Event Notification Report for May 24, 2021

EN Revision Imported Date: 5/24/2021

EN Revision Text: AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER STUCK OPEN

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

"During removal of the Cs-137 source (20 mCi, Serial # 5450CN) and holder (Ohmart/Vega Model SHLM-B1-P) by the manufacturer (VEGA), it was discovered the shutter would not operate and was stuck open. INEOS is actively working with the manufacturer to develop a suitable path forward for removal of the source. In the meantime, a physical barrier is installed to prevent vessel entry."

Ohio Reference No.: OH 2021-037

EN Revision Imported Date: 5/24/2021

EN Revision Text: MISSING IODINE-125 BRACHYTHERAPY SEEDS

"A brachytherapy treatment was performed at the hospital on 13 May 2021. From a total of 111 Iodine -125 seeds, 88 were implanted into the patient's prostate as planned. The oncology medical physicist mistakenly thought that she had placed the remaining, unused 23 in two lead containers, but did not perform a physical inventory to confirm it. She did not realized that 4 unused seeds were left in a shielded box. Each seed had approximately 0.26 mCi in each. After the procedure, Radiation Safety surveyed the treatment room. All radiation levels were background. The medical physicist returned the unused seeds to Radiation Safety indicating that 23 seeds were in two small lead pigs. The box containing the 4 seeds was put in the medical waste bag and were apparently processed as medical waste. On 14 May 2021, Radiation Safety initiated preparing the unused seeds for shipment to the vendor that provided them. At that point, Radiation Safety realized that only 19 were in the lead containers and 4 were not returned. At that point, Radiation Safety contacted Radiation Oncology. They were not able to locate them at their department. A team consisting of Radiation Safety and Radiation Oncology staff searched for them, unsuccessfully, in the [Operating Room]. The team then searched in the medical waste dumpster bins at the hospital. This search was also unsuccessful locating the missing seeds. It was determined that a dumpster container that likely had the missing seeds was picked up early in the day. The waste management company was contacted, but the company was not able to provide information about what truck or container was involved and its location. The hospital is currently waiting for more information from the waste management company."

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: 5/24/2021

EN Revision Text: SURVEILLANCE NOT PERFORMED IN REQUIRED TIMEFRAME

"The [Missouri University of Science and Technology Reactor] MSTR is required by Technical Specification 4.6.2(1) to perform an experimental verification of calculated airborne effluent release values every five years and when a change in licensed power occurs. An experimental verification was performed on October 24, 2019. However, in a follow-up assessment of the verification report and data, the results and analysis were determined to be non-credible. As the most recent experimental verification was completed on October 27, 2014, the MSTR does not meet the requirement of TS 4.6.2(1).

"This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day (reported as EN-55266). Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days. An experimental verification of gaseous effluent release will be performed as soon as practical following restoring the MSTR to an operable status, which is expected to occur no later than July 31, 2021."

The licensee will notify the NRC PM (W. Kennedy).