Event Notification Report for June 04, 2021

EN Revision Imported Date: 6/4/2021

EN Revision Text: INTERIM PART 21 REPORT - WELD PROCEDURES DO NOT MEET ASME CODE

The following is a summary of the report provided by the supplier:

On January 6, 2021, Crane Nuclear, Inc (CNI) received an e-mail message from a customer identifying that the weld procedures Crane summitted for use on the customer's purchase order were unacceptable, as the procedure did not meet the requirements of ASME Code Section IX. CNI immediately began research and determined the customer to be correct.

CNI is currently conducting research to determine where the affected weld procedures were used. The scope of supply is Code and safety related valve and valve parts supplied by CNI since 2009.

Joyce Hammam
Director, Safety and Quality
(678) 451-2280
Crane Nuclear, Inc.
860 Remington Blvd
Bolingbrook, IL 60440

* * * RETRACTION ON 6/3/21 AT 1453 EDT FROM JOYCE HAMMAN TO JOANNA BRIDGE * * *

The following was received from the supplier:

"Update 6/3/21: Eleven procedures were identified by CNI as not having a supporting [Procedure Qualification Record] (PQR) for welding on greater than 1 inch base metal. Of those eleven, three have never been used. Those three procedures are being corrected to identify the procedure applies to base metal of up to 1 inch only.

"The remaining eight procedures have had a 1 inch coupon welded and tested. All coupons passed the penetrant test, the hardness tests, and macro testing, as required by table QW-453 of ASME Code Section IX.

"As a result, CNI is updating the affected procedures. This is a paperwork issue for Crane and not a Part 21 concern for the industry."

Notified R1DO (Bicket), R2DO (Miller), R3DO (Dickson), R4DO (Groom) and PART 21/50.55 REACTORS (by email).

EN Revision Imported Date: 6/4/2021

EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE AND WRONG TREATMENT SITE

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

"On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event."

California Item Number: 051221

* * * RETRACTION ON 1 JUNE 2021 AT 1454 EDT FROM L. ROBERT GREGER TO JOANNA BRIDGE * * *

The following was received via e-mail from the state of California via e-mail:

"The licensee's initial dose calculation performed on the impacted non-target tissue was made to a non-dimensional point adjacent to the target tissue. Upon further licensee consideration, the non-target dose calculation was performed on the 1.55 cc non-target tissue (muscle) most impacted by a planning error for the gamma knife treatment. The revised calculation resulted in a dose to the non-target muscle tissue of 140 rad (1.4 Gy) compared to the 120 rad (1.2 Gy) that the 1.55 cc non-target muscle tissue would have received had the planning error not occurred. Therefore, the Medical Event criterion was not exceeded."

Notified R4DO (Groom) and NMSS Events (by 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: 6/4/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS ON TWO GAUGES

The following was received from the Texas Department of State Health Services (the Agency) by email:

"On May 26,2021, the Agency was notified by the licensee service provider that the shutters on two nuclear gauges were found stuck in the open position. Open is the normal operating position. The gauges are Vega model SH-F1 each containing a 20 milliCurie cesium-137 sources. The licensee stated there is no increased risk of exposure to members of the general public or workers at the facility due to the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 9850

EN Revision Imported Date: 6/4/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received from the North Carolina Division of Health Service Regulation via email:

"The facility had two I-125 prostate implant procedures scheduled for 5/26/2021, one from approximately 0800-1030 EDT and another one following that. During the preparation of the second patient, the [authorized medical physicist/ radiation safety officer] (AMP/RSO) realized he may have made a mistake inputting the source strength into the treatment planning computer. The treatment planning computer has two options for source strength (millicuries and air-kerma). He went back to verify and realized he had input the millicurie source strength (0.357 mCi) into the air-kerma strength (0.453 U) spot and not air-kerma. This resulted in the treatment planning computer to believe the activity of the sources were lower than they actually were and generated a plan off of this strength. This caused the delivered dosage to be 27 percent greater than the prescribed dosage (~1400 Gy not 1100 Gy). The referring physician was present for the procedure and was notified upon the realization of the error. The patient was still in recovery from the procedure and was informed by the authorized user as soon as he was recovered and able to receive the news, before leaving the facility. The AMP/RSO stated that no negative outcome was expected for the patient, as this was the first part of a two part treatment plan, with the second part being linear accelerator treatment on the prostate. The second part of the treatment can be adjusted to accommodate for the increased dose given during the permanent implant, with no expected harm to the patient."

NC Tracking Number: NC210008


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: 6/4/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE

The following was received from the Massachusetts Radiation Control Program via email:

"At 1551 EDT on May 27, 2021, the Massachusetts Radiation Control Program received a phone call from the Radiation Safety Officer (RSO) of Thermo Scientific Portable Analytical Instruments, License Number 55-0238. The RSO stated that a source was removed from the licensee's manufactured device that was sent to them for servicing. During this receipt procedure, a wipe sample taken on the device resulted in positive contamination. The Nickel-63 source was found to be leaking and the wipe test indicated a removable contamination level of 0.0728 microcurie. The limit for reporting the activity is 0.005 microcurie.

"Further information will be forthcoming as the event is under investigation."

* * * UPDATE ON MAY 28, 2021 AT 1603 EDT FROM ANTHONY CARPENITO TO BRIAN P. SMITH * * *

The following update was received from the Massachusetts Radiation Control Program [MRCP] via email:

"The licensee notified the MRCP at 1202 [EDT] on May 28, 2021 to correct and update its earlier report. The sealed source isotope of interest is Iron-55 (Fe-55), not Nickel-63 as reported earlier, and the source activity is 20 millicuries. [The] Source was contained within an X-ray fluorescence device Model XLi 969, SN 5249. The customer had shipped the device to the licensee for decommissioning rather than service/repair. The accompanying leak test result prior to shipment was negative for contamination. Wipe survey results for areas within the licensee's facility where the device had been were negative for contamination. End of update."

Notified R1DO (Bower) and NMSS Events Notification

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."