Event Notification Report for November 29, 2021

EN Revision Imported Date: 11/29/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SOURCE

The following was received by fax from the New York State Department of Health (NYSDOH):

"NYSDOH received a written report by mail of a leaking source. Suffolk Co. Public and Environmental Health Laboratory, [redacted], 725 Veterans Memorial Highway, Hauppauge, NY (NYSDOH Radioactive Materials License No. 1801) conducted routine leak testing on their two Agilent Technologies 8890 (03540A) GC [Gas Chromatograph] System (S/N US2106A027) ECO containing a 15 mCi (approx.) [Ni-63 source] G2397A (S/N U34601). Leak test samples were taken by the RSO on November 5th and sent to Agilent Technologies for analysis. The sample was processed on November 9th and preliminarily reported by Agilent to the Licensee on November 10th indicating that one of the ECO sources was leaking above the 0.005 uCi threshold. The Licensee RSO immediately obtained information from Agilent on the leaking source and copies of the preliminary reports. The Licensee provided NYSDOH with a written notification and report on November 10th by mail (received November 15th). The leaking quantity assessed at 45660 +/- 214 pCi. The GC unit was shut down and isolated. Agilent was notified (Radiation Safety Officer - RSO) to follow up on the leaking source and determine next steps. The system is less than one year old and still under service contract with Agilent.

"NYSDOH spoke with RSO upon receipt of this letter and GC/ECD was new as of March 2021. The defective detector (entire unit) has been isolated from service and Agilent is scheduled to arrive on 11/23/2021 to package and prepare unit for shipment. A radiological survey (contamination survey) was completed upon the isolation of the device showing radiation levels were consistent with background levels, indicating no fixed or removable contamination present.

"No further information on device or incident is available."


NY State Event Report ID No. NY-21-04

EN Revision Imported Date: 11/29/2021

EN Revision Text: AGREEMENT STATE REPORT - FOUND SOURCE

The following was received by email from the Kansas Department of Health & Environment:

"At approximately 1300 CST on 19 November 2021, Kansas Radioactive Material Program received a call from a corporate safety officer for a local business, Advantage Metal Recycling. Advantage Metal Recycling is located in Kansas City, Kansas. The recycling yard, not a licensee, notified the department that they had a radiation detector alarm on their metal shredder. The corporate representative was calling from out of state and did not have all the information on the handheld survey meters but they had a 'Ludlum meter with a pancake probe that was off scale at 1000 microR/hr and a model 19 that was reading approximately 2000 microR/hr.' The surveys were estimated at 2-4 feet.

"At 1415 CST on 19 November, two members of the Kansas Radiation Control Program left Topeka, Kansas to respond to the site. They arrived at approximately 1509 CST. Surveys taken by 2401-P and 451P indicated the highest exposure rate reading of a large pile of shredded metal was 26.2 mR/hr. The Kansas staff also performed surveys of the machinery which shreds the metal and did not identify any elevated exposure rate readings. Because of this it is suspected the source was not punctured and there is not residual contamination of the yard or the machinery. Given the high exposure rate and identity of the source being unconfirmed at this time (Identifinder indicated Ra-226) it was determined to report this incident to the HOO.

"The scrap yard had an appropriately licensed contractor onsite remove the material on the evening of 19 November. The contractor entered Kansas via reciprocity and confirmed they removed the material and placed it in their secured facility. More information will follow as it becomes available."

EN Revision Imported Date: 11/29/2021

EN Revision Text: AGREEMENT STATE REPORT - FOUND SOURCE

The following was received from the Ohio Department of Health Bureau of Radiation Protection (ODH) via email:

"Cohen Brothers, scrap metal facility in Middletown, informed ODH on November 19, 2021, that they discovered two devices containing radioactive material at their facility. An ODH inspector responded and identified the devices as Industrial Dynamics Filtec 3-G devices, each containing a 100 mCi Am-241 sealed source.

"Dose rates on the devices were 30 microR/hr. No contamination was detected. The gauges are secured at Cohen Brothers pending proper disposal.

"ODH is working with Industrial Dynamics to determine the owner of the devices."

The Filtec 3-G gauge serial numbers are 121015 and 121016.

Ohio Item Number: OH2100010

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: 11/29/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

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

"On November 22, 2021, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on November 19, 2021. A patient had been prescribed two administrations to different segments of the liver of 126 Gy and 138 Gy. However, the licensee has estimated that the administered doses were 256 Gy (103 percent [over]) and 294 Gy (113 percent [over]). The administered doses had been ordered with an incorrect calibration date. A full dose projection is ongoing by the vendor. The State will perform a reactive inspection."

Wisconsin event no.: WI210010

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: 11/29/2021

EN Revision Text: AGREEMENT STATE REPORT - Y-90 UNDERDOSE

The following was received from the California Department of Public Health (CDPH) by email:

"On Saturday, November 20, 2021, at 0928 [PST], a CDPH-Radiologic Health Branch inspector was notified by e-mail that a medical event had occurred on Friday, November 19, 2021, at UCLA during a Y-90 liver cancer treatment. There were four liver segments being treated with four vials of Y-90 TheraSpheres. The prescribed dose for 'Segment 2' was 120 Gy, but the dose delivered was 74.9 Gy (or 62.42 percent of the prescribed dose). Segments 3, 6 and 8 were prescribed 120 Gy each and the doses delivered were 108.0 Gy, 110.9 Gy and 107.0 Gy (90 percent, 92.42 percent and 89.17 percent of the prescribed doses, respectively). Using the post treatment radiation surveys of the Nalgene waste container, a UCLA medical physicist determined that a medical event had occurred. The delivered dose to the organ differed by more than 20 percent from the prescribed dose.

"The authorized physician tried unsuccessfully to use a 2.0 Fr Truselect microcatheter for an hour to access the artery to segment 2, but it was extraordinarily small in caliber. He eventually chose to use a 1.7 Fr Echelon microcatheter for the treatment. Other treatment options were considered, but this particular tumor was in a location that was not amenable to ablation or chemoembolization. The patient will have a follow-up MRI scan in 3 months. A 15-day written report will be generated by the UCLA."

CA 5010 Number: 112021

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: 11/29/2021

EN Revision Text: FOUND LICENSED RA-226 SOURCES

The following is a synopsis of a telephonic report from the RSO at South Dakota State University:

On about October 14, 2021, the University was contacted to collect two orphaned Ra-226 sources from a residence of a former employee. One source was within an Ionization Cell Model A-4149, the other was contained in a lead pig. Swipe surveys did not detect any leakage from the sources. Both sources are identical, 0.056 mCi Ra-226, Dated 09-66, Barber-Colman Company, Rockford, Illinois. There are no serial numbers to determine the original owner. The deceased employee also worked in the chemistry department at Southwest Minnesota State University.

The Radiation Safety Officer has properly secured the items and is herby notifying the NRC of the possession of this licensed material, which is allowed by their license.

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

AUTOMATIC ACTUATION OF THE EMERGENCY AC ELECTRICAL POWER SYSTEM

"At 0519 EST on November 27, 2021, with Unit 2 in Mode 5 at zero percent power, an actuation of the Emergency AC Electrical Power System occurred. The reason for the Emergency AC Electrical Power System auto-start was a lockout of the CT-2 transformer; causing a temporary loss of AC power to the main feeder bus. The Keowee Hydroelectric Units 1 and 2 automatically started as designed when a main feeder bus undervoltage signal was received.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Emergency AC Electrical Power System.

"Additionally, the temporary loss of AC power resulted in a loss of Decay Heat Removal (DHR) that was restored upon power restoration to the main feeder bus. Therefore, this condition is also being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v) for an event or condition that could have prevented fulfillment of a safety function.

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

The loss of the CT-2 transformer is under investigation. Main feeder bus power was restored within a minute so no plant heat up occurred as a result of the loss of the decay heat removal system.