Event Notification Report for December 20, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/19/2021 - 12/20/2021
Hospital
Event Number: 55639
Rep Org: Greenwich Hospital
Licensee: Greenwich Hospital
Region: 1
City: Greenwich State: CT
County:
License #: 06-09522-01
Agreement: N
Docket:
NRC Notified By: Adel Mustafa
HQ OPS Officer: Bethany Cecere
Licensee: Greenwich Hospital
Region: 1
City: Greenwich State: CT
County:
License #: 06-09522-01
Agreement: N
Docket:
NRC Notified By: Adel Mustafa
HQ OPS Officer: Bethany Cecere
Notification Date: 12/09/2021
Notification Time: 15:21 [ET]
Event Date: 12/01/2021
Event Time: 14:04 [EST]
Last Update Date: 12/10/2021
Notification Time: 15:21 [ET]
Event Date: 12/01/2021
Event Time: 14:04 [EST]
Last Update Date: 12/10/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
Person (Organization):
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
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 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."
Agreement State
Event Number: 55640
Rep Org: PA Bureau of Radiation Protection
Licensee: UPMC Passavant
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-0310
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Lloyd Desotell
Licensee: UPMC Passavant
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-0310
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Lloyd Desotell
Notification Date: 12/10/2021
Notification Time: 13:27 [ET]
Event Date: 10/28/2021
Event Time: 00:00 [EST]
Last Update Date: 12/10/2021
Notification Time: 13:27 [ET]
Event Date: 10/28/2021
Event Time: 00:00 [EST]
Last Update Date: 12/10/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_Events_Notification, (EMAIL)
Dentel, Glenn (R1DO)
NMSS_Events_Notification, (EMAIL)
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 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
Agreement State
Event Number: 55642
Rep Org: Georgia Radioactive Material Pgm
Licensee: Terracon Consultants, Inc
Region: 1
City: Kennesaw State: GA
County:
License #: GA 1383-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Kerby Scales
Licensee: Terracon Consultants, Inc
Region: 1
City: Kennesaw State: GA
County:
License #: GA 1383-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Kerby Scales
Notification Date: 12/13/2021
Notification Time: 09:55 [ET]
Event Date: 12/09/2021
Event Time: 00:00 [EST]
Last Update Date: 12/13/2021
Notification Time: 09:55 [ET]
Event Date: 12/09/2021
Event Time: 00:00 [EST]
Last Update Date: 12/13/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/21/2021
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 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
Power Reactor
Event Number: 55660
Facility: Browns Ferry
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Mark Acker
HQ OPS Officer: Brian Lin
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Mark Acker
HQ OPS Officer: Brian Lin
Notification Date: 12/16/2021
Notification Time: 14:57 [ET]
Event Date: 10/20/2021
Event Time: 07:05 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:57 [ET]
Event Date: 10/20/2021
Event Time: 07:05 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2)
Miller, Mark (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
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."
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."
Hospital
Event Number: 55643
Rep Org: Monument Health
Licensee: Monument Health
Region: 4
City: Rapid City State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Licensee: Monument Health
Region: 4
City: Rapid City State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Notification Date: 12/14/2021
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 12/14/2021
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 12/14/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/21/2021
EN Revision Text: NON-AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following is a summary of a phone call with the licensee:
A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
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 Text: NON-AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following is a summary of a phone call with the licensee:
A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
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.
Agreement State
Event Number: 55644
Rep Org: MA Radiation Control Program
Licensee: Lantheus Medical Imaging
Region: 1
City: North Billerica State: MA
County:
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Brian Lin
Licensee: Lantheus Medical Imaging
Region: 1
City: North Billerica State: MA
County:
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Brian Lin
Notification Date: 12/14/2021
Notification Time: 16:41 [ET]
Event Date: 12/13/2021
Event Time: 00:00 [EST]
Last Update Date: 12/16/2021
Notification Time: 16:41 [ET]
Event Date: 12/13/2021
Event Time: 00:00 [EST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
Young, Matt (R1)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/21/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING THALIUM-201 SHIPMENT
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"Lantheus Medical Imaging, Inc. notified the Agency at 1145 EST on 12/14/2021 that a thalium-201 (73.1 hr half-life) shipment in route to RLS USA, Inc. went missing in transit during vehicle maintenance operations. The vehicle had a flat tire that needed to be replaced. The flat tire occurred the early morning of 12/13/2021 around 0000 EST, but possibly before 0000 EST on the evening of 12/12/2021, [near Pallisades Park, NJ]. During the tire change, the packages were removed from the vehicle in order to complete the maintenance. RLS USA, Inc. reported to Lantheus Medical Imaging, Inc. on the evening of 12/13/2021 that the thallium material was not received. A Tc-99m generator package shipped in the same vehicle was received by RLS USA, Inc. as part of the delivery, but the thalium-201 package was not received.
"The missing package contained 117 mCi of thalium-201 as of 12/12/2021 (Yellow II package, 0.3 TI).
"The reporting requirement is within 30 days and is of 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open. New York State and New Jersey Agencies were contacted."
* * * UPDATE FROM ROBERT LOCK TO THOMAS KENDZIA AT 1121 EDT ON 12/16/21 * * *
The following information was received from the Agency via e-mail:
"Correction: Lantheus Medical Imaging, Inc. reports that the flat tire on the delivery vehicle occurred at 6:45 PM on 12/12/2021.
"Correction: The event was reported to the Massachusetts Radiation Control Program at 11:45 a.m. on 12/14/2021 (the 11:45 p.m. in the narrative is a typo and should be a.m.).
"MDS performed searches for the package [where the flat tire was changed] and surrounding areas, performed searches at another location on the delivery route (MDS warehouse located in Little Ferry, NJ) and contacted other facilities on the route where other packages were delivered.
"The package continues to be missing."
Notified R1DO (YOUNG), NMSS Events Notification group (email), and ILTAB (email).
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 Text: AGREEMENT STATE REPORT - MISSING THALIUM-201 SHIPMENT
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"Lantheus Medical Imaging, Inc. notified the Agency at 1145 EST on 12/14/2021 that a thalium-201 (73.1 hr half-life) shipment in route to RLS USA, Inc. went missing in transit during vehicle maintenance operations. The vehicle had a flat tire that needed to be replaced. The flat tire occurred the early morning of 12/13/2021 around 0000 EST, but possibly before 0000 EST on the evening of 12/12/2021, [near Pallisades Park, NJ]. During the tire change, the packages were removed from the vehicle in order to complete the maintenance. RLS USA, Inc. reported to Lantheus Medical Imaging, Inc. on the evening of 12/13/2021 that the thallium material was not received. A Tc-99m generator package shipped in the same vehicle was received by RLS USA, Inc. as part of the delivery, but the thalium-201 package was not received.
"The missing package contained 117 mCi of thalium-201 as of 12/12/2021 (Yellow II package, 0.3 TI).
"The reporting requirement is within 30 days and is of 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open. New York State and New Jersey Agencies were contacted."
* * * UPDATE FROM ROBERT LOCK TO THOMAS KENDZIA AT 1121 EDT ON 12/16/21 * * *
The following information was received from the Agency via e-mail:
"Correction: Lantheus Medical Imaging, Inc. reports that the flat tire on the delivery vehicle occurred at 6:45 PM on 12/12/2021.
"Correction: The event was reported to the Massachusetts Radiation Control Program at 11:45 a.m. on 12/14/2021 (the 11:45 p.m. in the narrative is a typo and should be a.m.).
"MDS performed searches for the package [where the flat tire was changed] and surrounding areas, performed searches at another location on the delivery route (MDS warehouse located in Little Ferry, NJ) and contacted other facilities on the route where other packages were delivered.
"The package continues to be missing."
Notified R1DO (YOUNG), NMSS Events Notification group (email), and ILTAB (email).
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
Agreement State
Event Number: 55645
Rep Org: Alabama Radiation Control
Licensee: Agriculture Veterinary Diagnostic Lab
Region: 1
City: Auburn State: AL
County:
License #: 15
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Agriculture Veterinary Diagnostic Lab
Region: 1
City: Auburn State: AL
County:
License #: 15
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 12/14/2021
Notification Time: 17:34 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [CST]
Last Update Date: 12/14/2021
Notification Time: 17:34 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [CST]
Last Update Date: 12/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/21/2021
EN Revision Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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 Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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
Fuel Cycle Facility
Event Number: 55666
Facility: Framatome ANP Richland
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Thomas Herrity
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Thomas Herrity
Notification Date: 12/20/2021
Notification Time: 17:26 [ET]
Event Date: 12/20/2021
Event Time: 09:20 [PST]
Last Update Date: 12/20/2021
Notification Time: 17:26 [ET]
Event Date: 12/20/2021
Event Time: 09:20 [PST]
Last Update Date: 12/20/2021
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
EN Revision Imported Date: 12/21/2021
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by Framatome ANP Richland via email:
"On December 20, 2021, at 0920 PST, Framatome received notification that a sealed source, which had been removed by a waste broker (Qal-Tek), had failed a leak test.
"The source, an acrylic rod type made in June 1986 and containing at that time 5 mCi of Cs-137, had been stored at Framatome in a shielding pig for many years. Leak tests had been performed on the storage pig as required by Framatome's radioactive materials license, most recently on November 12, 2021. The waste broker performed a confirmatory leak test on the storage pig on November 22, 2021 and removed the source from the Framatome site. All leak tests performed by Framatome and the waste broker indicated that there was less than 0.005 microcurie of removable contamination on the outside of the storage pig.
"The source was removed from its storage pig at the waste broker's facility in a controlled environment at which point a sample of the bare source indicated a removable beta activity of 0.015 microcurie. Upon discovering the leak, the waste broker placed the leaking source in a sealed container and decontaminated the inside of the storage pig. The source will be sealed with epoxy to prevent any further leak; being already in the waste stream, no further issue is anticipated from the source.
"This report is furnished to the NRC, concurrent to one sent to the Washington Department of Public Health."
The licensee has notified the State and NRC Region IV.
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by Framatome ANP Richland via email:
"On December 20, 2021, at 0920 PST, Framatome received notification that a sealed source, which had been removed by a waste broker (Qal-Tek), had failed a leak test.
"The source, an acrylic rod type made in June 1986 and containing at that time 5 mCi of Cs-137, had been stored at Framatome in a shielding pig for many years. Leak tests had been performed on the storage pig as required by Framatome's radioactive materials license, most recently on November 12, 2021. The waste broker performed a confirmatory leak test on the storage pig on November 22, 2021 and removed the source from the Framatome site. All leak tests performed by Framatome and the waste broker indicated that there was less than 0.005 microcurie of removable contamination on the outside of the storage pig.
"The source was removed from its storage pig at the waste broker's facility in a controlled environment at which point a sample of the bare source indicated a removable beta activity of 0.015 microcurie. Upon discovering the leak, the waste broker placed the leaking source in a sealed container and decontaminated the inside of the storage pig. The source will be sealed with epoxy to prevent any further leak; being already in the waste stream, no further issue is anticipated from the source.
"This report is furnished to the NRC, concurrent to one sent to the Washington Department of Public Health."
The licensee has notified the State and NRC Region IV.