Event Notification Report for June 25, 2021

EN Revision Imported Date: 6/25/2021

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: 6/25/2021

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: 6/25/2021

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: 6/25/2021

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: 6/25/2021

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: 6/25/2021

EN Revision Text: STUCK SHUTTER
The following information was received from the licensee via phone call:

During a routine inspection, the licensee found that a fixed nuclear gauge had a shutter stuck in the open position. The open position is its normal operating position. The gauge is located in an elevated position and is surrounded by fencing. The gauge contains a 1 Ci Am-241 source.
Gauge Serial #: G440039
Manufacturer: Thermo Fisher

EN Revision Imported Date: 6/25/2021

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.

EN Revision Imported Date: 6/25/2021

EN Revision Text: LOSS OF TECHNICAL SUPPORT CENTER CAPABILITY

"This is an eight-hour, non-emergency notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the Technical Support Center (TSC) supply fan belt had failed, which affects the functionality of an emergency response facility.

"Corrective maintenance activities will be performed to restore functionality. The work includes replacing the failed belt and restarting the TSC supply fan. The work duration is approximately 8 hours. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures. [The Emergency Response Organization team has been notified of the maintenance and the possible need to relocate during an emergency.]

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector and Illinois Emergency Management Agency have been notified."