Event Notification Report for December 20, 2021

EN Revision Imported Date: 12/20/2021

EN Revision Text: DEVIATION OF DELIVERY PROCEDURE BY COMMON CARRIER STAFF LEAVING RADIOACTIVE MATERIAL UNATTENDED

"A Medical Oncology employee discovered a radioactive source package when exiting the Medical Oncology suite around 1420 EST on Wednesday, 12/1/2021. She noticed the label 'Radiation' and proceeded to pick it up and bring it into the Radiation Oncology suite down the hallway on the same floor (2nd floor) of the building. Radiation Oncology Staff notified Chief Therapist and Physicist who promptly brought the source into the designated area, performed a survey and inspection to ensure no break in seals or radiation leakage and to document the receipt of the package. [The source was a 10 Ci Ir-192 source. On contact readings with the package were 4.2 mR/hr and one meter survey reading was 0.6 mR/hr.] Later that evening, the regional Smilow radiation oncology physicist notified the hospital radiation safety officer who started an investigation on Thursday, 12/2/2021, morning.

"[The common carrier's] tracking indicated that the package was delivered at 1404 EST on 12/1/2021, i.e., a few minutes prior to its discovery outside the Medical Oncology suite. The Medical Oncology secretary indicated that she had noticed a [common carrier] person in the hallway a few minutes prior to her finding the package outside the suite. The package was not delivered to the radiation therapy department at Greenwich Hospital as indicated by the shipper's declaration for dangerous goods and no signature/confirmation was obtained from the radiation therapy department for the delivery. Radiation exposure and potential risk to staff from this well shielded source over the incident encounter time would be negligible.

"The carrier has been notified of the incident, the fact that proper protocol was not followed in delivering the package and the fact that this is unacceptable.

"There was no measurable exposure to staff or patients. The incident is categorized as deviation from an already established and practiced radioactive material delivery procedure by [common carrier] staff. Radiation Oncology team had an in-service [training] to all concerned explaining this incident and as a reminder of procedures on delivery of radioactive material packages.

"We escalated this matter to the system [Yale New Haven Health System] (YNHHS) strategic resources who contacted the regional [common carrier] to obtain an explanation and corrective action from them."

EN Revision Imported Date: 12/20/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO UNINTENDED ORGAN

The following was received from the Commonwealth of Pennsylvania by email:

"On December 10, 2021, the Radiation Safety Officer for the licensee verbally reported a patient being treated for vaginal cancer was prescribed a 21 Gy total dose, to be delivered in 3 fractions of 7 Gy each via HDR [(high dose rate)]. The first fraction was delivered on October 28, 2021. At some point after that treatment, the patient began experiencing complications from the hysterectomy and ended up going to a different hospital for that issue. The patient did not return to the licensee's facility to complete her treatment. At the other hospital, a different Radiation Oncologist was consulted and was reviewing the patient's treatment and discovered that the treatment in October at the licensee was 3 cm off and the intestine received some fraction of the first treatment dose. It was discovered that the patient required re-suturing of the cervix and that the brachytherapy apparatus (used in the HDR treatment) passed beyond the apex of the vagina. This discovery was made yesterday, December 9, 2021. The licensee's medical physicist is currently calculating dose estimates. The referring physician is also being informed. No further information is available at this time. The Department of Environmental Protection will update this event as soon as more information is provided."

PA Event Report ID No: PA210021

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: 12/20/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST PORTABLE TROXLER GAUGE

The following is a summary of information received from the state of George via email:

A portable troxler gauge (Model 3430) with an Am-241/CS-137 was lost by a common carrier. The activity of the source is unknown at this time.

Serial Number: 21711
Am-241 Source Serial Number: 47-16983
Cs-137 Source Serial Number: 75-3259

Georgia Incident Number: 19

** HOO Developed Information **
CS -137 Manufacture Radiological Specification (8mCi plus or minus 10 percent)
Am-241 Manufacture Radiological Specification (40mCi plus or minus 10 percent)

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: 12/20/2021

EN Revision Text: INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM

* The following information was provided by the licensee via email:

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of the Reactor Protection System (RPS). On October 20, 2021, at approximately 0705 hours Central Daylight Time (CDT), Browns Ferry, Unit 1, 1B RPS bus unexpectedly lost power. The loss of the bus resulted in a half scram, automatic Primary Containment Isolation System (PCIS) Groups 2, 3, 6, and 8 isolations, and Trains A, B, and C SBGT [Stand-By Gas Treatment] and A CREV [Control Room Emergency Ventilation system] started. All systems responded as expected. At 0720 hours CDT, the bus was placed on the alternate power supply and the half scram and PCIS isolations were reset.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The cause of the RPS bus loss was a trip of the underfrequency relay due to drift of the relay setpoint. The relay was replaced and 1B RPS bus was returned to the normal power supply on October 21, 2021, at 0510 hours CDT.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Condition Report 1729592.

"The NRC Resident Inspector has been notified of this event."