Event Notification Report for November 10, 2021

EN Revision Imported Date: 11/10/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED

The following information was received from the Arizona Department of Health Services (the Department) via email:

"On November 2, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, two IsoAid Advantage I-125 breast localization seeds were removed by surgery on October 29, 2021 and were verified to be included in the specimen. The specimen with the seeds was delivered to pathology on the afternoon of October 29, 2021. The seeds were not removed from the specimen until November 1, 2021 by pathology. At this time, pathology was only able to locate one of the I-125 seeds. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the one missing I-125 seed. [The missing I-125 seed was between 0.3 and 0.4 microcuries.] The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona Incident No: 21-008

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: 11/10/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING I-125 SEED

The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:

"The Agency was notified at 12:46 CDT on November 2, 2021 by the University of Illinois at Chicago to advise of a lost/missing 2.5 mCi I-125 eye plaque brachytherapy seed. The amount and form of radioactivity contained in the seed would not be useful for illicit intent and there is no indication of intentional theft or diversion. The quantity, however, is reportable and will be transmitted to the US NRC electronically today.

"The Radiation Safety Officer, RSO, for the University of Illinois at Chicago (UIC) contacted the Agency to advise that a shipment of 21 eye plaque brachytherapy seeds from Theragenics Corporation received on September 27, 2021 was found to contain only 20 seeds upon opening of the package. The RSO reported that no damage to the package was observed and that the container holding the seeds was appropriately sealed. Surveys were performed of packing materials and the package receipt area to locate the potentially lost 2.5 mCi I-125 brachytherapy seed. The licensee's surveys and investigation did not result in locating the seed. Theragenics was notified on September 27, 2021 and initiated an investigation. A letter received by UIC from Theragenics on November 1, 2021 stated that no discrepancies were identified and the manufacturer/shipper maintained 21 seeds were shipped as ordered. An additional seed was ordered and received on September 28, 2021 from Theragenics and the patient treatment was successfully completed on September 30, 2021 to October 4, 2021.

"The incident is immediately reportable per 32 Ill. Adm. Code 340.1210(a). The matter was not reported timely by the licensee, which the Agency will address under separate correspondence. Additional information is being sought from the licensee at this time."

Illinois Item Number: IL210035

EN Revision Imported Date: 11/10/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"The licensee was at a temporary jobsite and stepped away from their vehicle. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case. The licensee notified the police and has begun actions to recover the gauge. The Division is waiting for additional information from the licensee. "

Utah Event Report ID Number: UT 210006

* * * UPDATE FROM SPENCER WICKHAM TO THOMAS KENDZIA AT 1259 EDT ON 11/4/21 * * *
The following information was received via e-mail:

"At the time of this notification (UT 210006) we did not have information pertaining to the gauge. Please see the following gauge information.
Model: Instrotek 3500, Serial Number: 3823, Cs-137: 11 mCi, Am-241: 44 mCi.

"The licensee has recovered the stolen gauge. The gauge was still locked and chained in the transport vehicle in it's transport package and had not been tampered with. The Division will update and send the NMED report once the event is closed."

Notified R4DO (KOZAL), NMSS Events Notification group (email), and ILTAB (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

EN Revision Imported Date: 11/10/2021

EN Revision Text: AGREEMENT STATE REPORT - FIRE IN POOL IRRADIATOR FACILITY

The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:

"The [Illinois Emergency Management] Agency was contacted at approximately 16:00 [CDT] on 11/2/21 by Isomedix Operations, Inc. (d/b/a Steris Applied Sterizliation Technologies, RML IL-01123-02) to advise of a fire in one of their irradiation cells that occurred at approximately 05:00 [CDT] this morning in Libertyville, IL. Sources, irradiator lift mechanisms, and associated safety/security systems were reportedly unaffected. Local fire personnel did respond, but maintenance crew were able to extinguish the fire prior to their arrival. This matter is reportable under 32 Ill. Adm. Code 346.830(a)(2).

"The radiation safety officer for Isomedix Operations, contacted the Agency at 16:00 [CDT] today and informed of a fire in a radiation room at their pool irradiator facility. Reportedly, maintenance crews were performing overhead welding in the source room when hot slag fell on a product tote. The tote was located near the portal entry of irradiator 192. The fire alarm was pulled and the maintenance crew was able to put out the fire using a handheld extinguisher. Local fire arrived, performed an investigation and departed without further concern. The irradiator was removed from service as Isomedix staff spent the duration of the day assessing safety systems. Water purity checks and exposure rates indicate no impacts to sources. Cables, cable shrouds and associated lifting mechanisms were assessed and were not impacted. Having found no additional radiological or safety mechanisms impacted, the facility returned to routine operations at 16:00 [CDT] today.

"IEMA staff are pursuing additional information from the licensee and performing a reactionary inspection on 11/3/21. Additional information will be communicated as it becomes available."

Illinois Report Number : IL210036

EN Revision Imported Date: 11/10/2021

EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MEDICAL EVENT

The following information was received from the Commonwealth of Massachusetts via email:

"On November 2, 2021, 3:00 PM [EDT], licensee reported medical event under license 60-0160 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a Y-90 5 mCi microsphere therapy treatment delivered to patient liver on November 2, 2021 remained in the delivery system causing delivery of approximately 3.67 mCi Y-90 of the prescribed 5 mCi. The error was discovered immediately after treatment. Administered dose to treatment area differed from prescribed dose by approximately 27 percent. Licensee stated the cause, including possible equipment malfunction, has not yet been determined. Prescribing physician, referring physician and patient have been notified. Licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment would be required due to this situation. Licensee stated all Y-90 was accounted for. Licensee stated 5 mCi prescription was unusually small compared to previous procedures (range 9-to-39 mCi with 15 mCi being the most prescribed dose). Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation.

Investigation ongoing. Agency considers this event docket to still be OPEN.

Report by Anthony Carpenito, 11/3/2021.

EN Revision Imported Date: 11/10/2021

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

The following information was received from the State of Texas via email:

"On November 3, 2021, a licensee reported a moisture density gauge was discovered missing on August 30, 2021. The licensee's attempts to locate the gauge were unsuccessful. The licensee last had eyes on the gauge during the previous inventory in January of 2021. The gauge is a Humbolt model 5001 serial 7442 containing 10 mCi of Cs-137 with serial 2376CZ and 40 mCi of Am-241 with serial 404-09. The empty transport container with locks on the latches was present at the licensee's storage location. The gauge may not be inside a transport container. The licensee was unsure if a lock was present on the source rod. The incident was reported to the local police department. More information will be provided per SA 300 as it is obtained."

Texas incident no.: 9892

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: 11/10/2021

EN Revision Text: OFFSITE NOTIFICATION

"At 1015 CST, a report was made to the State of Nebraska Department of Environment and Energy (NDEE) based on the analytical report for soil samples from the area surrounding the removed FO-10, Auxiliary Boiler Fuel Oil Storage Tank. The tank was removed as part of Fort Calhoun Station decommissioning and soil samples were tested due to historical information from a similar tank removal earlier this year (June 2021). The soil contamination levels are from the historic use of the tank. The contamination levels [of Volatile Organic Compounds] are above the lab reporting limits and thereby reportable to the State of Nebraska Department of Environment and Energy. There was no contamination noted in the groundwater samples. The NDEE will determine what, if any, remediation may be required. The state NDEE requested the District utilize their Spill Form because this is the simplest method of State notification for tanks exempted due to 40 CFR280.10(c)(4).

"No active petroleum spills are in progress and appropriate remediation actions will be taken in accordance with Nebraska State regulation and guidance."

The licensee will notify NRC Region 4 personnel.

OFFSITE NOTIFICATION DUE TO VIOLATION OF DISCHARGE PERMIT

"At 1040 hours EST, November 9, 2021, the site reported a violation of the station National Pollutant Discharge Elimination System permit. The 24-hour environmental report addressed an unauthorized discharge of 7,245 gallons of non-radiological water that was pumped into a storm drain to de-water an on-site electrical vault located outside of the protected area. This discharge occurred from 0800 to 1230 hours on November 8, 2021. Sampling and analysis of the vault water is in progress to assess for the presence of pollutants.

"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The licensee notified the U.S. Environmental Protection Agency and the Commonwealth of Massachusetts Department of Environmental Protection.