Event Notification Report for July 29, 2021

EN Revision Imported Date: 7/29/2021

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: 7/29/2021

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: 7/29/2021

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.

EN Revision Imported Date: 7/29/2021

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

The following was received from the Colorado Department of Public Health and Environment via email:

"Y-90 TheraSphere procedure misadministration: 60.8 mCi was the prescribed dose and 0 mCi was the administered dose."

Colorado Event Report ID No.: CO 210017

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: 7/29/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT

The following was received via an email from the Pennsylvania Bureau of Radiation:

"The licensee reported that on July 21, 2021, while using a QSA Global Model 880 containing a 135.5 curie source of iridium-192, the source failed to fully retract and lock. The source serial number is 32578M and the camera serial number is D9477. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company [Radiation Safety Officer] (RSO). The licensee then contacted QSA Global who will be onsite on July 22, 2021, to retrieve the source and take the camera and entire crank and assembly mechanism with them for evaluation. The licensee will remain onsite to secure the boundary until QSA arrives. No overexposures have occurred and all proper procedures were followed. The cause of the malfunction remains unknown. More information will be provided when received."

Pennsylvania Event Report ID No.: PA210007

* * * UPDATE ON 7/23/2021 AT 0738 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *

The following update was received via an email from the Pennsylvania Bureau of Radiation:

"QSA arrived on site at approximately 2000 EDT on July 22, 2021, and the source was moved to a locked position in the camera at 2155 EDT. At this time the drive cable is suspected to be the problem. The camera and drive system will be evaluated."

Notified R1DO (Gray) and NMSS Events Notification via email.

EN Revision Imported Date: 7/29/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGE TO PORTABLE MOISTURE DENSITY GAUGE

The following was received from the Virginia Radioactive Materials Program (VRMP) via email:

"On July 22, 2021, at 0950 EDT, VRMP received a report via telephone from the Radiological Duty Officer of the Virginia Office of Radiological Health that a portable nuclear moisture/density gauge was damaged when hit by a car at a temporary jobsite. At 1000 EDT, the VRMP contacted the Radiation Safety Officer (RSO) of the licensee. The RSO stated that a Troxler density gauge (Model 4640-B, serial number 2266, containing 8 milliCuries of cesium-137) was hit by a car at a temporary jobsite. The gauge housing was damaged, but the source appeared to remain intact within the safe position. The licensee's survey of the gauge yielded readings of 0.02 mR/hr at about a foot distance from the gauge. The gauge was taken to the licensee's office in its transport container. A survey was also performed on the ground and the reading was reported as background. The gauge will be tested for leakage and after testing, it will be sent to the Troxler Electronics Laboratories for evaluation. The VRMP is working with the licensee to obtain additional information. This report will be updated once the licensee's investigation is complete and the information is received by the VRMP. According to the RSO, no public or personnel exposure occurred."

Event Report ID No.: VA210004

EN Revision Imported Date: 7/29/2021

EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED PACKAGE

The following was received from the California Radiologic Health Branch (RHB) via email:

"The licensee reported that on 7/13/2021, they received an externally contaminated package containing two unit doses of F-18 (110 minute T1/2 [half life]). The licensee's receipt survey found the outer surface removable contamination level to be 5,417,497 dpm per 100 sq cm. The inside of the package, including the F-18 vials, were not contaminated. The radiopharmacy courier was informed of the excessive contamination, and the radiopharmacy was contacted. The package radiation levels were acceptable. The package was received from Optimal Tracers (CA-RML 7975). RHB will investigate this matter further, including onsite at Optimal Tracers' facility."

5010 Number: 071921

EN Revision Imported Date: 7/29/2021

EN Revision Text: 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."

FITNESS FOR DUTY REPORT

A licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been suspended.

The NRC Resident Inspector has been notified.