to be secured in its device by survey, and the evolution was declared secure at 0649 [EDT].

"RI Radiation Control Agency has investigated the report by Electric Boat Corporation and has determined that this does not have generic implications for the security of sources in radiography equipment at Electric Boat Corporation. The incident is considered closed by RI Radiation Control Agency."

EN Revision Imported Date: 5/6/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via e-mail from the Texas Department of State Health Services:

"The licensee reported that on April 28, 2021, a medical event involving a High Dose Rate (HDR) afterloader gynocological treatment, using a Varian VariSource iX device, with an iridium-192 sealed source of 6.93 curies, at the time of treatment, had occurred at is facility. The wrong length transfer tube was used which resulted in a dose of 600 centigray, the intended dose fraction, to an area, mostly skin, approximately 12 centimeters from the intended treatment site. The authorized user does not expect any harm to the patient. The patient has been informed. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9843

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.

FITNESS FOR DUTY REPORT

A non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.