Event Notification Report for June 24, 2021

EN Revision Imported Date: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - SOURCE LOST DURING SHIPPING

The following was received from the Georgia Radioactive Materials Program (Agency) via email:

"Hurst Boiler Welding Company used [a common carrier] to ship a source changer back to QSA Global. It was shipped on May 19, 2021, and officially declared lost on 6/14/21. Hurst Boiler reported the loss to [the Agency] on 6/16/21. The licensee intended to ship a source changer back to QSA global via [a common carrier] on 5/19/2021. After approximately 14 days without a confirmation of receipt. The licensee contacted [the common carrier] on 6/14/21, who confirmed the source had been lost. The Radiation Safety Officer (RSO) then contacted [the Agency] on 6/16/21. When speaking with the RSO by phone, he stated the source changer contains an Ir-192 source (Serial # 9887G Model SC-800). The source activity when shipped (5/19/21) was 8.3 Ci and as of 6/16/21 it has decayed to 6.3 Ci. The most current leak test was performed on 8/31/21. The RSO was advised to provide a written report and submit all supporting documents as soon as possible."

Georgia Incident #41

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: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"University of Chicago Medical Center contacted the Agency on the afternoon of 6/15/21 to report a medical underdose of Lu-177 that occurred that day. Although information provided was preliminary, no untoward medical impact is expected to the patient. The Radiation Safety Officer (RSO) for the licensee contacted the Agency at approximately 1615 CDT on June 15, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 68 percent of the dose prescribed (136 mCi) in the written directive. The underdosing was reportedly due to leakage in the adaptor/needle connection. No personnel or area contamination occurred. The licensee is still evaluating whether or not the remaining dose will be delivered at a future date. The RSO confirmed the patient and referring physician were notified within 24 hours.

"IEMA inspectors will perform a reactive inspection on June 17, 2021. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated once additional details become available on 6/17/21."

Item Number: IL210019

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: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - PORTION OF THE DOSE DELIVERED TO THE WRONG LOCATION

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

"On June 16, 2021, the Radiologic Health Branch was notified of a reportable medical event that occurred on June 15, 2021 during a patients' liver metastases treatment with Y-90 Sirtex SIRSpheres. The AU's treatment plan called for treating the left lobe of the liver with 0.29-0.83 GBq of Y-90 SIRSpheres. The reason for the range was that if the liver became saturated, the treatment would be stopped at that point. During the treatment, periodic flushing cycles with contrast and flouroscopy were performed. At a mid-way point, the team discovered contrast material in the right liver lobe, indicating the microcather had moved from the left artery to the right artery. Upon discovery, the procedure was stopped, the microcatherter was removed and a new one was placed and the they began to infuse the left liver lobe again with the remaining Y-90 SIRSpheres without incident. Post treatment, a bremsstrahlung image of the two liver lobes indicated that both lobes had received Y-90 activity. The Radiation Oncologist estimated that the left lobe received less than the intended Y-90 activity. The right lobe received between 33%-67% of the Y-90 activity.

"The actual dose to either lobe has not been calculated, but based on dosimetry information in the package insert, the dose to the right lobe was > 0.5 Gy ( 50 rem). Treatment of the liver's right lobe was not intended during this procedure. On June 1, 2021, the patient had been treated with Y-90 SIRSpheres of the patient's right liver lobe. The patient was informed of the issue and there are no negative consequences expected for the patient."

California Item Number: 061621

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: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - POSSIBLE MISADMINISTRATION

The following was submitted by Alabama Department of Radiation Control via email:

"The licensee reported that a patient was treated with fraction 2 of 3 on Friday 6/11/2021 using a vaginal cylinder. Once the fraction was completed, the treatment team noted that the vaginal cylinder had been displaced about 6 cm, a shift of about 5 cm. Unknown when the cylinder shifted during treatment. Licensee estimated a dose difference of approximately 5.58 Gray."

Alabama Event 21-19

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: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - PRIVATE CITIZEN IN POSSESSION OF NUCLEAR MATERIAL

The following was received from the New Jersey Department of Environmental Protection (DEP) via email:

"On Tuesday evening, June 15, 2021, the DEP was notified that a member of the public had come to the Mountain Lakes police HQ to report that he had in his possession some radioactive material that he had obtained 60 years ago when he worked for Westinghouse as an engineer. The material was reported to be "Nuclear Reactor grade U-238 with 5 percent U-235 enriched". The citizen further stated that the material is wrapped in lead foil and placed in a lead pipe with the ends pinched over. The material allegedly consists of three or four rejected pellets, approximately 3/8 inch diameter. These were rejected because of dimensional irregularities. They are allegedly doughnut shaped with a hole in the center. They were reportedly to be used in Westinghouse nuclear reactors/steam power. The citizen stated that the material in question has been stored for decades in a lead pipe, sealed off at the ends, and then tightly wrapped in lead sheeting. It was also clearly labelled with the word "Radioactive" and then placed inside a large can, which has been securely stored in the citizen's garage for several decades. DEP personnel responded to the citizen's home on June 17, 2021. The material was found stored as the citizen had previously described. The container was not opened. There was no detectable removable contamination on the outside of the container. The material was returned to the garage where it will be secured pending proper disposal."

EN Revision Imported Date: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - PRIVATE CITIZEN IN POSSESSION OF NUCLEAR MATERIAL

The following was received from the New Jersey Department of Environmental Protection (DEP) via email:

"On June 16, 2021, the DEP was notified that family members were cleaning out the home of a deceased relative, and discovered an item marked "radioactive." The DEP responded on June 17, 2021. The item in question appeared to be some sort of tile, or piece of rock, and was identified as containing Ra-226. There was some removable activity on this item. It was re-wrapped in the lead sheeting it was found in and placed in a plastic bucket, sealed, labelled, and secured in a safe location in the basement (where it was originally discovered), pending proper disposal. The on-contact reading was 4 mR/hr."

EN Revision Imported Date: 6/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST LICENSED MATERIAL

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

"On 5/21/2021 TSI, Inc. received two of three boxes containing radioactive material shipped from NRD, LLC, 2937 Alt Boulevard, Grand Island, NY, 14072. The third package, containing paperwork for 1 NRD model P-2042 static eliminator with an activity of 5 millicuries of Po-210, was received repackaged on the same date. TSI, Inc. contacted NRD and [the common carrier] to inquire about the status of the missing static eliminator. The [common carrier] website indicates that they were unable to deliver the package in question. TSI contacted [the common carrier] who has to date been unable to locate the static eliminator. TSI plans to request that a formal investigation be performed by [the common carrier]. The investigation was ongoing at the time of this notification."

State Event Report ID No.: MN-21-0004

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: 6/24/2021

EN Revision Text: HIGH-ENERGY LINE BREAK DOOR UNABLE TO BE LATCHED

"At 1208 [EDT] on 6/22/2021, the high-energy line break door separating Auxiliary Feedwater Train Rooms 1 and 2 was not able to be latched following normal usage. The door was able to be closed, protecting Train 1 equipment from a break in Room 2. However, it is assumed a break in Room 1 would push the unlatched door open and allow high-energy fluids to enter Room 2. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. The door was able to be latched at 1215 [EDT] on 6/22/2021 following repairs to the door latch interlocking mechanism. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). No other equipment was inoperable during this event.

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 6/24/2021

EN Revision Text: MANUAL RX TRIP DUE TO STEAM LEAK IN MOISTURE SEPARATOR RE-HEATER CROSSOVER PIPE

"On June 22, 2021, at 2331 EDT, DC Cook Unit 2 Reactor was manually tripped due to a large steam leak in a crossover pipe of the Moisture Separator Re-heater (MSR) to the low pressure turbine.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report.

"The DC Cook Resident NRC Inspector has been notified.

"Unit 2 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 2 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event."

Unit 1 was not affected.