Event Notification Report for May 13, 2022

AGREEMENT STATE REPORT - MALFUNCTIONING SHUTTER

The following was received from the state of Pennsylvania [the Department] via email:

"On May 4, 2022, the licensee informed the Department of an equipment malfunction. The licensee reported that on May 3, 2022 a QSA Global Model 880 containing a 37 Curie source of Iridium-192 malfunctioned. The camera's serial number is D15520 and the source serial number is 36110M. During the course of radiographic operations, the automatic lock slide that secures the source failed to completely close. While the source was completely retracted, secured, and verified using a survey meter, the camera was not fully functioning as intended. The licensee contacted with QSA Global, who suspect a spring malfunction. The camera was sent back to QSA for evaluation and repair. There were no overexposures because of this event."

PA Event Report No: PA220015

AGREEMENT STATE REPORT - GAUGE STRUCK AND DAMAGED BY BULLDOZER

The following was received from the Texas Department of State Health Services [the Agency] via email:

"On May 4, 2022, the licensee's radiation safety officer contacted the Agency and reported one of it's Humboldt 5001EZ gauges containing an 8 millicurie cs-137 source and a 40 mCi am-241 source had been struck by a bulldozer at a temporary field site. The gauge was damaged, and the licensee stated their engineer was going to the site to inspect and recover the gauge. The RSO contacted the Agency later that day and stated the source was in the shielded position and readings on contact with the transport case was 5 millirem an hour and 2 millirem an hour at three feet. The licensee transported the gauge back to it's facility. The licensee contacted it's service provider who will dispose of the gauge. No significant exposures were received as a result of this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number I-9930

EN Revision Imported Date: 5/13/2022

EN Revision Text: AGREEMENT STATE REPORT - TRANSPORTATION EVENT

The following was received from the State of Kansas Department of Health and Environment via email:

"At approximately 0945 CDT on May 5, 2022, the Kansas Department of Health and Environment (KDHE) was notified of a Cardinal Health carrier involved in an incident where the vehicle was swept off the road due to flooding. The nearest intersection to the site of the incident is E 520th Ave and S 240th Ave in Pittsburgh, KS, near the Missouri border. The vehicle was transporting unit doses of Tc-99m [total activity unknown at this time] from its Springfield, Missouri facility to locations in Kansas. The vehicle [type unknown at this time] is currently sitting in approximately 3 to 3.5 feet of water. KDHE was informed that the driver had to exit the vehicle through the window, which remains open. KDHE was informed that the driver left the area and the vehicle is currently unattended. The weather forecast includes additional rain and potential flooding for the rest of the day into the evening and a towing company is unable to assist until the water recedes. It is unknown at this time when the vehicle will be able to be retrieved."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Container information:
Syringes containing Tc-99m individually contained in pigs
Pigs contained in nylon bag
No placarding of vehicle
Containers labeled with RADIOACTIVE WHITE-I (less than 0.5 mrem/hr on surface)
Vehicle also likely contained empty used Tc-99m syringes

Notified: DHS, FEMA, USDA, HHS, DOE, CISA, EPA, DOT, KS All Hazard Notification System
Notified via email: FDA, DHS, FEMA National Watch Center, FEMA NRCC SASC,CWMD Watch Desk

* * * UPDATE FROM KIM STEVES TO MICHAEL KUNOWSKI (R3 DNMS) AT 1859 CDT ON 5/7/2022 * * *
The following information was received via email from the State of Kansas:

"The Cardinal Health RSO was able to access the vehicle on Friday (5/6/2022) afternoon and removed the radioactive material which was then returned to the pharmacy. The RSO also performed surveys and wipes and found them to be below action levels.

The contents of the vehicle was confirmed as follows: "There were two containers of doses containing a total of 121 doses and about 200 mCi of Tc-99m, calibrated for between 0700 and 1300 CDT on Thursday (5/5/2022)."

Notified R3DO (Skokowski), R3DO (Stoedter), R4DO (Gaddy), IR (Kennedy), NMSS Events Notification email group.

AGREEMENT STATE REPORT - DIAGNOSTIC RADIOPHARMACEUTICAL MISADMINISTRATION

The following was received from the Utah Department of Environmental Quality (the Division) via email:

"At approximately 1030 MDT, the [Radiation Safety Officer] for the licensee notified the Division that a patient had been administered an isotope to perform a PET scan. The technician double checked with the ordering physician and found that the order was supposed to have been for a CT scan, not a PET scan. The order received showed it was a PET scan. An investigation is being conducted to see how the order was changed.

"The patient was administered about 10.6 mCi of FDG when a CT scan was to be performed. Therefore, the dose was greater than 20 percent of the prescribed dose. The order received by the radiology department showed that a PET scan had been ordered. The TEDE to the patient was less than 5 rem and the highest organ dose (to the bladder wall), was less than 50 rem. The patient was administered the FDG at about 1300 EDT on May 4, 2022. The FDG was allowed to decay and the patient was later given a CT exam.

"At this time, this is all the information that the Division has, an investigation will be conducted, and an update will be provided at a later date."

Event Report ID No.: UT220004


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.

NON-AGREEMENT STATE REPORT - STOLEN GAUGE

The following is a synopsis of information received via telephone:

A portable nuclear density gauge was stolen from the bed of a pickup truck parked at a hotel in Hurricane Creek, WV. The chain securing the gauge had been cut. The licensee notified the Putnam County sheriff's office who indicated other thefts had occurred in the area. The licensee indicated that the theft occurred within a day of discovery.

Gauge Information:
Make: Troxler
Model number: 3430
Sources (nominal): 8 mCi of Cs-137 and 40 mCi of Am-241:Be.
Serial number: 65490

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: 5/11/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE

The following was received from the state of New York, Bureau of Environmental Radiation Protection (BERP):
"A portable XRF device containing a 6 millicurie Cobalt-57 source was shipped via [common carrier] to Viken on April 13, 2022. Viken (device manufacturer) was contacted on or around May 4, 2022, and indicated they never received the package. Specific device information is below. Based on tracking information, the package arrived in Syracuse but there are no records of it leaving. BERP is monitoring this situation under Incident No. 1396.

"Device Manufacturer: Viken; Device Model: Pb200i; Device S/N: 2599; Source Manufacturer: Isotope Products Laboratory; Source Model: Model 3901 Series; Source S/N: TBD; Isotope: Cobalt-57"

NEW YORK EVENT REPORT ID NO. NYDOH - 22-03

* * * UPDATE ON 05/10/2022 AT 14:24 EDT FROM DESMOND C. GORDON TO BRIAN P. SMITH * * *

The following was received via fax from the state of New York, Bureau of Environmental Radiation Protection (BERP):

"On Friday, May 6, 2022, BERP was notified via electronic mail that the device was located in New Hartford, NY [common carrier] Package Center. A representative from the Herkimer District Office went to the Center and picked up the device on Monday. The package appears intact with no damage."

Notified R1DO (Ferdas), NMSS Events Notification, ILTAB, and CSNC (Canada)

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 REPORT - LOST RADIOPHARMACEUTICAL PACKAGE

The following was received from the Illinois Emergency Management Agency (the agency) via email:

"The Agency was contacted on 5/5/22, by GE Healthcare to advise that a radiopharmaceutical package was damaged in transit and reported as lost at the carrier's facility. GE Healthcare reports the 6 inch x 6 inch package (UN2915, Type A Package, Yellow II, TI 0.1) was shipped from Arlington Heights, IL to Richland, MS on 5/3/22. The package contained a lead shielded container with 1.956 mCi of In-111 (activity at the time of shipment on 5/3/22). The package reportedly arrived in one piece at the [common carrier's] Memphis hub on 5/3/22. On 5/5/22, the carrier advised the licensee that they had found the damaged package at their Memphis hub with its inner contents missing. Dangerous Goods is currently working with the shipper and conducting a search of the facility. The package now contains approximately 1.2 mCi [of In-111].

"There is no indication of intentional theft or diversion, and the contents would not be useful for illicit intent.

"This matter has a 30-day reporting requirement to the US NRC. Updates will be provided as they become available."

Item Number: IL220015

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 REPORT - THREE MEDICAL EVENTS - UNDERDOSES

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On May 6, 2022, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that they had discovered that multiple medical events had occurred at their facility. The licensee had discovered on Tuesday, May 3, 2022, the needle used on a high dose rate unit (HDR) was shorter than what they thought. This resulted in underdoses to the intended tissue. The licensee has identified three cases that resulted in underdoses of 92 percent, 95 percent, and 67 percent for a single fraction on three patients. The three events occurred between November 2020, and February 2021. The RSO stated they were notifying the prescribing physicians and patients involved. They are continuing to review previous cases to determine if any additional patients were involved. The licensee will notify the appropriate individuals as the events are discovered. The RSO did not know how many patients may be involved. The source was an iridium-192 source and the activity would vary depending on the date the treatment occurred. The RSO stated that due to the needle being shorter than believed, other tissue may have been exposed to higher-than expected dose and in some events the source may have never entered the patient. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9931

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 REPORT - LEAKING SEALED SOURCE

The following was received from the Massachusetts Radiation Control Program (the "Agency") via email:

"On 05/06/2022, at 1340 EDT, the Agency received a call from RSO [Radiation Safety Officer] at Thermo Scientific Portable Analytical Instrument, Inc. (the `licensee') reporting a leaking sealed source. The 20-year-old source/device (Thermo Scientific Portable Analytical Instruments, Inc.; Model XLi 969; Device s/n 5243; Source s/n EG-8804) is currently containing 0.12 mCi of Fe-55 (original activity was 20 mCi on 04/07/2002). The RSO received the leak test report on 05/06/2022 and he noticed that the source is leaking as 0.0058 microcuries of removal activity which is in excess of regulatory limits (0.005 microcuries). This device was sent to the licensee for decommissioning and was received from the licensee's customer on 04/21/2022. The source was removed from the device as part of decommissioning. There was no external contamination spread outside of the device or surrounding work area surfaces. The source will be secured and properly disposed of in accordance with the regulations."

EN Revision Imported Date: 5/12/2022

EN Revision Text: BOTH TRAINS OF LOW PRESSURE COOLANT INJECTION (LPCI) INOP

The following information was provided by the licensee via fax:

"At 1359 CDT on May 10, 2022, the 1B LPCI Loop Upstream Injection valve (1-1001-28B) was found to have a motor operated torque switch issue and inadequate lubrication. This issue called into question the ability of the valve to close when required.

"At 1746 CDT on May 10, 2022, both trains of Unit 1 LPCI were made simultaneously inoperable. TS 3.6.1.3 Condition A required de-activation of 1B LPCI Loop Downstream Injection valve (1-1001-29B) which was completed at 1746 CDT. Because of the de-activation of the 1B LPCI Loop downstream injection valve and LPCI Loop select logic, both trains of LPCI were made inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(V). Unit 1 HPCI and both loops of Core Spray are operable. After further engineering review, it was determined that 1B LPCI Loop Upstream injection valve condition was minor in nature and would not have affected the ability of the valve to close when required.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

* * * UPDATE AT 12:32 EDT ON 05/11/22 FROM MARK HUMPHREY TO BRIAN P. SMITH * * *

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

The last sentence in the second paragraph, "After further engineering review, it was determined that 1B LPCI Loop Upstream injection valve condition was minor in nature and would not have affected the ability of the valve to close when required," has been deleted. The licensee is continuing to follow up on the issue and believes that sentence to be unclear and premature.

Notified R3DO (Skokowski).

FITNESS FOR DUTY REPORT

The following information was provided by the licensee via email:

"A licensed operator had a confirmed positive for alcohol during a follow-up fitness-for-duty test. The employee's access to the plant is on hold in accordance with the licensee's fitness-for-duty policy.

"The licensee notified the NRC Resident Inspector."

HIGH PRESSURE COOLANT INJECTION INOPERABLE

The following information was provided by the licensee via email:

"During performance of High Pressure Coolant Injection (HPCI) Pump and Valve Operability surveillance in accordance with procedure 24.202.01, the turbine tripped without operator action. The plant was operating in Mode 1 at 10 percent power with the HPCI turbine running in a test mode at 5100 gpm with all surveillance criteria met. The surveillance was near completion at the point where the HPCI turbine is manually tripped. Before the manual trip was performed, the HPCI turbine tripped without operator action.

"Prior to performance of the surveillance, HPCI was provisionally operable with only satisfactory completion of Post Maintenance Testing (PMT) surveillance remaining to declare HPCI operable. HPCI surveillance testing was performed at low reactor pressure (165 psig) in Mode 2 satisfactorily. Investigation into the cause of this trip is in progress. HPCI has been declared inoperable from the time of release of the surveillance. Reactor Coolant Isolation Cooling (RCIC) was verified to be operable prior to and after the surveillance in accordance with Technical Specifications 3.5.1 condition E.1.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."