Event Notification Report for July 01, 2021

EN Revision Imported Date: 7/1/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF RADIOACTIVE MATERIAL

The following report was received from the North Carolina (NC) Division of Health Service Regulation via email:

"A NC General Licensee reports the loss of 8 NRD Advanced Static Control devices. Each device contained Po-210 with an activity of 10 mCi, each. General License: TBD as at the time of this report our General License Coordinator is currently unavailable. The licensee reports that the devices may have been inadvertently disposed of and their search continues at this time. This report remains incomplete but shall be updated to complete and close the record."

Advanced Static Control Device:
Manufacturer: NRD Inc.; Model: P-2021-Z705; S/N's: A2MB768, A2MB770, A2MB771, A2MB775, A2MB777, A2MB731, A2MB736, A2MB738

Sources Information:
Po-210 Activity .01 Ci each

NC Item Number: NC210010

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: 7/1/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following was received from the state of Ohio via email:

"Event occurred on 6/22/21. The patient was scheduled for therapy with Y-90 Sir-Spheres. The prescribed dose was 4389 rem. [However, they] administered only 3336 rem, or 76 percent (-24 percent) of the prescribed dose. During the infusion of the Sir-Sphere particles, the infusion catheter became clogged due to the high volume of particles. The catheter was removed, a new catheter placed and used for the infusion of the remaining particles. Stasis was not reached, there was not a patient event, and the estimated difference in dose to the patient exceeds 50 rem to the liver. There were no negative effect to the individual patient, no additional treatment is necessary as a result of this occurrence (administered therapy is sufficient), and no further actions are necessary to prevent recurrence. The physician notified the patient and [their] personal representative of the event, post therapy on 6/22/2021."

Ohio Item Number: OH210005

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: 7/1/2021

EN Revision Text: UNPLANNED CONTAMINATION TO AN INDIVIDUAL

The following synopsis was received via phone call from the licensee's Radiation Safety Officer (RSO):

At 1800 EDT on June 24, 2021 at the licensee facility, an employee left the work site unaware that he was contaminated on his skin and his clothing. The only places the individual traveled to were his car and his home before being called back to work at 1924 EDT to investigate the contamination event. When the individual came back to the facility, contamination was found on his hand including Sr-82, Sr-85, Rb-83, and Rb-84. The activity was 600,000 counts or 0.18 micro curies. Dose calculations have not been performed, however, the RSO does not believe the dose will be near any federal limits. The work area has been decontaminated and the individual's car has been surveyed and no contamination was found. The licensee plans to survey the individual's home as well as contact the NRC Region 3 materials inspector. The licensee is reporting the event under both 30.50(a) and 30.50(b)(1) as a precaution as more data is being collected.

* * * Update from Matthew Trusner to Donald Norwood at 1914 EDT on 6/25/2021 * * *

The following information was received via E-mail:

"On June 24, 2021, at approximately 1800 EDT, Curium-Noblesville RSO became aware of a radioactive spill in a restricted (production) area. The spill occurred behind the production hot cells. The affected area is designated as a triple shoe cover area and cordoned to limit access.

"The RSO directed a Radiation Safety Technician to respond to and initiate the investigation and data collection. The Radiation Safety Technician performed contamination surveys and found a maximum count rate of 800,000 cpm. The Radiation Safety Technician subsequently remediated the spill to 70,000 cpm (below the administrative level of 100,000 cpm) within minutes of completing the survey.

"The spill initiated when a Chemist tried to manually un-crimp a vial containing approximately 695 mCi of Sr-82 and 703 mCi of Sr-85. As the the Chemist tried to un-crimp the vial, the glass below the crimp broke leading to a few drops to fall on the concrete floor behind the hot cells. During the initial investigation surveys, the RSO discovered that the production batch record was contaminated. This prompted the RSO to find the Chemist to ensure he was free of contamination. The RSO discovered that the Chemist had already left the site.

"The RSO immediately contacted the Director of Health Physics for assistance. They made the decision to bring the Chemist onsite for a survey. The RSO discovered that the Chemist's work clothes presented spots reading approximately 600,000 cpm on contact with the pants and 200,000 with the shirt. The RSO also found contamination on the right hand reading approximately 34,000 cpm. Because the Chemist had left the site, the RSO surveyed the Chemist's car and did not identify contamination above background levels. The RSO communicated the findings to the Director of Health Physics and initiated the decontamination activities for the Chemist.

"Prior to decontaminating the Chemist's hand, the RSO obtained a gamma spectrum to identify the radioactive contaminants. He found a mixture of Sr-82, Sr-85, Rb-83 and Rb-84. The Director of Health Physics reviewed the notification requirements prescribed in Part 20 and Part 30 and escalated the event to Curium management and legal teams. Curium made the decision to proactively report the event to the NRC Operations Center under 10 CFR 30.50(a) given that the notification was required within 4 hours of discovery and Curium had not acquired enough data to verify if any regulatory limit was exceeded or not. After the notification, the RSO stopped the decontamination activities after no further contamination was being removed. The RSO measured a residual contamination of 4,200 cpm on the hand. He then followed the Chemist to his home and performed a contamination survey of the areas in which the Chemist indicated that he had been present after leaving the work site that day. The RSO found no contamination above background levels.

"The Director of Health Physics performed an initial dose estimate on June 25, 2021. The RSO used Rb-84 as the most restrictive nuclide that yielded the highest dose in the mixture. The estimates indicated that the Chemist received approximately 1,203 mrem to the maximally exposed shallow dose equivalent (extremity), 636 mrem shallow dose equivalent (whole body) and 13 mrem deep dose equivalent. The RSO performed 24-hour urinalysis and did not find the presence of the radionuclides. All license material was accounted for.

"Curium personnel discussed the incident with NRC Region-III on June 25, 2021. Curium is in the process of completing formal root cause analysis."

Notified R3DO (Stone) and the NMSS Events Notification E-mail group.