Event Notification Report for June 03, 2021

EN Revision Imported Date: 7/30/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING FIXED GAUGING DEVICE

The following information from the state of Utah was received by email:

"The Utah Division of Waste Management and Radiation Control (DWMRC) was notified by the licensee that a fixed gauge was missing on 06/04/2021 at approximately 1430 MST.

"The licensee was reconfiguring a portion of their facility and had relocated a number of gauges from one location to another location in their operations for use at the new location. One of the fixed gauging devices, a Thermo Fisher, model 5202, serial number B3339, containing 500 milliCuries of cesium-137 (Cs-137) would not fit at the new location. The fixed gauge was supposed to be removed from the hopper where it was located and placed in storage for future use. For some reason, this removal did not occur. The fixed gauge was left in place and had not been moved to a secured storage location. The shutter on the gauge was locked in the closed position.

"Yesterday afternoon (06/03/2021), the Radiation Safety Officer (RSO) was notified that the structure that the gauge had been located on had been demolished and the whereabouts of the gauge was not known. All of the materials from the demolition of the structure are still located in the area and are on the licensee's property. The licensee's staff began looking for the device. At about 1000 to 1100 MST this morning (06/04/2021), the licensee indicated that they had verified which gauge was missing and that it could not be located. The RSO began notifying all of the company personnel he is to notify when this occurs. The RSO thought he had 24 hours to report the gauge as missing to the DWMRC instead of the immediate notification that was required and did not immediately notify the DWMRC.

"At this point, the licensee is continuing to search through the demolished parts of the structure for the gauge and will continue to do so. The materials from the demolition are not to be relocated or removed from the licensee's property until a through search of all of the materials can be made or the device is located. The DWMRC will conduct an on-site investigation of this issue."

UT Event Report ID No.: UT-21-0001

* * * UPDATE ON 7/1/21 AT 1744 EDT FROM CONLEY CHRISTOFFERSEN TO BETHANY CECERE * * *

The following is a synopsis of information reported by the state of Utah by email:

"The device is a density meter used in a conveyance system. The conveyance system has been recently upgraded. Several similar devices were transferred to the upgraded system. This device was not scheduled to be transferred and was to be placed in storage for evaluation upon the completion of the project. Miscommunication occurred in that this device was not removed when the other devices were transferred and was instead left in place during initial demolition activities of the conveyance system. The device remained onsite, located in a pile of the larger scrap materials pending further processing (size reduction and sorting) prior to offsite recycling. It was in this scrap pile that the device was recovered intact.

"The device was located and recovered shortly after the recovery effort began on June 10, 2021, and transported offsite for disposal on June 11, 2021."

Notified R4DO (Werner), NMSS Events Notification, and ILTAB (email).

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: 7/8/2021

EN Revision Text: The following was received from the Florida Department of Health via email:

"Center for Diagnostic Pathology discovered a lost source on June 3. It was a seed that was implanted in breast tissue on May 24 and removed on May 25. Two specimens with seeds were removed and one was processed in the Operating Room. The pathologist thought the seed was removed but it was discovered that a biopsy clip was mistaken for the seed. The clip was sent to the lab instead and when the lab manager did the inventory on June 2, they could not find the seed. On June 3 a survey could not locate the seed. They believe the seed was left in the specimen that was frozen to be sliced by histology. They could see in the slices where the seed was, but they could not find the seed and believe it was dislodged during the slicing and collected with the rest of the waste to be incinerated by Daniels. That waste was picked up June 1. It was stated that due to the source being low energy, the exposure risk was low.

"A follow up investigation is pending."

Florida incident number: Not yet assigned.

* * * UPDATE ON 6/08/21 AT 0800 EDT FROM MATTHEW SENSION TO LLOYD DESOTELL * * *
Florida Department of Health re-sent the incident report and provided the incident number.

Florida Event Number: FL21-075

Notified R1DO (Ferdas)(email), ILTAB (email) and NMSS Event Notifications (email).

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: 7/2/2021

EN Revision Text: REPORT OF OFFSITE NOTIFICATIONS

"Event meets ACD2-RG-044 App. B N.1 'The licensee shall notify the NRC Operations Center of any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'"

"Received preliminary notification from TestAmerica Colorado that there was an exceedance of the Total Suspended Solids NPDES permit limit at Outfall 013. This was not unexpected with the current state of the settling pond above Outfall 013. An Ohio EPA [OEPA] 24 hour non-compliance notification form was filled out and sent to OEPA NPDES inspector.

"Notification [to NRC] concurrent to the OEPA notification."

EN Revision Imported Date: 7/2/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Radioactive Materials Inspection & Enforcement, of the Illinois Emergency Management Agency (the Agency) via email:

"Rush University Medical Center in Chicago, IL-01766-01, contacted the Agency the afternoon of June 4, 2021, to report a medical underdose of Y-90 that occurred on June 3, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.

"The Radiation Safety Officer for the licensee, contacted the Agency at 10:05 on June 4, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) received only 75 percent of the dose prescribed in the written directive. The Agency understands this to be one of two fractions delivered. Additional data is forthcoming.

"Reportedly, the underdose was due to a pinch clamp that was remaining on the infusion line during administration. It was noticed after the authorized user felt more pressure than normal when pushing the syringe, and stopped. The clamp was removed, and the authorized user completed the administration. No personnel or area contamination occurred.

"The system was flushed five times to ensure no microspheres were caught in the tubing of the kit. Images of the waste container were taken immediately after the event, showing the remaining microspheres were contained in the inlet and outlet lines. Following the manufacturer's procedures, the license determined the patient only received 21.62 mCi of the intended 28.86 mCi. The licensee believes that it was still a clinically effective dose.

"Agency staff are evaluating, and this report will be updated as information becomes available."

Illinois Item Number: IL210017

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: 12/3/2021

EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE DUE TO LOW LEVEL INSTRUMENTATION

"At 0241 [EDT] on June 3, 2021, during performance of a High Pressure Coolant Injection (HPCI) Condensate Storage Tank (CST) level functional surveillance, the HPCI torus suction inboard isolation valve was slow to open during swap of suction from the CST to the Torus. On June 9, 2021, it was determined that as a result of the June 3, 2021, slow swap condition, TS 3.3.5.1 Required Action D.1 to declare HPCI inoperable within 1 hour was applicable due to inoperable CST low level instrumentation channels. At 1817 [EDT] on June 3, 2021, HPCI suction was swapped to the torus, making TS Required Action D.1 no longer applicable. Reactor Core Isolation Cooling (RCIC) was available throughout this condition.

"At 0900 [EDT] on November 3, 2021, it was determined that an NRC event report due to HPCI inoperability should have been made. This event is being reported as a late 8-hour non-emergency notification pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"The cause of the slow valve opening was later determined to be corrosion products on contacts of a relay in the CST low level instrumentation logic. On June 4, 2021 at 1451 [EDT], the HPCI CST Level Functional Test was completed Satisfactorily, restoring HPCI Instrumentation to Operable.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."