Event Notification Report for August 24, 2021

EN Revision Imported Date: 9/24/2021

EN Revision Text: POINT BEACH - EXTERNALLY CONTAMINATED PACKAGE

The following was received from the Point Beach Station Radiation Protection Manager (RPM) via phone call to the Headquarters Operations Officer:

Per 10 CFR 20.1906(d)(1), the Point Beach Station RPM reported to the NRC receipt of a package of radioactive material (new fuel shipment) with removable surface contamination greater than NRC reporting limits. The package was received Tuesday, August 24, 2021, at 0645 CDT. The package was surveyed and it was determined that the external surface of the package contained removable contamination that exceeded the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. The measured level of removable contamination was 337.3 dpm/cm2 for beta-gamma emitters and contained Cobalt 60. The licensee's corrective actions were to conduct additional smears of the package, trailer, and truck, and to frisk the truck driver to ensure no further contamination. No contamination has been identified.

EN Revision Imported Date: 9/24/2021

EN Revision Text: APPENDIX R HOT SHORT UNANALYZED CONDITION

"During an extent of condition review of DC control circuits, it was identified there are additional unprotected DC control circuits which are routed between separate Appendix R fire areas. A postulated fire in one area can cause a short circuit and potentially result in secondary fires or cable fires in other fire areas where the cables are routed. The secondary fires or cable failures degrade the degree of separation for redundant safe shutdown trains and are outside the assumptions of the 10 CFR 50 Appendix R Safe Shutdown Analysis. This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B).

"Compensatory actions for affected fire areas have been implemented. Design modifications in the affected control circuits are being developed and will be scheduled to correct this condition."

EN Revision Imported Date: 9/23/2021

EN Revision Text:
AGREEMENT STATE REPORT - UNDERDOSE

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

"The licensee's radiation safety officer contacted the Agency to advise that a patient scheduled to receive Y-90 microsphere therapy (SirSpheres) for hepatocellular cancer on August 24, 2021, received only 77% of the dose prescribed in the written directive. This administration called for only 16.2 mCi of activity. The licensee's radiation safety officer is reviewing the delivery system as well as the specifics of the administration to determine root cause. The licensee suspects a clogged catheter but is currently investigating. No personnel or area contamination was reported. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. No untoward medical impact was expected to the patient.

"Agency inspectors will perform a reactionary inspection on Friday, August 27, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."

Illinois Item Number: IL210027

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: 9/27/2021

EN Revision Text: MISSING ELECTRON CAPTURE DETECTORS

The following is a summary of a phone call with the licensee:

A container in transit to the licensee was discovered to be missing from a warehouse in Elkton, Maryland. The package contained ten sealed electron capture detectors. Each detector contained 15 millicuries of Ni-63 for an aggregate amount of 150 millicuries. The licensee is in contact with the carrier and continuing to investigate.

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

* * * UPDATE ON 08/27/2021 AT 1522 EDT FROM ATNATIWOS MESHESHA TO OSSY FONT * * *

The following update was received from the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email:

"On August 26, 2021, at about 0825 EDT, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone by the Radiation Safety Officer (RSO) of Agilent Technologies, Inc., located at 2850 Centerville Road, Wilmington, Delaware 19808, stating that ten (10) radioactive materials were lost during transportation. The MDE/RHP spoke to the RSO who stated that Agilent Technologies, Inc. lost ten (10) Electron Capture Detectors (ECD), Model 2397 which contain nickel-63 sealed sources with estimated nominal activities of 15 millicuries. The ECDs are to be used in applications for chromatography, ion generators. The sources were manufactured on January 12, 2021, and the products are registered under NRC Sealed Source and Device Registry for the finished product, G2397A as Generally Licensed materials.

"The case has been reported to the NRC (Event Number 55430) by the RSO of the company. Agilent Technologies, Inc. is licensed by the NRC to conduct research and development as defined in 10 CFR 30.4, manufacture, test with authorized sources of H-3 and Ni-63 as per Materials License number 07-28762-01 and for distributions of Generally Licensed materials, Materials License number 07-28762-02G.

"Agilent Technologies suspected that the sources were lost on Friday, August 20, 2021, or even before, and most probably at common carrier transfer station, in Maryland. Agilent Technologies' imported shipment contained the lost ten (10) Ni-63 sources that were transported by land from Chicago to Wilmington, Delaware through Maryland. The shipment is managed by a company called Kintetsu World Express, USA and [carried out by a] common carrier.

"MDE/RHP will finalize a reactive investigation."

Maryland Event No. 5

Notified R1DO (Greives), ILTAB, and NMSS Event via email.

EN Revision Imported Date: 10/7/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDER-DOSING EVENT WITH Y-90 THERASPHERES

The following information was received via E-mail:

"On 8/24/21, a Y-90 TheraSphere treatment was to deliver a planned 13.65 GBq to the patient's anterior right hepatic lobe. The written instructions were followed in the usual fashion and the dose was administered to the patient. The catheter and administration set tubing were placed into the waste container. The patient, personnel, and room were surveyed. No spill was detected. Upon post-calculation measurements, it was found that the patient only received approximately 77 percent of the expected dose of 200 Gray. While the received 154 Gray was medically appropriate given the patient's condition, tumor type and tumor location, this treatment still fell below that intended on the written directive. Further investigation found that this patient was rescheduled multiple times and the dose had decayed further than it was planned to, the patient really should have been treated the day before on a Monday instead of the Tuesday to get the full dose as planned or a new Treatment Window Illustrator to secure a more appropriate Y-90 dose should have been completed. Patient and referring provider were notified. There were no contaminations verified by survey meter measurements. The licensee is currently implementing an Excel spreadsheet program to review accuracy prior to patient scheduling and dose ordered. Reporting Criteria under 10 CFR 35.3045."

Kentucky Event Report ID No.: KY210002

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: 1/7/2022

EN Revision Text: AGREEMENT STATE REPORT - MISSING SHIPMENT

The following information was received via email:

"The licensee contracted a common carrier to transport a Sr-82/Rb-82 generator to their RWM [radioactive waste management] site in Utah from the Warner Robins Facility (temporary job site). The package was picked up from the licensee's office on August 23, 2021 to be delivered in Utah on August 24, 2021. The package never arrived. The licensee contacted the common carrier, but was told they had to file a claim online. The package has not been found. The package was 84.63 mCi (3.13 GBq) with a Transport Index of 0.4. Results of a surface wipe test done before shipping were 203 dpm and surface reading was 6 mr/hr. "

GA Incident No.: 48

* * * UPDATE ON 12/7/2021 AT 1552 EST FROM JUSTINE JOHNSON TO TOM KENDZIA * * *

The following is a summary of information received from the Georgia Radioactive Materials Program (Department) via email:

On October 6, 2021 the Licensee reported the lost generator to the common carrier's Danger Goods Administration. The common carrier assigned an investigator to the case. After a month of searching, the investigator was unable to locate the package, and suspended the search efforts as of November 8, 2021. On November 15, 2021, the common carrier discovered that the generator was delivered to the appropriate recipient on August 24, 2021 under a different tracking number. The Licensee then notified the Department of this updated information.

Notified R1DO (Dentel), ILTAB (via email) and NMSS Events Notification group (via email).

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