Event Notification Report for August 02, 2021

EN Revision Imported Date: 8/2/2021

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).

* * * UPDATE ON 7/30/2021 AT 1030 EDT FROM MICHAEL SNEE TO SOLOMON SAHLE * * *

The following update was received via an email from the Ohio Department of Health Radiation Protection:

"On July 23, 2021 Prime NDT reported that the source has been located. [The common carrier] indicated that the source was located in their Canton, Ohio facility. Contrary to an earlier report, the source was never transported to [the common carrier] in Memphis, TN. Prime NDT retrieved the source from [the common carrier] facility in Canton."

Notified R3DO (Hanna), INES-National Officer (Smith), ILTAB (Richardson), IR MOC (Grant), NMSS Day (Rivera-Capella), NMSS Events Notification (email), CNSC Canada (email), 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: 8/2/2021

EN Revision Text:
AGREEMENT STATE REPORT - PATIENT UNDER DOSE

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

"On July 22, 2021 a patient was receiving a Lutetium-177 (Lutathera) treatment when technicians had difficulty establishing an IV injection site and flow. Several attempts were made, but ultimately they all failed. The prescribed dose was 200 milliCuries, but it is estimated that the patient received only 18 millicuries. No adverse effects to the patient are noted at this time and none are expected. The patient and prescribing physician have been informed. Preliminary cause is suspected to be poor venous access for patient as well as incorrect gauge needle used for patient access. The DEP will update this event as soon as more information is provided.

"The Department will perform a reactive inspection."

Pennsylvania Event Report ID No: PA210008

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: 8/2/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST I-125 BRACHYTHERAPY SEED

The following was received via email from the North Carolina Radiation Protection Section (NC RPS) via email:

"On 07/06/2021 at 1554 EDT [the licensee] Chief Diagnostic Medical Physicist emailed NC RPS about a lost Iodine-125 seed. Seeds are used for localization of non-palpable breast nodules. The event occurred on 06/30/2021 but was not reported to [the Chief Diagnostic Medical Physicist] until 07/06/2021. On 07/07/2021 North Carolina Inspections Supervisor forwarded the email to an Inspector for review.

"The seed was assayed on 06/09/2021 with an activity of 0.15 mCi. The event originated at Atrium Health Union, 600 Hospital Drive, Monroe, NC 28112 under license number 090-0739-1. The seed was identified by imaging at the Monroe Breast Center prior to shipment. Surveys of the transport container were also performed before it left the facility confirming the seed was present. Image was included with follow up email. Atrium Health Union nuclear medical staff used a Ludlum Mo. 14-C with GM pancake probe, serial number 73404, calibration due 07/28/2021. Survey of package exterior showed a reading of 0.05 mR/hr and less than 0.02 mR/hr at one meter. The package left the facility at 1347 EDT on 06/30/2021. A courier service is used to transport specimens.

"Charlotte-Mecklenburg Hospital Authority's Carolinas Medical Center (CMC) pathology lab received the package at 1525 EDT on 06/30/2021. CMC pathology lab staff failed to perform package survey at time of receipt. The specimen was removed from the transport case and radiographed using a Faxitron cabinet x-ray unit on 06/30/2021. At this point, pathology staff found that the seed was not present in the specimen tissue. Image was included with initial notification email. At this point, pathology staff did not follow established procedures to notify CMC Radiation Safety staff.

"On 07/06/2021 [the CMC] Radiation Safety Officer (RSO) was notified of the incident. Radiation Safety staff immediately went to the CMC pathology lab and surveyed the lab using a Ludlum Mo. 2241 with a NaI probe, serial number 217339. Surveying began at 0830 EDT on 07/06/2021. The transport container, all work areas, all biological waste containers, floor areas, counters, and all areas where the seed could be located were surveyed. All readings were at background radiation levels (<0.02 mR/hr) and seed was not located.

"Seed Information:
Manufacturer: Best Medical
Lot#: 52188A-6
Radiation Type: low E gamma emitter
Activity: 0.15 mCi, assayed on 06/09/2021

"Licensee identified multiple failures which lead to the incident, including:
1. Failure of pathology lab staff to carefully handle specimen.
2. Failure to notify RSO at initial finding of incident.
3. Failure of pathology lab to follow established procedures.
4. Receiving notification at such a later date greatly diminishes likelihood of finding lost seed.

"Licensee proposed several corrective actions to prevent reoccurrence, including:
1. All pathology staff on radiation program will receive refresher training.
2. CMC pathology will have more accountability regarding the handling of radioactive material.
3. All specimens containing radioactive material received from outside facilities must be received at CMC pathology lab prior to 1600 EDT.
4. Extra stickers and labels will be utilized to clearly identify specimens containing radioactive material.
5. CMC pathology lab will handle specimens with extreme caution due to small size of seeds."

North Carolina Incident Number: NC210012

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: 8/2/2021

EN Revision Text: INOPERABLE SECONDARY CONTAINMENT

"At 0922 PDT, on 07/28/21, the reactor building roof hatch was opened to support maintenance activities on the roof. Secondary containment differential pressure lowered and was recovered by the operating crew. Secondary containment differential pressure was maintained negative during the transient and was verified to have met technical specification requirements the whole time, however it was not identified at the time that the secondary containment was inoperable due to the roof hatch exceeding the allowable containment breech size and as such a TS 3.6.4.1.A entry was warranted.

"This report is being made pursuant to 10 CFR 50.72(a)(1)(ii) when it was identified that the secondary containment was inoperable while the roof hatch was open and a report should have been made under 10 CFR 50.72(b)(3)(v)(C) and (D) for loss of safety function.

"There were no radiological releases, system actuations, or isolations associated with this event."

The licensee has notified the NRC Resident Inspector.

MANUAL REACTOR TRIP OF UNIT 1

"At 1646 [CDT] on 7/31/21, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to control board indications of a Unit 1 'B' Main Feed Pump trip. After the reactor trip, one of the Condenser Steam Dump valves cycled to intermediate and remained stuck. The Condenser Steam Dump Valve was isolated locally using manual isolation valves. The 'B' Feed Regulating Bypass Valve did not control in automatic and was taken to manual to control the level in 'B' Steam Generator. The Auxiliary Feedwater System automatically actuated as designed when the valid actuation signal was received. Operations stabilized the plant in Mode 3. Decay heat is being removed by atmospheric dump valves due to condenser unavailability. Unit 2 is unaffected. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident Inspector has been notified."

During the transient, all control rods inserted into the core. There is no known primary to secondary leakage. During the transient, no relief valves or safeties lifted. The plant is currently maintaining normal operating temperature and pressure with all safety equipment available. The plant is in its normal shutdown electrical lineup.