Event Notification Report for July 28, 2021

EN Revision Imported Date: 7/28/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone:

The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs.

The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around.

EN Revision Imported Date: 7/28/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE

The following was received from the Ohio Bureau of Radiation Protection via email:

"Prime NDT Services, Inc. reported that a 64.7 Ci Ir-192 source was shipped via [the common carrier] on July 12, 2021 from their facility in Strasburg, Ohio to their facility in Michigan. As of July 21, the source has not been delivered by [the common carrier]. [The common carrier] is aware of the situation and believes that the package was delayed at their facility. On July 20, [the common carrier] informed Prime NDT Services, Inc. that the package could not be located.

"The State of Tennessee has been informed."

Ohio Item Number: OH210007

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

EN Revision Imported Date: 7/28/2021

EN Revision Text: AGREEMENT STATE REPORT - Y-90 BRACHYTHERAPY UNDERDOSE

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

"A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000.

"Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent).

"Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure.

"Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT [Certified Nuclear Medicine Technologist] on July 20, 2021."

5010 Number: 072121

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: 7/28/2021

EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE

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

"The RSO [Radiation Safety Officer] called the Agency on July 21, 2021, to report that a patient scheduled to receive Y-90 microsphere therapy (SIR Spheres) for hepatocellular cancer on April 23, 2021, received only 35 percent of the dose prescribed in the written directive. The underdosing was reported as due to a clogged catheter. No personnel or area contamination was reported. The licensee reported that the dose delivered was still a `clinically effective dose' to the patient and was following up to see if any further treatment was planned.

"The RSO discovered the underdosing/medical event during an audit he was conducting in Radiation Therapy on July 20, 2021.

"Notification to the referring physician was made as required; however, confirmation that notification to the patient was made is pending.

"A reactionary inspection will be performed."

Item Number: IL210020

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.

REACTOR SHUTDOWN DUE TO CONTROL ROD DRIVE FAILURE

"On July 26, 2021 at 1731 CDT, while the reactor was subcritical during a reactor startup, the University of Missouri-Columbia Research Reactor (MURR) was manually shut down due to the failure of the control rod drive mechanism for shim control blade B. MURR was not in compliance with one (1) Limiting Conditions of Operations (LCO). TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation.'

"A spare control rod drive mechanism was installed for control blade B, post-installation operability testing was conducted satisfactorily, and permission from the Reactor Facility Director was obtained prior to the reactor returning to operation later on July 26, 2021. Currently, MURR is operating at 10 MW [full power]. A detailed event report will follow within 14 days."