Event Notification Report for June 16, 2021

EN Revision Imported Date: 6/16/2021

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: 6/16/2021

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. "

OFFSITE NOTIFICATION

"At 1230 CDT a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-1, Emergency Diesel Generator Fuel Oil Storage Tank, and the removed FO-32, TSC/Security Fuel Oil Tank. The tanks were removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to soil discoloration at the time the tanks were pulled. The soil contamination levels are from the historic use of the tank. The contamination levels are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40CFR280.10(c)(4).

"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."

The licensee notified the NRC Region IV Office.