Event Notification Report for November 30, 2021

EN Revision Imported Date: 11/30/2021

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: 11/30/2021

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: 11/30/2021

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: 11/30/2021

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

EN Revision Imported Date: 11/30/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT

The following was a summary of an e-mail received by the state of California's Radiation Health Branch (RHB):

"The Radiation Safety Officer (RSO) at the licensee facility contacted the RHB and Los Angeles County Radiation Management (L.A. County) on November 22, 2021, to report a medical event. The event occurred on November 19, 2021. According to the RSO, a patient, who was part of a clinical trial, was under-dosed during a therapeutic treatment procedure for prostate cancer that involved the injection of actinium 225 (Ac-225) in the peripheral vein. The prescribed dose to the patient was 150 microcuries; however, the dose delivered was only 114 microcuries due to an accidental discharge of the radioisotope on the chux pad before it was administered to the patient. There was no spread of contamination. A site visit will be conducted to gain a better understanding of the details of the event."

California Event Number: 112221

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.

AUTOMATIC REACTOR TRIP

"On November 29, 2021 at 1458 CST, Arkansas Nuclear One, Unit 1, (ANO-1) automatically tripped due to high Reactor Coolant System pressure after the 'A' Main Feedwater Pump was manually tripped due to lowering speed.

"ANO-1 is currently stable in MODE 3 (Hot Standby) maintaining pressure and temperature with the P-75 Auxiliary Feedwater pump and steaming to the Condenser.

"There are no indications of a radiological release on either unit as a result of this event.

"This report satisfies the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A) for the Reactor Protection System actuation.

"The NRC Senior Resident Inspector has been notified."

Unit 2 was not affected.