Event Notification Report for June 17, 2022

EN Revision Imported Date: 6/17/2022

EN Revision Text: AGREEMENT STATE REPORT - DOSE TO EMBRYO/FETUS

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

"The RSO [(Radiation Safety Officer)] for the licensee contacted IEMA to report that on March 2, 2022, a patient was administered a 100 mCi I-131 dose. A pregnancy test was performed in advance of the administration and indicated negative (not pregnant). On April 13, 2022, the RSO received a call notifying him the patient was determined to be 7 days pregnant when the administration occurred. The patient was informed and returned to the hospital to do a whole-body count as a means to estimate biological half-life. The licensee has calculated upwards of 20 microCi of I-131 was retained by week eleven of the pregnancy and 75 percent was taken up by the fetus. Dose prior to eleven weeks was reportedly estimated as that to the maternal uterus (ICRP 88 states this is accurate to 8 weeks). It is unclear if the calculation methodology used was consistent with RG 8.36 (NUREG/CR-5631) or ICRP 88 but will be reviewed when staff investigate.

"The licensee is estimating the dose to the fetus through 12 weeks of development as 266 mGy (26.6 rads)."

Illinois Item Number: IL220018

* * * UPDATE FROM GARY FORESEE TO BRIAN PARKS AT 1526 EDT ON 6/16/2022 * * *

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

"A reactionary inspection was performed 6/2/22. The required 15-day report was received on 6/12/22 and put forward root cause and corrective action. The cause of the event was determined to be the ineffectiveness of the pregnancy testing policy to account for very early stage (i.e., first week of gestation) pregnancies that standard pregnancy tests cannot detect. The licensee revised its pregnancy testing policy to include patient instruction to abstain from intercourse for at least ten days prior to the administration of the dose. The licensee will be cited for failing to provide timely notification and corrective action to prevent a recurrence sought in the response. Pending no further developments and resolution of appropriate enforcement action, this matter is considered closed."

Notified R3DO (Feliz-Adorno) and NMSS Events Notification E-mail Group.

EN Revision Imported Date: 6/17/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO TREATMENT SITE

The following information was received from the Washington State Department of Health via email:

"On 06/08/2022, Inland Northwest (INW) Multicare's radiation safety officer (RSO) reported a medical event had occurred. A Y-90 therasphere procedure was done on the previous day (06/07/2022), the procedure went according to plan, however after the procedure was completed the after injection surveys and quality assurance was done, it revealed that a portion of the microspheres did not come out of the tubing as designed. After calculation it was determined that the patient only received 26 percent of the target dose. The licensee immediately notified the manufacturer to see what happened. The manufacturer told them this is a known issue and has happened before. INW is writing up a full report and will submit it when completed."

WA incident No.: WA-19-004

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.

* * * UPDATE FROM TRISTAN HAY TO DONALD NORWOOD AT 1441 EDT ON 6/16/2022 * * *

The following is a summary of information received via E-mail:

"There has been no indication of non-target embolization delivered to the patient. Crucially, no patient harm has resulted from this medical event. The patient has been contacted and notified by the Authorized User as to the reduced dosage administration during the procedure and is doing well with no indication of post procedure complications.

"The conclusion that was arrived at, after the span of this investigation, is that a definitive root cause cannot be drawn as to why this event occurred. Given all of the information that has been gathered, the source of this medical event can be attributed to microspheres settling out and/or clogging in the delivery system. Whether this can be attributed to the technique used by the performing physician or an equipment failure I cannot definitively say. What is known is over 70 percent of the activity remained in the delivery system and more specifically the tubing. Had the activity that remained in the delivery system been delivered to the patient, there would not have been a medical event occurrence. The known documented and published cases of the microspheres settling out and/or clogging in the delivery system are attributed more commonly to equipment failure as opposed to administration techniques. Given this data it is reasonable to conclude that equipment failure is the most likely cause of this medical event.

"What is also know through the investigation, is that all proper procedures were followed throughout the entire duration of this procedure. Because of that, there are no corrective actions that can be identified to prevent recurrence. This concludes the investigation."

Notified the R4DO (Azua) and the NMSS Events Notification E-mail group.

AGREEMENT STATE REPORT - STUCK SHUTTERS

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

"On June 8, 2022 inspectors [names redacted] went to Domtar Paper Company, LLC (SCRAM License Number 438) to perform a periodic re-inspection. During their inspection, they were presented with a copy of the inventory and their shutter check information. While reviewing the information, the inspectors saw that there were items on the checklist dated March 23, 2022, and March 30, 2022 that denoted the failed functionality of some of their gauge shutters. After discussion with radiation safety officer (RSO), it was determined that the shutters did, in fact, fail to operate as designed. There were other instances that were similar that the licensee stated that they will pull together and evaluate. At this time, the only information given by the licensee is the information below. The inspectors went to each of the source housings during the inspection and all shutters were all operational.

"The sources and housings are the following:
Kay Ray source housing model 7064P
Source model: 7700-5000 Serial number: 27007C Activity: 5 Curies

"Kay Ray source housing model 7064P
Source model: 7700-5000 Serial number: 27007F Activity: 5 Curies"

EN Revision Imported Date: 6/17/2022

EN Revision Text: PARTIAL LOSS OF POWER TO RPS DURING MAINTENANCE

The following information was provided by the licensee via email:

"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing lncore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to an unplanned valid actuation of a system pursuant to 10 CFR 50.72(b)(3)(iv)(B)(2). Additionally, this is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"Emergency assessment capability was restored at 1008 PDT upon system restoration."

The NRC resident was notified by the licensee.

* * * UPDATE FROM SIMEON MORALES TO DONALD NORWOOD AT 1547 EDT ON 6/16/2022 * * *

The following information was received via email:

"This event is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) only for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"The containment isolation was not due to actual plant conditions or parameters meeting design criteria for containment isolation. Therefore, this is considered an invalid actuation.

"Updated ENS Text:
"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing Incore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.

"This is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"Emergency assessment capability was restored at 1008 PDT upon system restoration.

"The plant is stable, and all effected systems have been restored.

"There was no impact to the health and safety of the public or plant personnel.

"The NRC resident has been notified."

Notified R4DO (Azua).

MANUAL REACTOR TRIP AND AUTOMATIC AUXILIARY FEEDWATER ACTUATION

The following information was provided by the licensee via email:

"At 0724 EDT on 6/15/2022, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering Steam Generator levels due to a secondary plant perturbation in the Heater Drain System. All control rods fully inserted into the core and the Auxiliary Feedwater System automatically started as designed in response to the full power reactor trip. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves. Unit 2 is not affected and remains at 100 percent power and stable.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater System.

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

EN Revision Imported Date: 6/14/2022

EN Revision Text: AGREEMENT STATE REPORT - ARMED BREAK-IN AT LICENSED FACILITY

The following is a summary of information received from the Colorado Department of Public Health and Environment by e-mail:

"Two armed individuals broke into the Colorado location for Acuren Inspection, Inc. The licensee described this event as part of a chain of local break-ins. The individuals were able to access the vault which contained the radiography cameras but were unsuccessful in accessing the radiography cameras stored within a secure container in the vault. It appears that no radioactive materials were accessed or removed in any way from the licensee's storage area. LLEA (Denver Police) was dispatched and responded to the facility. According to the [National Source Tracking System] (NSTS), as of June 11 the licensee is currently in possession of six Ir-192 sources, ranging from 98 curies to 24 curies."

CO Event Report ID No.: CO220016

AGREEMENT STATE REPORT - MISSING FIXED LEVEL DENSITY GAUGE


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

"On June 11, 2022, the licensee's Radiation Safety Officer (RSO) reported that at approximately 1120 CDT the technicians performing routine (6 month) surveys discovered that a Ronan GS400 (SN: 7192CO) level/density gauge, containing 100 millicuries of cesium-137, that had been mounted on the side of a vessel was not there and neither was its mounting bracket. Some demolition work had been performed on areas of the unit but there was no work being done on that particular vessel. Repeated searches were conducted at the facility. The licensee has been contacting supervisors and employees but has had some difficulty since it is the weekend. The search and interviews of employees and the demolition contractor's employees will continue. The gauge was mounted on the first (lower) level and there is another mounted higher on the vessel. Therefore, the fact it had been removed had not been identified by operations prior to the physical survey. Further information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I- 9933

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: 6/14/2022

EN Revision Text: AGREEMENT STATE REPRT - STOLEN TRUCK CONTAINING A MOISTURE DENSITY GAUGE

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

"On June 13, 2022, the licensee notified the Agency that on Friday, June 10, 2022, a truck containing a Insto Tek 3500 moisture density gauge was stolen. The gauge contained a 44 millicurie americium-241 source, and an 11 millicurie cesium-137 source. The licensee reported that the technician had stopped at a convenience store to buy some items and when they came back out the truck was missing. The licensee stated the gauge was locked in the back of the truck but was unsure if the keys to the locks were also taken. The licensee stated the gauge has an old [Global Positioning System] (GPS) tracking device that was inactive. The licensee stated they had contacted the GPS service company to see if the tracking device was still active and the gauge tracked that way. The licensee stated it would take up to 24 hours to determine if the tracking device could be used. The licensee stated the local police was notified of the theft. The individual who contacted the Agency stated they had not interviewed the technician about the event so some of the information requested by the Agency was unknown. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9934

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 - DAMAGED RADIOGRAPHY GUIDE TUBE

The following information was provided by the Kansas Department of Health and Environment via email:

"On June 13, 2022, at approximately 1415 CDT the licensee experienced an incident with the 9 Ci Ir-192 source in their 880 Delta radiography camera at their Lenexa, Kansas office location. They reported that during routine maintenance, the source became restricted in the source tube while cranking the source back into the shielded position. When the source was being retracted back into the camera, the cart on which it was sitting shifted. This put the guide tube into a bind which restricted the source from easily being returned into the camera. The Radiation Safety Officer (RSO) was immediately notified and arrived shortly thereafter to evaluate the situation. The licensee reported that once they realized it was just the position of the source tube putting the source in a bind, they were able to move the cart back to the position that then allowed them to retract the source back into the shielded position of the camera. The licensee reports that the source was exposed for no more than three minutes.

"The Kansas Radiation Control Program is currently performing a reactive inspection on June 14, 2022, and additional information will be provided at a later date."

AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE INTO RADIOGRAPHY EXPOSURE DEVICE

The following information was received by the Iowa Department of Public Health via e-mail:

"At 0229 CDT on 06-14-22, the Assistant RSO (ARSO) received a phone call from one of the radiographers involved stating that he was working at a temporary jobsite and was unable to fully expose the source into the guide tube/collimator (Device Model: QSA 880D, Source Model: QSA A424-9, Source Activity: 80.8 Ci). Upon noticing the resistance, the radiographer extended his Restricted Area boundaries, notified the on-site personnel to maintain clearance of the area and proceeded to contact the ARSO.

"During the phone conversation, the ARSO was able to guide the radiographer through disassembly of the crank body to the point that he could manually pull the drive cable and retract the source into a fully shielded position within the exposure device. Once the source was successfully locked into the exposure device and the appropriate surveys were completed, the ARSO instructed the radiographer to perform an inspection of the drive cables and guide tube to look for the presence of any bends, kinks or dents that could have contributed to the binding of the drive cable. It was at this point that the radiographer noted an area on the drive cable sheathing that appeared to be melted on the `retract' side of the drive cable assembly.

"At this point (approximately 0254 CDT), The ARSO contacted the PROtect, LLC RSO and informed him of the details of the incident. A follow-up Corrective Action Report and additional detail regarding the cause of the event will be submitted to the State of Iowa within 30 days.

"Reporting requirements:
30.50(b)(2)(ii) - The 24 hour report of an event where required equipment is disabled or fails to function as designed when the equipment is required to be available and operable when it is disabled or fails to function.
IAC 40.96(2)'c'(2)."

EN Revision Imported Date: 6/17/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - DOSE TO SKIN OTHER THAN WRITTEN DIRECTIVE TREATMENT SITE

The following information was received from the Oregon Health Authority via e-mail:

"The following is a report of a medical event corresponding to Subpart M, 35.3045(a)(1)(iii) for a high dose rate afterloader (HDR) dose to the skin other than the treatment site that exceeds 50 rem and 50% of expected dose to the location.

"Description of event: A patient was scheduled for two HDR (Varian GammaMed Plus iX) treatments, one each for two separate lesions located on the patient's lower right leg. The first lesion treatment (5100 cGy total; 17 fractions @ 300 cGy ea) was performed in February without incident. The first fraction of 500 cGy for the second lesion was performed on June 7th. The second treatment was scheduled for June 10th, however, during set-up and after drawing a circle on the patient's leg to help align the second lesion and monitor positioning during treatment, the patient informed the physicist that after the first fraction on June 7th, he noticed the circle had been drawn at that time around the first lesion treated in February. Treatment staff immediately alerted the patient's physician. Images from the patient's treatment on June 7th were compared to the February treatment and found to be the same location as the first lesion. The physician stated there is no adverse effect to the patient since the dose went to the site of the previous February treatment that was 'well tolerated' by the patient and 'the additional one HDR fraction of 500 cGy is likely of benefit to the patient.' The patient's written directive was updated to reflect an additional fraction to be given to the second lesion.

"Cause and corrective actions: The licensee is still gathering information but from the preliminary data received, verification of the treatment site was not performed for the June 7th fraction and former treatment plan location was used. No corrective actions have been submitted at this time.

"Concerns: Verification of treatment site may not be robust enough in separating separate treatment sites that are close together. Only through patient notification was this event identified. Awaiting further information/explanation from licensee."

Oregon Report Identification Number: 22-0028

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.

* * * UPDATE FROM DARYL LEON TO DONALD NORWOOD AT 1544 EDT ON 6/16/2022 * * *

"The following updated / revised information was received via E-mail:

"Description of event: The patient was scheduled for two treatments, one each for two separate lesions located on the patient's lower right leg. The first lesion treatment (5100 cGy total dose; 17 fractions @ 300 cGy ea) using beam therapy (SBRT) was performed in February without incident. The second lesion was not present during this treatment but appeared shortly after. On June 7th, the first fraction of 500 cGy (4000 cGy total dose; 8 fractions at 500 cGy ea) was performed. The second treatment was scheduled for June 10th, however, during set-up and after drawing a circle on the patient's leg to help align the second lesion and monitor positioning during treatment, the patient informed the physicist that after the first fraction on June 7th, he noticed the circle had been drawn at that time around the first lesion treated in February. Treatment staff immediately alerted the patient's physician. Images from the patient's HDR fractionated dose on June 7th were compared to the February external beam treatment and found to be the same location. The physician stated there is no adverse effect to the patient since the dose went to the site of the previous February treatment that was "well tolerated" by the patient and "the additional one HDR fraction of 500 cGy is likely of benefit to the patient". The patient's written directive was updated to reflect an additional fraction to be given to the second lesion.

"Cause and corrective actions:

"Facts to note:
- The second lesion was not present during the February external beam treatment.
- The written directive for the HDR treatment plan for the second lesion stated it was "lateral" than the "more medial" first lesion. Both were within approximately 1.5 inches of each other.
- The patient positioning for external beam was supine and for the HDR, prone.

"This event occurred due to human error. The licensee failed to note the change in patient positioning from supine to prone while using photos of the treatment area resulting in `visual flip' of image nor confirm treatment site from the written directive. A contributing factor is the proximity of the two lesions and another is that the second lesion was not present during the February external beam treatment.

"Stated corrections are to add a pretreatment step for multiple lesions close to each other that include:
- Asking the patient to point to the site to be treated.
- Verification by including more images of the body (hand or foot) along with the lesions to better identify the site and orient treatment personnel.

"Source: Irridium-192
Activity: Approximately 4.8 Ci
Model: Gammamed 232
Serial number: 24-01-0285-001-020422-15242-99
Leak test date: March 17, 2022."

Notified R4DO (Azua) and the NMSS Events Notification E-mail group.

PART 21 REPORT - FAILURE OF AN ARNOLD MAGNETICS POWER SUPPLY

The following is a synopsis of information received via facsimile:

On June 16, 2022, vendor Nutherm International, Inc. was informed that a defect caused the failure of Arnold Magnetics power supply PBM-24-106. The unit had been supplied by Nutherm to a nuclear power plant. The unit failed on or before March 15, 2022 during a 24-hour burn in period and was returned to Nutherm which did an inspection and analysis. Nutherm then returned the unit to Arnold Magnetics, the manufacturer, which completed further analysis. The manufacturer determined the unit failed due to the EMI filter assembly not functioning as designed as a result of the manufacturer's assembler not installing no-mex paper and thus not in accordance with manufacturer's procedure. Both the manufacturer and Nutherm have initiated corrective actions to prevent recurrence.

One facility is listed as being affected: TVA - Browns Ferry. Nutherm notified the affected facility on June 17, 2022.

If you have any questions or wish to discuss this matter or this report, please contact: Adrienne Smith at adrienne.smith@nutherm.com or at (618) 244-6000 x3034.