Event Notification Report for August 27, 2021

EN Revision Imported Date: 8/27/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following information was obtained from the state of Iowa via email:

"On August 18, 2021, at approximately 1000 CDT, the DAV-015 #4 shutter was reported to be stuck in the open position. A survey meter measured a background level of 0.02 mR/hr outside of the gauge house, and 0.05 mR/hr inside the gauge house at that time. Locks were changed to the gauge house to prevent entry. The service company, SenTek, was notified and requested to provide service. They are expected to arrive on August 19, 2021, to provide service and repairs. This event will be updated after the service company determines the cause of the failure and the licensee provides a corrective action plan."

The gauge was manufactured by Isotope Measuring Systems, Inc., model number 5221-02, serial number 2332-2336L, and contains 5 Curies of Am-241.

NMED Number: IA210003

EN Revision Imported Date: 8/27/2021

EN Revision Text: AGREEMENT STATE REPORT - UNINTENDED DOSE TO AN ORGAN

The following information was received from the state of North Carolina via email:

"A licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 iodine-125 brachytherapy seeds, containing a total activity of 1.012986 GBq (27.378 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 14500 cGy (rad). The seeds were implanted on 7/26/21. On 8/17/21, the patient's follow up implant CT scan revealed that all 54 seeds were implanted in the penile bulb, outside of the intended target. An inspector was dispatched on 8/18/21. The patient and physician were notified. Through subsequent interviews with the Medical Physicist involved, the Radiation Safety Officer, and the Chief Physicist, malfunction of the ultrasound unit was ruled out. A discussion evolved during review of the ultrasound images from the procedure where a foley catheter inserted in the patient appeared partially visible marking the location of the bladder. The physicist's retrospective review indicates that if the foley catheter is not clearly visible then it could result in seed implantation in a patient's anatomy other than the prostate.

"An unintended dose to the penile bulb of approximately 14500 cGy (rad) was received, where no dose was anticipated.

"Currently, the cause appears to be human error and our investigation is ongoing. Pending corrective actions include changes to the prostate brachytherapy protocol to incorporate an additional step to ensure personnel clearly identify the prostate gland and the surrounding anatomy. Previous cases involving this type of procedure do not indicate that this error has been occurring, unaccounted for, prior to this event, due to the follow-up CT scans performed post-op per the licensee's internal procedures."

NMED Report No.: NC210014

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: 8/27/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF PROTECTIVE COVER OVER LOCKING MECHANISM

The following was received from the Alabama Department of Public Health, Office of Radiation Control (Agency), via email:

"During the Agency's inspection on 8/12/2021, of licensee Applied Technical Services, license no. 1454, the representative stated that a technician lost the protective cover over the locking mechanism on a QSA 880D exposure device. The representative stated that the metal lanyard connecting the cover to the device housing snapped, and the cover fell between metal grating. The representative did not remember the date of this occurrence. The representative stated that no exposures to personnel or members of the public resulted from the lost cover. The Agency has followed up with Applied Technical Services for more information, with no more information at this time. The Agency is continuing to investigate.

"Device QSA 880-Delta, Ir-192 source, source activity and device serial number is not available at this time."

Alabama Event 21-28

EN Revision Imported Date: 8/27/2021

EN Revision Text: CONTAMINATED ITEMS DISCOVERED AT WAREHOUSE

The following was received from the Nuclear Fuels Services, Inc. (NFS) Nuclear Safety & Licensing Manager via email:

"This event was reported previously as an amendment to EN55161 on March 31, 2021 The purpose of this report is to establish a new Event Number containing only the transportation related notification and to ensure severance from of all security related information. A 30-day written report was provided to the NRC on April 28, 2021 (Reference NFS Document Number 21G-21-0076). The 30-day written report will be revised to redact all security related information and resubmitted following this telephone notification.

"On March 30, 2021, NFS identified legacy equipment that contained contaminated items at an NFS owned offsite warehouse. This equipment was transported on public roads to this facility during/prior to 2016.

"There were no actual or potential safety consequences to workers, the public, or the environment.

"The licensee notified the NRC Resident Inspector 3/31/2021 at 1350 hours EDT."

NFS Event (PIRCS) Number: 83261