Event Notification Report for August 25, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
08/24/2021 - 08/25/2021

EVENT NUMBERS
55409 55410 55412 55414 55425 55427
Agreement State
Event Number: 55409
Rep Org: NORTH CAROLINA DIV OF RAD PROTECTIO
Licensee: Duke University Medical Center
Region: 1
City: Durham   State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: Ken Bugaj
HQ OPS Officer: Kerby Scales
Notification Date: 08/17/2021
Notification Time: 13:49 [ET]
Event Date: 08/26/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JACKSON, DON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 8/25/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE-125 SEED

The following information was obtained from the State of North Carolina via email:

"On 25 August 2020, an iodine-125 (I-125) seed was implanted into a perirectal mass in a patient for the purpose of localization and excisional biopsy. Following implantation, the Imaging team surveyed the needle and patient with a Geiger-Mueller detector per standard procedure to confirm proper placement of the seed within the mass. In addition, a post-implantation CT scan confirmed the presence of the seed within the mass. The seed and patient data were entered into the on-line 'Seed Tracker' software by the Imaging team per standard procedure. Excision of the tumor containing the seed was planned for the next day, and the patient was discharged home.

"At the time of surgery on 26 August 2020, the operative team was unable to detect the seed within the mass. Although the absence of the seed was documented in the operative note, the surgical team did not report that unusual occurrence to the Imaging team or the Radiation Safety Division. The specimen, which contained no seed and was not labeled as containing a seed, was sent to Surgical Pathology as a routine specimen and was processed as such. However, the Surgical Pathology team failed to notice that an entry for that patient and seed had been made in the 'Seed Tracker'. The error was not detected until an audit of the information in the 'Seed Tracker' was performed by staff of the Imaging teams and the Radiopharmacy in July 2021. The discrepancy between the 'Seed Tracker' data and the labeling and processing of the specimen as 'non-radioactive' was resolved when the surgical team's operative note was consulted. Because locating the seed would have been unlikely and impractical after 10 months (activity estimated to be 4 microcuries), our efforts were focused on investigating the root causes and identifying corrective actions.

"Probable disposition of lost material: Based upon the confirmation of seed placement in the perirectal mass by survey and CT scan, and its absence upon excision the following day, the seed most likely migrated out the implantation track and was discharged into the sanitary sewer during a bowel movement. Migration of seeds is uncommon but does occur. In this case, it would not have been noticed by the patient."

North Carolina Item Number: NC210013

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


Agreement State
Event Number: 55410
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: Polyclinic
Region: 4
City: Seattle   State: WA
County:
License #: WN-M0218
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Kerby Scales
Notification Date: 08/17/2021
Notification Time: 15:33 [ET]
Event Date: 07/26/2021
Event Time: 00:00 [PDT]
Last Update Date: 08/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 8/25/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE-125 SEEDS

The following is a summary of a report received from the state of Washington via email:

On Monday, 7/26/2021, nuclear cardiology personnel identified and reported a loss of Radioactive Seed Localization (RSL) seeds.

Background: RSL seeds are obtained by the Polyclinic as individually loaded implant needles containing one seed, in sterile, one needle use packs. Nuclear cardiology personnel receive the seed shipments, conduct the required surveys and maintain a seed inventory. Needle packs are distributed to mammography personnel on days of RSL seed implant.

On Wednesday, 7/21/2021, the seed was obtained by mammography personnel. The intent was not for RSL implant, but rather to utilize the needle for qualification of new Hologic mammography equipment. The needle pack was provided to the Hologic applications technologist for the qualification. Mammography personnel indicated that the Hologic applications technologist unexpectedly opened the needle pack and ejected the seed within the plastic sterile pack as she needed the needle not the RSL seed. Mammography personnel took the pack, and seed, and stored the pack. At the end of the day, mammography personnel indicated they taped the pack closed and returned the pack to the nuclear cardiology hot lab.

On Thursday, 7/22/2021, mammography personnel again took the needle pack from the hot lab, and utilized the needle for equipment qualification, indicating that the pack, and seed, was returned again to the nuclear cardiology hot lab at the end of the day. Mammography personnel indicate that the seed was visible in the pack at the end of the day.

On Monday, 7/26/2021, nuclear cardiology personnel indicated that the subject pack was visually inspected and no seed was identified. Nuclear cardiology personnel indicated the needle pack was surveyed with an exposure rate calibrated Ludlum 14C w/ 44-9 GM pancake and no evidence of the seed was identified. Nuclear cardiology personnel also indicated the lead foil shielded box was similarly visually inspected and surveyed and no evidence of the seed was identified.

On Tuesday, 7/27/2021, nuclear cardiology personnel surveyed the Nuclear Cardiology hot lab and other areas. Nuclear cardiology personnel indicated that no evidence of the seed presence was identified.

Washington State Incident Number: WA-21-019

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


Fuel Cycle Facility
Event Number: 55412
Facility: Westinghouse Electric Corporation
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion (Uf6 To Uo2)
Commercial Lwr Fuel
Region: 2
City: Columbia   State: SC
County: Richland
License #: SNM-1107
Docket: 07001151
NRC Notified By: Elise Malek
HQ OPS Officer: Kerby Scales
Notification Date: 08/17/2021
Notification Time: 19:15 [ET]
Event Date: 08/17/2021
Event Time: 02:30 [EDT]
Last Update Date: 08/17/2021
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(3) - Med Treat Involving Contam
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
GOTT, WILLIAM (IR)
Event Text
EN Revision Imported Date: 8/25/2021

EN Revision Text: MEDICAL TREATMENT WITH CONTAMINATION

"On August 17, 2021, at approximately 0230 [EDT], a Westinghouse employee was washing piping over a container of nitric acid in the Conversion Decontamination Area. The piping fell into the container of nitric acid and employee reached into the container to retrieve the piping and received nitric acid burns to hands and left wrist. Appropriate treatment for exposure to nitric acid was provided by on-site medical response staff. With an abundance of caution, after review with on-site medical, the employee was transported to an off site medical facility [Prisma Hospital]. Per procedure the employee's hands and arm were wrapped in plastic, and the employee was transported to an off site medical facility accompanied by plant health physics personnel for evaluation.

"Contamination was detected on the exposed area of the employee's skin during Health Physics surveys. Direct survey results were 1500 dpm/100 cm squared alpha for the left hand and 900 dpm/100 cm squared alpha for the right hand. All smear results of the exposed area were below clean area limits (<200 dpm/100 cm squared). Contamination surveys were performed in the ambulance and at the hospital and all results were below clean area limits indicating no spread of contamination during care for the employee. All potentially contaminated materials associated with the issue were collected and returned to the [Commercial Fuel Fabrication Facility] CFFF for disposal. Operator was provided with over the counter medication and released.

"The task that the employee was performing required a chemical suit, chemical gloves, fresh air bubble hood, chemical boots, and required taping the gloves to the sleeve of the acid suit jacket with chemical tape. After inspection of employee's personal protective equipment, its was noted that chemical tape was not applied to the gloves which enabled the nitric acid solution to enter the left glove and acid suit sleeve when employee reached into the nitric acid container."

NRC Regional staff was notified.


Agreement State
Event Number: 55414
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Rock Engineering and Testing Laboratory, Inc.
Region: 4
City: San Antonio   State: TX
County:
License #: L 05168
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Howie Crouch
Notification Date: 08/18/2021
Notification Time: 11:21 [ET]
Event Date: 08/18/2021
Event Time: 01:49 [CDT]
Last Update Date: 08/18/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
DEESE, RICK (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO), - (EMAIL)
Event Text
EN Revision Imported Date: 8/25/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was received from the state of Texas (the Agency) via email:

"On August 18, 2021, the Agency was notified by the licensee that a Troxler model 3430 moisture density gauge was stolen from the back of an employee's truck. The employee's truck was parked at their apartment overnight. The licensee stated that the apartment complex security camera system showed the theft occurred at about 0149 CDT on August 18, 2021. The gauge contains a 40 milliCurie Americium - 241 source and an 8 milliCurie Cesium - 137 source. The licensee stated the gauge was locked using chains in the back of the pickup truck. The licensee reported local law enforcement has been notified of the theft. The Agency requested additional information from the licensee. Additional information will be provided in accordance with SA-300."

TX Incident #: 9877

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


Power Reactor
Event Number: 55425
Facility: Columbia Generating Station
Region: 4     State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: Dan Sharpe
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/23/2021
Notification Time: 23:20 [ET]
Event Date: 08/22/2021
Event Time: 08:30 [PDT]
Last Update Date: 08/23/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
KOZAL, JASON (R4)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 8/25/2021

EN Revision Text: OFFSITE NOTIFICATION OF POTENTIAL OIL DISCHARGE

"On August 22, 2021, Columbia Generating Station determined that no more than approximately eight (8) gallons of silicone oil was inadvertently released into a plant service water system due to a failed heat exchanger on a plant installed air compressor. The plant service water system returns water to a water basin that contains at a minimum 300,000 gallons of water. The water basin is connected to the Columbia River via a blowdown line. Although not confirmed, it is suspected that an unknown quantity of silicone oil may have been released to the Columbia River. A visual inspection of the basin did not identify any oil sheen or film, and there are no additional actions needed to mitigate this issue. It does not appear the oil release poses a threat to human health or the environment, however because there could have been a discharge of an unknown quantity of silicone oil into the Columbia River this matter is immediately reportable under RCW 90.56.280 to the US Coast Guard National Response Center and Washington State Department of Ecology.

"This condition is being reported pursuant to 10 CFR 50.72(b)(2)(xi) for news release or notification of other government agencies concerning an event related to the health and safety of the public or protection of the environment. Notifications to off-site agencies were performed at 1825 PDT on 8/23/2021. The NRC resident has been informed."


Power Reactor
Event Number: 55427
Facility: FitzPatrick
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Andrew Weaver
HQ OPS Officer: Brian P. Smith
Notification Date: 08/24/2021
Notification Time: 16:51 [ET]
Event Date: 08/24/2021
Event Time: 14:06 [EDT]
Last Update Date: 08/24/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
GREIVES, JONATHAN (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event 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."