Event Notification Report for July 15, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/14/2022 - 07/15/2022

Agreement State
Event Number: 55980
Rep Org: OR Dept of Health Rad Protection
Licensee: Salem Hospital
Region: 4
City: Salem   State: OR
County:
License #: ORE-91006
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Kerby Scales
Notification Date: 07/07/2022
Notification Time: 16:03 [ET]
Event Date: 06/29/2022
Event Time: 00:00 [PDT]
Last Update Date: 07/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Event Text
AGREEMENT STATE REPORT - POTENTIAL HIGH DOSE TO OTHER THAN TREATMENT SITE

The following was received from the state of Oregon via email:

"On June 29, a deviation on the length of the transfer tube was identified where the tube was found to be 2.9 centimeters longer than the vendor's specification (122.9 cm vs. 120 cm). This tube is used specifically with Channel 1 of the afterloader [(source: 10 Ci Ir-192; model: VS2000; s/n: 02-01-0235-001-031622-11038-12)] with a tandem and ring (T and R) applicator. Treatments therefore will be 2.9 centimeters shorter than the programmed distance for treatments and involving 1.5-2 cm of unintended tissue which shall exceed 50 rem and quite probably 50 percent to the location. The transfer tube length was last measured on July 27, 2020 and the licensee noted that the tube "measured length appeared to reflect the specified length by the manufacturer at the time." Because of this, the licensee believes they may have under-dosed some of their T and R patients using this transfer tube with Channel 1 of the afterloader. The licensee has already indicated two T and R treatments where this may be the case, May 13 and June 22, and is putting together a list of all cases since the most recent tube length verification in 2020.

Oregon Report ID Number: 22-0031

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
Event Number: 55982
Rep Org: Wisconsin Radiation Protection
Licensee: 3M Company
Region: 3
City: Menomonie   State: WI
County:
License #: 033-2030-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 12:19 [ET]
Event Date: 07/07/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 7/11/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Wisconsin Department of Health Services via email:

"On July 8, 2022, the State was contacted by a representative of the licensee to report a radiation event that had been identified on July 7. The licensee was performing routine checks on a fixed gauge device, and the individual servicing the gauge identified that the shutter was unable to be closed. All indicators are functioning as required to alert that the gauge is open. The device is believed to have been stuck open for approximately 13 hours. Staff who work in the area have been instructed that the device is unable to be closed, and to avoid working around the gauge even when it is not being utilized. The device is a Mahlo Model 11-200933, [serial number] SN: 11-011988. It contains an Eckert and Ziegler Pm-147 [Model] PHC.C1 source, SN:AH-4968. It has an assay date of April 15, 2016, 1000 mCi. It currently contains approximately 193 mCi. The licensee performed a dose reconstruction of any individual who would have been at the 8 foot boundary of the gauge, which indicates minimal exposure. The manufacturer was notified and is currently coordinating with the licensee to get a service engineer on site. The department will continue to follow-up with the licensee."

WI incident no.: WI220014


Agreement State
Event Number: 55983
Rep Org: Colorado Dept of Health
Licensee: Facebook-Denver
Region: 4
City: Denver   State: CO
County:
License #: GL002581
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 15:39 [ET]
Event Date: 06/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received from the Colorado Department of Public Health and Environment (the department) via email:

The department was notified on June 6, 2022, that two SLX-60 Exit signs containing 7.62 Ci each of H-3 were lost in 2021. No additional information was provided.

CO incident no.: CO220021

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
Event Number: 55984
Rep Org: Iowa Department of Public Health
Licensee: 3M
Region: 3
City: Knoxville   State: IA
County:
License #: 0042163FG
Agreement: Y
Docket:
NRC Notified By: Derek Elling
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:38 [ET]
Event Date: 07/07/2022
Event Time: 15:15 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lafranzo, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Iowa Department of Public Health (IDPH) via email:

"At 1515 CDT, July 7, 2022, an NDC Technologies, Model 302 fixed gauge with [approximately] 80 mCi of Kr-85 had a shutter stick open when the line was turned off. The shutter was first identified as stuck open around 1600 when the Radiation Safety Officer was conducting their entrance radiation survey. Radiation safety perimeter was established. The service provider was called and arrived the morning of July 8, 2022. They were able to close the shutter but unable to conduct cause analysis. The gauge will be shipped back to vendor to safely analyze for cause. The IDPH will decide on a reactive inspection based on the cause of stuck shutter identified by the vendor.
Licensee aware of 30 day written notification requirement."

IA incident no.: IA220004


Agreement State
Event Number: 55985
Rep Org: Colorado Dept of Health
Licensee: Home Depot
Region: 4
City: Denver   State: CO
County:
License #: GL000714
Agreement: Y
Docket:
NRC Notified By: Kathryn Kirk
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:06 [ET]
Event Date: 07/06/2022
Event Time: 00:00 [MDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following summary was received from the Colorado Department of Public Health and Environment via email:

On June 6, 2022, the Colorado Department of Public Health and Environment reported one model 2040 exit sign containing an unknown amount of tritium lost by the licensee. The incident occurred between 2009-2010.

CO incident no.: CO220022

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
Event Number: 55986
Rep Org: Alabama Radiation Control
Licensee: Wiregrass Medical Center
Region: 1
City: Geneva   State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 17:56 [ET]
Event Date: 03/11/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Event Text
EN Revision Imported Date: 7/11/2022

EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:

"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."

AL incident no.: 22-10

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
Event Number: 55987
Rep Org: Alabama Radiation Control
Licensee: Southeast Health
Region: 1
City: Dothan   State: AL
County:
License #: 448
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 18:17 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Event Text
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION

The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:

"Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions."

AL incident no.: 21-29

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.


Part 21
Event Number: 55993
Rep Org: Framatome Anp
Licensee:
Region: 2
City: Lynchburg   State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: Gayle Elliott
HQ OPS Officer: Thomas Herrity
Notification Date: 07/13/2022
Notification Time: 14:28 [ET]
Event Date: 05/02/2022
Event Time: 00:00 [EDT]
Last Update Date: 07/13/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 REPORT - FAILURE OF AN EATON ELECTRICAL CUTLER HAMMER RELAY

The following information was provided by Framatome Inc. via email:

"Framatome Inc. (Framatome) supplied an Eaton Electrical Cutler Hammer, Inc. (Eaton) D26MRD704A1 Relay to Duke Energy Carolinas, LLC, McGuire Nuclear Station, that failed to change state during testing of their load sequencer. This relay was supplied as a safety related component by Framatome. A molded contact bar in the D26 top adder deck prevented a contact spring from settling into its proper position. Top adder decks manufactured between 2003 and 2022 were inspected for the existence of flashing, but no specific time frame where the excess flashing was found could be identified.

"Testing of additional relays with this similar excess flashing condition, by both Framatome and Eaton, showed that contact springs tended to stay in place and were unaffected by the excess flashing. There have been no past similar relay reports by Framatome customers despite there being at least 587 other relays with top adder decks supplied as commercially dedicated components. Eaton has also indicated that they have had no other reports of this condition or failures associated with it.

"The extent of condition determined that the failure is an isolated incident. Only one relay, supplied to McGuire Nuclear Station, failed to change state.

"In the future, as a precaution, the Framatome commercial grade dedication process will include the inspection of the adder deck contact bars. Relays containing contact bars with excess flashing will be rejected."