Event Notification Report for June 15, 2021

EN Revision Imported Date: 6/15/2021

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: 6/15/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT UNDERDOSE

The following event was received from the South Carolina Department of Health [the Department] via email:

"The licensee notified the Department on June 7, 2021 at 1300 [EDT] that it had determined at 1200 [EDT] a medical event had occurred because of a Y-90 Therasphere procedure that occurred on June 4, 2021. The licensee is reporting that the administered dose differed from the prescribed dose by more that 20 percent. The written directive specified that the patient was to be administered with 135.5 mCi of Y-90 Therasphere to the left lobe of the liver. During the procedure it was discovered that there was an apparent leak in the microcatheter. The dose delivered calculated to be less than 93 mCi. The remainder of the dose had leaked onto the floor. The licensee has decontaminated the room. The On-call Duty Officer is meeting with the licensee's Radiation Safety Officer on June 8, 2021 to investigate this incident. This is an initial notification and further updates will be forthcoming once the investigation is complete."

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: 6/15/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the South Carolina Department of Health and Environmental Control via email:

"The South Carolina Department of Health and Environmental Control discovered a potential reportable event during a routine inspection of GS2 Engineering, Inc. on 06/08/2021. During the inspection it was discovered that a Troxler Model 3430 portable gauge (serial number 25345) [nominally 8 mCi Cs-137, 40 mCi Am-241:Be source] had been damaged and hit by a vehicle while on a temporary jobsite. The event appears to have occurred on 06/02/16 according to past utilization logs. The Troxler Model 3430 portable gauge has been stored at the licensee's facility within a locked cabinet. Survey results using a NDS ND-2000A survey instrument around the surface of the gauge indicated readings as high as 12 mR/hr. Survey results using a Ludlum 14-C survey instrument around the surface of the gauge indicated readings as high as 25 mR/hr. The gauge is secure within the licensee's storage area. This event is still under investigation by the South Carolina Department of Health and Environmental Control. "

EN Revision Imported Date: 6/15/2021

EN Revision Text: 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."