Event Notification Report for June 14, 2021

EN Revision Imported Date: 6/14/2021

EN Revision Text: AGREEMENT STATE REPORT - MALFUNCTIONING GAUGE

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

"On April 21, 2021 a Licensee found that the count rate for one of their gauges was the same with shielding present and not present. The count rate was consistent with previous count rates with the shielding present. The Licensee shut down the device and called for service and repair who replaced two items resulting in the device working properly again. The Licensee then sent a letter dated May 2, 2021 to the Agency who received/stamped it on May 10, 2021. The letter was eventually passed to Randall Redd of the Investigations group on June 4, 2021. The letter provided a serial number for something. The Licensee was contacted on June 4, 2021 multiple times but I was unable to get any further information as multiple people are not in the office but on vacation. One person was able to give me the license number for the Licensee but when they looked at the serial number in the report it did not match any of the devices on their inventory. A meeting is set up for late Monday [June 7, 2021] to get this information. Additional information will be provided in accordance with SA-300."

Texas Event Report Number: 55289

EN Revision Imported Date: 6/14/2021

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: 6/14/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE MATERIAL SHIPMENT

The following report from the state of Wisconsin was received by email:

"On June 4, 2021 the licensee reported to the Department [of Health Services] that a package containing 25 Curies of Cs-137 had been shipped from Wisconsin on April 16, 2021 and did not arrive at its destination in California. The last known location of the package was in Chicago, Illinois on April 22, 2021. The licensee is following up with the common carrier, but to date the package has not been located."

WI Event Report ID No.: WI210004

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: 6/14/2021

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

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: 6/14/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Florida Department of Health (FDH) via email:

"Source: Co-60, Gamma-Knife treatment
"Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado

"On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original [Adventist Health Orlando] Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different [Adventist Health Orlando] Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called [FDH] at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient.

"The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident."

Florida Event Number: FL21-074

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: 6/14/2021

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: 6/14/2021

EN Revision Text: PART 21 INITIAL REPORT - DEVIATION IDENTIFIED IN BOLTING UTILIZED TO MAINTAIN SEISMIC QUALIFICATION:

"Pursuant to 10 CFR 21.21 (d)(3)(i), Paragon Energy Solutions is providing initial notification of the identification of a deviation.
"Condition that requires evaluation:
"NLI 280-ton Custom Chillers, Serial Numbers XHX-0001A / XHX-0001B / XHX-0001C. The Chillers were originally supplied by Nuclear Logistics under PO: NU-02SR726683 in 2010.
"The original seismic qualification was questioned by plant personnel related to the size of the bolting utilized for the diagonal cross braces on the two lower chiller frames. Paragon performed a review and additional analysis of the original qualification report. It was confirmed that the bolting which was utilized to install the pinned diagonal braces on the condenser and compressor frame sections does not have a sufficient load bearing capacity to support the application loading during a seismic event.
"The upset and emergency loading for the diagonal brace is 5.59 kip and 8.59 kip, respectively. Compared to the load capacity of 2.32 kip and 3.09 kip for upset and emergency, respectively, for the 3/8" bolt in single-shear configuration with threads included in the shear plane.
"This condition does not affect normal operation of the chiller. However, this deviation has the potential to impact the ability to maintain structural integrity during a seismic event.
"Date of Discovery: 6/8/2021
"Formal notification will be submitted on or before 7/8/2021.
"Paragon contact: Tracy Bolt, Chief Nuclear Officer, Paragon Energy Solutions, 817-284-0077, tbolt@paragones.com."

This equipment was supplied to V.C. Summer Nuclear Station.

TECHNICAL SPECIFICIATION REQUIRED SHUTDOWN

"At 1710 EDT on June 11, 2021, a Technical Specification required shutdown was initiated at Plant Hatch Unit 1. Technical Specification Condition 3.4.4.B unidentified LEAKAGE increase not within limits, was entered due to a greater than 2 gpm increase in unidentified LEAKAGE within the previous 24 hour period in MODE 1. This specification was entered on June 11, 2021, at 1615 EDT with a REQUIRED ACTION to restore leakage increase within limits within 4 hours. This REQUIRED ACTION could not be completed within the COMPLETION TIME; therefore, a Technical Specification required shutdown was initiated, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i).

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

"The NRC Resident Inspector has been notified."

MAIN STEAM LINE (MSL) RADIATION MONITOR NON-FUNCTIONAL

"At time 1725 CDT on 06/12/21, Main Steam Line 2-03 Radiation Monitor 2-RE-2327 was declared to be non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in Steam Generator 2-03 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity. Compensatory measures are in place to assure adequate monitoring capability. Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-03. Corrective actions are being pursued to restore 2-RE-2327 to functional status.

"The NRC Resident Inspector has been notified."

MAIN STEAM LINE (MSL) RADIATION MONITOR NON-FUNCTIONAL

"At time 2227 CDT on 06/12/21, Main Steam Line 2-01 Radiation Monitor 2-RE-2325 was declared to be non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in Steam Generator 2-01 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity. Compensatory measures are in place to assure adequate monitoring capability. Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-01. Corrective actions are being pursued to restore 2-RE-2325 to functional status.

"The NRC Resident Inspector has been notified."