Event Notification Report for May 16, 2022

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.

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."

AGREEMENT STATE REPORT - UNDERDOSE

The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (Department) via fax:

"On May 6, 2022, the University of Pennsylvania informed the Department of an underdose incident on May 4, 2022, involving yttrium-90 (Y90) SIR-Spheres. A patient underwent a Y90 SIR-Sphere treatment and the catheter placement changed during a SIR-Spheres administration and the Authorized User intentionally stopped the administration as continuing could have resulted in harm to the patient. The administered activity was 67 percent of the prescribed activity (15.1 mCi vs 22.51 mCi). The Department will perform a reactive inspection and is currently in contact with the University of Pennsylvania. The event will be updated this as soon as more information is provided. It is reportable as per 10 CFR 35.3045(a)(1)(i)."

Pennsylvania Report Number: PA220017

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 - INDUSTRIAL RADIOGRAPHY EQUIPMENT FAILURE

The following is a summary received from the New Mexico Environmental Protection Division (the agency) via phone:

On 05/09/22, at 0934 MDT, the agency was notified of an industrial radiography event that occurred on 04/11/22. The licensee reported a mechanical equipment failure and that no exposure occurred. The agency is en route to follow-up and gather additional details on the event.

The agency also notified R4 (Erickson).

CONTROL ROOM ENVELOPE INOPERABLE

The following information was provided by the licensee via email:

"On 5/13/22 at 1111 CDT the station entered LCO 3.7.4 Condition B for Control Room Envelope being inoperable. This was due to results from an inspection in the Steam Jet Air Ejector room that identified steam leakage exceeding the leakage rate assumptions made in the Alternate Source Term (AST) dose analysis calculation. Therefore, this is being reported in accordance with 10CFR50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades plant safety and 10CFR50.72(b)(3)(v)(D) for any event or condition that at the time of discovery could have prevented fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"There is no impact to the health and safety of the public. NRC Resident has been notified."

GAMMA MONITORS NON-FUNCTIONAL

The following information was provided by the licensee via fax or email:

"Two gamma monitors on filters associated with the waste water treatment system were discovered to be non-functional during their monthly calibration check. These gamma monitors are designated as an Item Relied on for Safety (IROFS) and are used to prevent gradual long term accumulations of uranium from exceeding a safe mass.

"The system has been shut down and will remain down until the required safety function is restored.

"This condition is being conservatively reported under the requirements of 10CFR70 Appendix A b(2) due to two Failed IROFS although Framatome believes that the performance requirements of 10CFR70.61 are still met."