Event Notification Report for June 09, 2022

EN Revision Imported Date: 6/3/2022

EN Revision Text: AGREEMENT STATE REPORT - DELIVERED SOURCE NOT SECURED

The following licensee provided information was forwarded from the Mississippi State Department of Health via email:

"A replacement Ir-192 source [(100 Ci)] was ordered from QSA Global on 3-24-22. QSA sent an `Advanced Shipping Notice' email after hours at 1800 CDT on 5-26-22. The source arrived the following day, Friday, 5-27-22. The source was delivered to the Shipping/Receiving dock (building 9145), operated by S3 [(Syncom Space Services)]. (Note: the standard practice is for the source to be delivered directly to the building where S3 licensed sources are secured.) The Receiving worker signed for the shipment at 1000 CDT on 5-27-22. The Receiving worker is not a radiation safety qualified employee. The RSO [(Radiation Safety Officer)], nor any other radiation safety qualified personnel were contacted upon delivery of source. The RSO was not at work on Friday, and unaware the source was being delivered that day. The source was in the Shipping/Receiving building (locked when personnel are not on site) until Tuesday morning, 5-31-22. Upon arrival to work at 0600 CDT Tuesday morning, the RSO read the email from QSA Global and checked the tracking information. At that time, he realized the source had been delivered. The RSO identified which Receiving worker signed for the source. Their shift starts at 0700 CDT. Upon their arrival, the RSO verified that the source was at the Shipping/Receiving building. The RSO immediately picked up the source and brought it to the secure vault. Management was then notified, and the investigation began.

The S3 Heath Physics Coordinator and RSO (with concurrence from NASA HP [(Health Physicist)]) concluded that no employee was exposed to an unallowable amount of radiation based on where the source was placed and its proximity to employees in the area. The investigation is ongoing to identify the process failures that lead to this incident. NASA has been notified and the incident has been entered into a formal tracking system."

UF6 LEAKAGE INSIDE AUTOCLAVE

The following information was provided by the licensee via email:

"The plant is in a safe configuration. On June 3, 2022, isolated pressure fall (IPF) and isolated pressure rise (IPR) tests were completed satisfactory on manifold 1. A satisfactory Item Relied on For Safety [IROFS] surveillance was completed for manifold 1 and 1003 Autoclave was placed in service. On June 7, 2022 during the disconnect of 1003 Autoclave, an Operator noticed a white/yellowish film on the hex nut of the manifold and the upper portion of the cylinder valve. The Operator surveyed the film and found 4,000 to 6,000 dpm alpha and beta contamination. Prior to opening the door of 1003 Autoclave, the internal atmosphere was sampled for hydrogen fluoride (HF). No HF was detected by HF monitor. 1003 Autoclave has been taken out of service. Autoclave sampling manifold 1 has been isolated and IROFS 28 declared INOPERABLE."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
No employee exposures occurred. The leakage was contained inside the autoclave.

UNEXPECTED CONTAMINATION DISCOVERED IN URANIUM AUTOCLAVE

The following information was provided by the licensee via email:

"The plant is in a safe configuration.

"On June 7, 2022, while performing a disconnect on the 3LS1 autoclave, an Operator noticed a white/yellowish film on the hex nut of the manifold and the upper portion of the cylinder valve. The Operator surveyed the film and found 4,000 to 6,000 dpm alpha and beta contamination.

"The 3LS1 autoclave was posted as a Contamination Area at 0152 MDT on June 7th. Surveys of the cylinder and manifold were 1,500 dpm alpha and 3,000 dpm beta/gamma after the disconnect. Decontamination efforts continued throughout the day. The area was still posted as a contamination area on the morning of June 8th. UUSA [Urenco, USA] is reporting this event per 10 CFR 70.50.(b)(1)(i). Decontamination efforts are continuing.

"This issue has been entered in UUSA's corrective action program as EV151830."

The licensee reported leakage inside the autoclave under EN 55930.

EN Revision Imported Date: 6/9/2022

EN Revision Text: AGREEMENT STATE REPORT - DENSITY GAUGE SOURCE FOUND

The following was received from the Florida Department of Health (the department) via email:

"[The Radiation Safety Officer] from Mosaic Fertilizer called at 1130 EDT this morning to report a failed fixed density gauge on a pipeline. They reported that an employee found a [5 mCi Cs-137] sealed source on the ground, picked it up, held it in their hand for anywhere between 30 to 60 seconds before realizing what it was, then dropped it and reported it to management. The source was transported in an empty bucket and placed on a shelf in the onsite RAM [(Radioactive Material)] storage cabinet. The department's Materials Licensing was notified and will be sending out an inspector as soon as possible to conduct an immediate onsite inspection. The NRC was also notified. Source Assay Date June 2009."

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

Based on the information provided, the department calculated 1.42 R dose. They shared the information with the Radiation Emergency Assistance Center/Training Site (REAC/TS), which calculated 2.24 R dose, with no decay correction. It was determined that no medical attention is required.

Florida Incident Number: FL22-062

* * * UPDATE FROM MARK SEIDENSTICKER TO LLOYD DESOTELL AT 1024 EDT ON 06/08/22 * * *
The following was received from the Florida Department of Health (the Department) via email:

"Decay corrected calculations done by Bureau of Radiation Control, and verified by REAC/TS [Radiation Emergency Assistance Center/Training Site], for a 30 second dose to the hand was 1.42 R. (Contact dose rate constant to the hand of 770 R/min/Ci x 1 min/60 sec x 0.0037 Ci x 30 sec = 1.42 R) REAC/TS calculation = 2.24 R w/no decay correction. REAC/TS comments: there was very little to no medical concern, just observe the employee's hand. The Radiation Safety Officer [was] notified the morning of 6/8/22 of the inspectors' findings, dose calculation results and REAC/TS comments."

Notified R1DO (Greives) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - HDR THERAPY ADMINISTERED TO WRONG SITE

The following was received from the New York State Department of Health Bureau of Environmental Radiation Protection (the Department, BERP) via email:

"A New York State licensee informed the Department on June 3 that a patient received a HDR [(High Dose Rate)] therapy to the wrong site. The male patient was diagnosed with Basal Carcinoma of the skin on the left scalp. The patient received a total of 36 Gy over 6 weeks (6 Gy per week). Doses were delivered using a Varian Model Vari-Source XI.

"The Physician/Authorized User discovered the event and made the initial report to the Department. He indicated he misidentified the treatment site. It seems the error was discovered June 3, 2022. Treatment dates, notification of patient/family and other details regarding this event are not available to BERP yet.

"The Radiation Safety Officer is conducting an investigation. The Department will follow-up and provide an update."

New York Report ID No. NY-22-04

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: 6/8/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST COPPER-64 RADIOPHARMACEUTICAL

The following was received from the New Jersey Department of Environmental Protection (NJDEP) via email:

"The NJDEP staff was notified of the loss of a 5 mCi syringe of Cu-64 from the Hackensack University Medical Center (NJ License no. 450695).

"The licensee contacted the NJDEP hotline at approximately 1933 EDT on 6/3/2022. The NJDEP staff was contacted at 1958 EDT. The NJDEP staff contacted the licensee RSO [(Radiation Safety Officer)] at 2002 EDT and asked for an update of the situation. The licensee RSO stated that the search for the syringe was continuing and that they contacted the isotope supplier to confirm its delivery. The supplier confirmed they had delivered the dose in the early morning of 6/3/2022.

"The NJDEP staff is monitoring the situation and more details will be provided as they become available."

* * * UPDATE ON 6/7/22 AT 0853 EDT FROM JACK TWAY TO KERBY SCALES * * *

The following update was received from the New Jersey Department of Environmental Protection (NJDEP) via email:

"A unit dose of Cu-64 calibrated for 4.4 mCi at 1500 EDT on 6/3/2022 (current activity estimated as 0.023 mCi) was discovered missing at Hackensack University Medical Center (NJ License no. 450695). The licensee reported the missing material to NJDEP who then reported the incident to NRC Operations Center. The NJ licensee followed up with their isotope suppliers to determine what might have happened to the dose. Video surveillance footage confirmed that the dose, in its Type A package was delivered by Nuclear Diagnostic Products to the Hackensack Nuclear Medicine PETCT Department at 0500 EDT on 6/3/2022. The driver was recorded on video leaving the Nuclear Medicine Department with a security guard and one black Type A package as expected. At 1020 EDT a driver from Medical Delivery Services, employed by Sofie Pharmaceuticals, was recorded delivering 1 Type A package and then leaving at 1022 EDT with 3 Type A packages, one of which bore the Yellow II label indicating it was not 'empty'. Sofie interviewed the driver who stated that he only picked up 2 packages, counter to what the video footage portrays. The driver has been suspended while Sofie continues to attempt to locate the package."

Notified R1DO (Greives), NMSS Event Notifications and ILTAB via 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