Event Notification Report for June 22, 2022

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.

AGREEMENT STATE REPORT - LOST THEN FOUND I-125 SEED

The following information was received via E-mail:

"On 6/14/22, one Theragenics, I-125 brachytherapy seed (0.501 mCi) from the inventory was discovered missing. It was one of 10 spare seeds used for a patient prostate implant should they be needed. The inventory of concern was that required for a patient who was implanted with 88 seeds using 16 needles as planned. He did not need any of the spare seeds for his implant.

"In accord with our standard procedure, five of the 10 spare seeds were prepared in spare needles by one of our radiation oncology dosimetrists, one seed per needle, on Monday, 06/13/22. All prepared needles and loose seeds remained in the hot lab (SP 22244) until the patient's surgery. This means that five loose I-125 seeds should have remained in their transport vial in the hot lab (SP 2244) adjacent to the surgery room (SP 2245). However, when preparing to return the five spare needle prepared seeds to the transport vial, post patient implant, it was evident that there were only four rather than the expected five loose seeds in the vial. I surveyed the hot lab (SP 2244) but could not locate the missing seed in the hot lab or its surrounding area. The five spare needle prepared seeds were returned to the transport vial for a total of nine seeds rather than the inventory of 10. This vial was taken to the radiation oncology hot lab safe. Several surveys were performed of the Surgery Pavilion area (SP 2244) but the seed was not found.

"On 6/15/2022, the missing I-125 seed (0.501 mCi) was found and returned with the other loose seeds to the 'Medak' vial now located in the radiation oncology hot lab. On an inspired guess, the dosimetrist returned to the SP 2244 hot lab in the prostate pavilion and in a high cupboard searched a steel container used for sterilizing all 10 loose seeds before creating the five spare needles. This is where the missing seed was found.

"As corrective actions, the unused seeds will be visually counted and the checklist updated to include this process."

Washington Incident Number: WA-22-015

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 - STOLEN PORTABLE NUCLEAR GAUGE

The following information was received from the State of Nevada via email:

"At approximately 1350 PDT, the RSO/CEO for IQC Southwest LLC, 00-11-0745-01 notified the Nevada Radiation Control Program (NRCP) that a Portable Nuclear Gauge (PNG) had been stolen from a work site located near the intersection of Sierra Vista and Paradise Road working off of Paradise Road in Las Vegas, Nevada. In addition, Las Vegas Metro Police Department was on scene and taking a report during the Radiation Safety Officers (RSO) notification call to the NRCP.

"The RSO stated that they had video of the theft as it occurred. An unknown (possibly transient) individual walked through the work site, picked up the gauge and walked off, appearing to hide the gauge with his body while the Authorized User (AU) was getting material from his vehicle. The source rod was not locked when the gauge was taken.

"The gauge was a Troxler model 4640-B with a 9 mCi Cs-137 source.

"An incident inspection will be performed June 16, 2022 by the NRCP."

Nevada Item Number: NV220006

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 - HDR AFTERLOADER MOTOR FAILURE RESULTS IN ABORTED TREATMENT

The following information was received via E-mail:

"The following is preliminary information, and will be updated as the State of Washington learns more about this event:

"A mechanical incident occurred with the HDR (high dose rate) afterloader unit, and a treatment had to be aborted. It appears that a motor in the afterloader failed. The manufacturer's representative removed the active and dummy wires and is in the process of making the necessary repairs. There does not appear to be any radioactive material contamination in the system. No staff or patients received any excess dose. Plans are to exchange the source and complete all of the needed QA checks so that patient treatments may resume.

"The equipment involved was a Varian HDR remote afterloader, Model VariSource iX, Serial Number 600501, containing less than 11 curies of Iridium-192."

Washington Incident Number: WA-22-016

OFFSITE AGENCY NOTIFICATION DUE TO CHEMICAL LEAK

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

"At 1547 EDT on June 21, 2022, it was determined that Beaver Valley Power Station Unit No. 1 experienced a reportable chemical leak. Approximately 261 gallons of a Sodium Hypochlorite/Sodium Bromine mixture reached the ground and approximately 130.5 gallons (of the 261 gallons) progressed to the Ohio River (via storm drain). The source of the leakage has been isolated and absorbent material has been placed to contain the leakage. Following confirmation of this leakage, notifications were made to the following offsite agencies starting at 1615 EDT:

"National Response Center (Incident Report # 1339391)
"Pennsylvania Department Of Environmental Protection
"Beaver County Emergency Management

"This condition is being reported as a four-hour, non-emergency notification per 10CFR50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."