Event Notification Report for June 13, 2022

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

AGREEMENT STATE REPORT - FIXED GAUGE INADVERTENTLY DISCARDED

The following report was received from the state of Kentucky via email:

"A Berthold fixed gauging device containing 16 milli-Curies of Cs-137 was out of service and scheduled for replacement when it was inappropriately removed from a belt line by a maintenance worker and thrown in a scrap metal hopper for later recycling on May 13, 2022. The licensee conducted scheduled 6 month physical inventory on June 1, 2022 and discovered a gauge was missing from the belt line where it had been installed. Carmeuse personnel conducted a search of the premises and discovered the gauge in scrap metal hopper under additional scrap metal and approximately 10 inches of gravel. The licensee reported the material contained in the hopper is placed there using equipment (e.g. forklifts, etc.). The licensee removed the device from scrap the metal bin and conducted radiation surveys. Reported exposure rates approximately were 30 mR/hr on contact. The gauge was placed in a steel cabinet for storage with reported exposure rates of less-than 1 mR/hr on exterior. All was work performed without notification to or consultation with [Radiation Health Branch] RHB. The licensee indicated the metal cabinet is located in a warehouse on premises, but made no mention of security, access control, posting, relationship to occupied spaces, etc. The licensee reported to RHB in written response that 'device was rusted and shutter was not reliable' which was itself reportable. No mention was made of lock out/tag out, position of shutter mechanism, condition of labels, presence of posting, training of worker who performed removal work, etc. A reactive inspection planned for June 8, 2022."

EN Revision Imported Date: 6/13/2022

EN Revision Text: 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.

* * * RETRACTION ON 06/10/22 AT 1411 EDT FROM BARRY LOVE TO THOMAS HERRITY * * *

The following was provided by the licensee via email:

"The IROFS28 boundary, components, associated accident sequences and manifold leak were evaluated by Urenco-USA (UUSA) engineering. The evaluation determined that the leakage from the manifold did not result in IROFS28 being inoperable. IROFS28 was determined to be operable during this event.

"Based on this reevaluation, UUSA is retracting event notification EN 55930.

"UUSA will be notifying Region II."

Notified R2DO (Miller), and NMSS (Clark), NMSS Day (Rivera-Capella), NMSS Events (email).