Event Notification Report for December 09, 2021

EN Revision Imported Date: 12/9/2021

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

The following was received from the Commonwealth of Virginia (the Agency) via email:

"On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."

Virginia Event Report ID No.: VA210008

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: 12/9/2021

EN Revision Text: AGREEMENT STATE - LEAK TEST EXCEEDS LIMITS

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

"On November 30, 2021, the Department received notification from the licensee of a leak test (0.0129 microCi) that exceeded the regulatory limit of 0.005 microCi. The licensee is going to return it to the manufacturer for repair. The Department has requested additional information and continues to investigate the event.

"Particle Measurement System, Inc.
Air Sentry II Ion Mobility Spectrometer unit
SN# 59369
Cell SN5935
10 mCi of Ni-63"

Arizona Incident Number 21-011

EN Revision Imported Date: 12/9/2021

EN Revision Text: AGREEMENT STATE - LOST I-125 SEED

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

"On December 1, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, one IsoAid Advantage I-125 breast localization seed [approximately 0.4 mCi] was removed by surgery on 11/30/2021 and was verified to be included in the specimen. The specimen with the seed was delivered to pathology on the afternoon of 11/30/21. When a nuclear medicine technologist went to retrieve the seed from pathology, the technologist noticed only a marker and not an actual seed. 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 missing I-125 seed. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number 21-012

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: 12/9/2021

EN Revision Text: AGREEMENT STATE - OCCUPATIONAL OVEREXPOSURE

The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:

"Dosimetry results for the month of October 2021 for one employee showed ring extremity dosimeter readings of 77,156 millirads for one hand and 29,391 millirads for the other hand. The employee was interviewed and it appears that the radiation exposures were received during experiments involving yttrium-90 radiolabeling and injections into mice on October 25-27, 2021. The activity used during the experiments is not known at this time, but they had received a shipment of 40 milliCuries of yttrium-90 just before these experiments.

"This event is still being investigated by the licensee, but some [preliminary] calculations using the `beta activity to dose-rate' online calculator in Rad Pro Calculator suggest that the high dosimetry results could have been caused if the outside of the employee's ring extremity dosimeters were contaminated with as little as a few thousandths of a microCurie of yttrium-90. This possibility of contamination on the ring extremity dosimeters is also supported by the employee's low whole body dosimeter results for the month of October 2021, which were 0 millirems deep dose, 45 millirems lens dose, and 97 millirems shallow dose. The much lower dosimetry results of a coworker who was working alongside of the exposed employee also suggest that contamination on the ring extremity dosimeters of the exposed employee may have been the cause. The coworker's results were ring extremity dosimeter readings of 6025 millirads on one hand and 889 millirads on the other hand, and whole body dosimeter results of 0 millirems deep dose, 32 millirems lens dose, and 68 millirems shallow dose."

Washington Reference Document Number: WA-21-025

EN Revision Imported Date: 12/9/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING TROXLER GAUGE

The following was received from the state of Florida by email:

"Received a call from Atlantic Drilling Supply Co. about a missing Troxler gauge (#21834) which has sent to his company for service. The gauge was shipped to the old address of the customer, NOVA Engineering in Tallahassee, FL vice the new address. The shipper cannot locate the gauge. Gauge was shipped 11/18/21 and scheduled for delivery 11/19/21. Gauge was reported missing to Atlantic drilling 11/29/21.

"As of 11/30/21, at 1035 EST, the shipper has found the Troxler gauge on their loading dock and will deliver it to the correct address."

FL Incident number FL21-139

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

RESEARCH REACTOR TECH SPEC DEVIATION RESULTING IN A REACTOR SCRAM

"On 12/7/2021 at 1248 EST, the Breazeale reactor (50-005) [a TRIGA reactor] was operating for a NUCE 451 lab. The reactor operator was trying to perform a $0.75 [measure of reactivity] square wave with a setpoint of 500 kW. When the operator entered the setpoint, he did not hit ENTER so the 500 kW was not stored in the console, which defaulted to the current power level (100 W) as the setpoint.

"Once the square wave was executed, the control rods immediately began to move in to counter the $0.75 of reactivity from the pulse rod and maintain the power level at 100 W. The operator noticed that the setpoint was incorrect, and after 9 seconds, changed the power setpoint to 500 kW. At this time, the rod bank began to move out, adding $1.20 over the course of 4 seconds. (The maximum total reactivity beyond critical is estimated to be ~$1.10).

"The reactor scrammed based on high log range (fission chamber) power and high wide range (GIC) power. The last two points of data from the data historian indicate that the period was +0.25 seconds. Based on the rod insertion speed and differential rod worth at the position from which the scram was initiated, it was estimated that the maximum power following the scram (setpoint = 1.08 MW) was approximately 1.29 MW. The highest data point recorded by the historian was 1.38 MW (log fission chamber data), which is corroborated by the estimate calculated based on rod speed, and 1.38 MW represents the best estimate of the maximum reactor power.

"The reactor technical specifications (TS) dictate that: "The maximum power level SHALL be no greater than 1.1 MW (thermal)." (TS 3.1.1.b). This condition applies to non-pulse operation. According to the TS definitions, the reactor is neither "secured" nor "shut down" during a scram, and therefore must be considered to be operating while the rods are in motion after the scram is initiated. Therefore, this event resulted in the violation of TS 3.1.1.b by allowing power to reach 1.38 MW, higher than the 1.1 MW scram setpoint. It is worth noting that TRIGA reactors like the Breazeale reactor are designed to be pulsed to several gigawatts of power, and the 1.1 MW limit is based on steady state power analysis, not power transient analysis. The fuel reached a maximum temperature of 42 C, far below the safety limit of 1150 C (TS 2.1).

"This event is reportable due to: exceeding an LCO in the technical specifications (1.1 MW power limit) and an unanticipated change in reactivity greater than $1 when the rod bank drove out following the change in power setpoint.

"The root cause of this event was operator error. The operator failed to follow best practices by checking that the setpoint was entered correctly, and then acted outside of procedure to attempt to correct the setpoint.

"The reactor was immediately secured and tagged out pending corrective actions identified in the event evaluation document, AP4 2021-03. The immediate corrective actions, completed on 12/8/21, were to:
1 - add a pen-and-ink revision to SOP-1 instructing the operator to verify the power setpoint;
2 - hold a reactor staff training on the event, its causes, and the importance of following procedure and checking values entered into the console;
3 - implement an administrative prohibition on square waves until the console software can be changed to add a feature to prevent recurrence of this event.

"Following these corrective actions reactor operation was approved by the ADO (Level 2).

"A detailed written report will be sent to the Reactor Safeguards Committee and NRC by December 21st."

The licensee will notify the Non-Power Production or Utilization Facility (NPUF) Licensing Branch Project Manager.