Event Notification Report for December 01, 2021

EN Revision Imported Date: 12/1/2021

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.

EN Revision Imported Date: 12/1/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received via email from the Mississippi State Department of Health (the agency) via email:

"On 22 November 2021, the licensee notified the Agency by email regarding an incident that took place on 19 November 2021. The [Berthold Technologies] reciprocity crew, working under reciprocal recognition, was conducting turn around, replacing three gauge systems at the Licensee plant's Operating Processes. Two of the three sources retracted while one source was discovered to be stuck in the dip tube (Source Information: Co-60, 7.43 mCi, Manufacturer/Model: EG&G Berthold Model P-2608-100, Serial #: 1540-08-05, Device Information: Manufacturer EG&G Berthold, Device Model#: LB 7671, Serial Number: TBD). Reciprocity personnel attempted to dislodge the source to get it to retract but all attempts failed. The technician attached a blind plate (surveys below background) to prevent access and he documented surveys which the reciprocity personnel stated will be provided at a later time. According to the reciprocity licensee personnel, surveys were approximately 0.2 to 0.3 mR/hr at the detector side. Licensee personnel stated that the source is secured and remains shielded. Reciprocity licensee stated that they will continue to consider options to dislodge the source. The investigation into this event is ongoing and information will be provided as it is received in accordance with SA-300."

Mississippi Item Number: MS-210003

EN Revision Imported Date: 12/1/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL MISSING IN TRANSIT THEN RECOVERED

The following was received from the Massachusetts Radiation Control Program [the Agency] via email:

"On 11/17/2021, 1113 EST, the licensee reported 3 packages containing radioactive material were not received at PerkinElmer facility in Groningen, Netherlands. Extensive searches were conducted in Boston, Amsterdam and Zurich. The packages were destined to arrive in Zurich on November 13, 2021. The 3 packages, each with a Transport Index 0.1, were shipped, along with 20 other excepted packages, from Logan International Airport in Boston, MA on 11/12/2021. The transfer of the packages was planned in the following sequence: Logan International Airport, Boston - Zurich - Amsterdam - Groningen, The Netherlands. All 23 packages were received in Zurich on November 13. Only 20 of the 23 packages were recorded as received in Amsterdam. The 3 missing packages were positively identified as the packages labeled as Yellow II with a TI of 0.1 each. The 3 packages contained the following radioactive material: Package 1 had 3 vials of P-32 with total activity of 1.5 mCi, Package 2 had 1 vial of I-125 at 0.160 mCi, and Package 3 had 1 vial of P-32 at 0.800 mCi. Each package was 25 cm x 15 cm x 13 cm in dimension and constructed of white cardboard with Styrofoam packing in shielded vials. A shipping manager at PerkinElmer, Inc., Boston, was first notified via email at 0719 EST on November 17 that the package was not received by the PerkinElmer facility in Groningen, Netherlands. The Radiation Safety Officer was first notified around 0900 EST. On November 19, the licensee notified the Agency that the 3 packages were found in Zurich.

"The Agency considers this matter closed. "

Massachusetts Event Number: 23-4724

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: 12/1/2021

EN Revision Text: AGREEMENT STATE REPORT - GAMMA KNIFE SHUTTER DOORS FAIL TO CLOSE

The following report was received via email from the New Jersey Department of Environmental Protection:

"While conducting the routine spot check prior to patient treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6114, the unit's shutter doors failed to close during the "Emergency Off" button test. The licensee's authorized medical physicist (AMP) followed emergency procedures and entered the room to manually close the doors. The doors closed, but the AMP decided to try again with the same result. The AMP carried a handheld survey meter with them each trip. Their calculated total exposure for their trips based on the exposure rate was 0.575 mR. There was no patient involvement. The unit is secured and Elekta is in the process repairing the unit. The licensee will follow-up with a full report."

EN Revision Imported Date: 12/1/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT

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

"On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries.
Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9896

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: 12/1/2021

EN Revision Text: 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.

UNIT 1 AUTOMATIC SCRAM

"At 1254 EST on November 30, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed during Turbine Valve Cycling surveillance activities.

"Unit 1 reactor was being operated at approximately 80 percent rated thermal power with turbine valve cycling surveillance activities in progress. The Control Room received indication that both divisions of RPS [reactor protection system] actuated from turbine valve closure signals and all control rods fully inserted. The Main Turbine was manually tripped, and turbine bypass valves opened automatically to control reactor pressure. Reactor water level lowered to -35 inches causing Level 3 and Level 2 isolations. No ECCS [emergency core cooling systems] actuations occurred. RCIC [reactor core isolation cooling] automatically initiated as designed at -30 inches. The Operations crew subsequently maintained reactor water level at the normal operating band using Feedwater pumps and RCIC was placed in a standby lineup.

"The reactor is currently stable in Mode 3. An investigation is in progress into the cause of the turbine valve closure signals.

"The NRC Senior Resident Inspector was notified. A voluntary notification to PEMA [Pennsylvania Emergency Management Agency] will be made.

"This event requires a 4-hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8-hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A)."

Unit 2 was not affected and remains at 100 percent power, Mode 1.