Event Notification Report for April 08, 2022

EN Revision Imported Date: 4/8/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC METER

The following information was received from the State of Oklahoma via email:

"Goodyear Tire and Rubber Co. has reported the loss of a 3M Model 703 Static Meter (S/N 411617). This device was possessed under Oklahoma GLD [generally licensed device] registration GLD0013. It was manufactured in 1977 and initially contained 250 mCi of tritium, which would have decayed to approximately 20 mCi today. Goodyear obtained the device in 2002 and used it for 2 or 3 years before placing it into storage. It was discovered missing earlier this month."

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: 4/8/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/RECOVERED SOURCE

The following information was provided by the Oregon Health Authority via email:

"On March 22, 2022, a High Dose Rate Delivery (HDR) sealed source of Iridium-192 was delivered by a common carrier to the wrong floor and clinic in a licensed (Salem Hospital) hospital. Instead of the shipping destination (given as Radiation Oncology/Attn: Dr xxx) on the 1st floor, the package was delivered to the 4th floor of the same building. The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding of what it was and placed it on the floor of an access-controlled staff working area.

"On March 28, 2022, the licensee received an email request from the vendor (Varian) to schedule a date/time for installation of the new source. It was at this time that the licensee realized that the source had not arrived at their location and found the source had been delivered on March 22, 2022. An investigation was initiated and the source package was located in the 4th floor clinic. The package was surveyed and observed to be intact with no evidence of tampering . The transport index for the Type A Yellow -II package was noted at 0.9. The package was taken to the licensee's office and secured in locked storage.

"The licensee evaluated the dose received by clinic staff working in the proximity of the package. Clinic staff does not work a full shift in the area (five hours maximum/day) and the closest estimated distance from the package was measured at 2 feet (60 cm). The exposure period was 5 working days. The licensee performed dose measurements on and near the source package at various distances and orientations with a survey meter. The maximum dose received was while sitting in a chair and was calculated to be 0.4 mR/hr.

"Total dose received was given as:
0.4 mR/hr * 5 hrs/day * 5 days = 10 mR total exposure (~10 mrem or 0.01 rem equivalent dose). This dose-risk standard was based upon National Council on Radiation Protection and Measurements (NCRP) Report No. 91.

"Cause and corrective actions :

"The two subsequent causes are of the same nature, human error. First, the carrier failed to deliver the package to the labeled destination and person. Second, the hospital clinic signed for the package without checking the proper destination or person it was intended for. A potential third cause of human error is that the licensee failed to check on package delivery sooner if a tracking number was associated with this shipment. Corrective actions have not been instituted at this time since not all information has been collected for this event. The licensee indicated that they receive these shipments quarterly and wait for the vendor to schedule an installation. There was no indication given of tracking a replacement source package while it is in transit to the licensee's site. This is being investigated further.

"Information regarding the source activity, manufacturer, model, serial number and leak test date will be provided to the NRC Headquarters Operation Center when it is received from the Licensee."

Oregon Report Identification Number: 22-0016

EN Revision Imported Date: 4/8/2022

EN Revision Text: NON-AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the licensee via phone:

The licensee reported that a generally licensed device has tested positive on a routine leak test (0.006 microCurie). The leaking sealed source was Ni-63 (15 milliCurie), which is used in an Agilent Gas Chromatograph (model G2397A). The gas chromatograph has been tagged out and no exposures were identified.

* * * UPDATE FROM MARK TAMASHIRO TO DONALD NORWOOD AT 1217 EDT ON 4/1/2022 * * *

The following information was received via E-mail:

"Please change the CFR reference to the subject call from 10 CFR 30.50(b)(2) to 10 CFR 31.5(c)(5)."

Notified R1DO (Werkheiser) and NMSS Events Notification E-mail group.

EN Revision Imported Date: 4/8/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 SOURCE

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

"The Washington Agreement State program was notified on 3/31/2022, about a lost source. Kaiser Permanente Bellevue lost a 10 mCi Gd-153 source. The source was in its leaded container in a shipping box and had not been processed in yet to the facility when housekeeping picked it up and threw it away. It then went to their own [trash] compactor and unfortunately was picked up by the garbage company. This event was only discovered a few hours ago.

"Washington State arrived onsite at Kaiser Bellevue at 1300 PDT and spoke with the Director of Imaging. Surveys of the garbage compactor [indicate that] the source is likely intact, as no contamination was found. The source is still lost, but is likely in the company garbage or landfill."

WA incident no.: WA-022-006

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: 4/8/2022

EN Revision Text: AGREEMENT STATE REPORT - FAILED INDICATOR

The following information was received from the South Carolina Department of Health and Environmental Control via email:

"During a routine inspection of a licensee's specific license on 03/23/22, the South Carolina Department of Health and Environmental Control was informed that a generally licensed fixed gauging device (80 milliCurie, Kr-85, Mahlo Model 6270, serial number PH847) had a failed indicator and had been repaired by the manufacturer on 01/11/22. Dose rate surveys of the fixed gauging device were performed by Department inspectors and indicated readings below the external radiation levels outlined in the sealed source and device registry certificate. The licensee submitted a written notification of the event to the Department on 03/30/22. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

EN Revision Imported Date: 4/8/2022

EN Revision Text: AGREEMENT STATE REPORT - SOURCE DISCONNECT OF AN INDUSTRIAL RADIOGRAPHY CAMERA

The following information was received from the Louisiana Department of Environmental Quality (LDEQ) via email:

"On April 1, 2022, LDEQ received this event notification. The licensee was working at Bayer Crop Science, LP performing industrial radiography work on March 28, 2022. At approximately 1051 CDT, the RSO [(Radiation Safety Officer)] was notified of a source disconnect. The event involved a QSA 880 Delta, serial number 7511, source serial number 4806514. The source was an Ir-192 with an activity of 59 Ci. The drive cable end connector had broken off from the drive cable. The source was retrieved back into a shielded condition.

"The person performing the source retrieval received 460 mR exposure.

"The radiographer involved had his pocket ion chamber go off scale and his badge was sent in. The badge read 337 mR which was at the end of the working month."

Louisiana Event Report ID No.: LA 20220004

EN Revision Imported Date: 4/8/2022

EN Revision Text: NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE

The following information was provided by the licensee via telephone and email:

"Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT.

"At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received.

"The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter)."

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: 4/8/2022

EN Revision Text: PART 21 - CURTISS-WRIGHT ACTUATOR BRAKE WIRING DEFICENCY REPORT

The following information was provided by Curtiss-Wright Nuclear Division via fax:

"The Tennessee Valley Authority (TVA) Browns Ferry Plant notified us (QualTech NP, Curtiss-Wright Nuclear Division) of two separate RCS/Dresser actuator failures which we had provided as safety related components. According to TVA, the first failure occurred on February 7, 2022, after being installed for approximately 167 days. The 2nd failure occurred on February 9, 2022, and was in service for approximately 24 hours when it failed.

"According to TVA in both cases the actuator's brake assembly wire harness shorted out to the frame, causing the on-board fuse to blow, disabling the actuator. The electrical short was caused by the wire harness laying against a sharp edge of the metal frame, which over time led to fraying of the wire insulation and subsequent bare wire to frame contact.

"Both units were returned to QualTech NP for evaluation and our findings confirmed TVA's assessment.

"The root cause of the issue is friction between the wires and the sharp metallic edge that over time cut through the insulation via vibration, which in turn shorted the power leads to the frame. This shorting effect was due to poor positioning and restraint of the wire harness/bundle by the manufacturer during assembly. It is not considered a design flaw, but a workmanship issue caused by the factory assembler.

"The corrective action taken with the two units was to install new brake assemblies and reposition the wire harness to prevent contact with the sharp edge. In addition, wire ties were added to restrain the wire's movement and keep it away from the sharp edge. As a follow up action, the associated dedication plan will be revised to inspect for this workmanship issue and correct as needed.

"Additional details are provided in the failure evaluation. QualTech NP has only sold this part to TVA (Browns Ferry) and could not find any additional failures of this type reported by the industry. Identification of the customer's orders and hardware involved are provided in the evaluation.

"Please phone (513) 528-7900 if you should have any questions."

EN Revision Imported Date: 4/8/2022

EN Revision Text: FITNESS-FOR-DUTY REPORT - FAILED FITNESS-FOR-DUTY TEST

The following information was provided by the licensee via phone call:

"At 0909 EDT on 4/7/2022, it was determined that a security officer tested positive during a random fitness-for-duty test. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."