Event Notification Report for August 01, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/29/2022 - 08/01/2022

EVENT NUMBERS
56010 56011 56012 56014 56015 56023
Agreement State
Event Number: 56010
Rep Org: Minnesota Department of Health
Licensee: Mayo Clinic
Region: 3
City: Rochester   State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Lloyd Desotell
Notification Date: 07/22/2022
Notification Time: 12:13 [ET]
Event Date: 07/21/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Burgess, Michele (NMSS)
Einberg, Christian (NMSS)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Minnesota Department of Health via email:

"A patient was prescribed 100 mCi of Lu-177 Lutathera to treat a metastatic neuroendocrine tumor. On 7/21/2022, the patient received their therapy and was administered 206 mCi by mistake. The root cause of this event is unknown at this time and is being investigated. Based on the additional 106 mCi administration, the licensee calculated the additional whole body effective dose equivalent to be 30.1 rems using ICRP 103 methodology."

MN Event Report ID No. MN330003

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: 56011
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream   State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/22/2022
Notification Time: 17:03 [ET]
Event Date: 06/29/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Gaddy, Vincent (R4DO)
Event Text
AGREEMENT STATE REPORT - LOST SOURCES

The following information was provided by the Illinois Emergency Management Agency (Agency) via email:

"The Agency received a report from the licensee on 7/16/22, indicating the potential loss of (4) brachytherapy seeds, accounting for a maximum estimated activity of 1.02 mCi. The licensee has conducted an investigation and believes the seeds were likely lost or miscounted during patient implant and prior to shipment from a medical facility. Requests for clarification and the nuclide (either I-125 or Pd-103) have not yet been returned. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion.

"DETAILS: On June 29th, 2022, the licensee received a package from a hospital in California (CA). The package contained a source that was outside of the primary container but was found in the corner of the shipping box. The shipping box, reportedly, appeared undamaged from the outside, but the inside lacked appropriate packing materials to cushion the pewter containers. This package was then opened, and all the sources were counted. The hospital sent return fax paperwork saying that the package had six containers from different orders with a total of 218 sources. After fully disassembling all sources from their cartridges, the licensee's staff counted 214 sources. This count at 214 was reverified multiple times by multiple associates. Surveys were also conducted of the licensee's receiving area and returns processing area, as well as, the path in between to verify that the unaccounted-for sources were not in the facility. The hospital staff was contacted to verify the number of sources returned. They responded confirming their records showed they returned 218 sources from six orders but explained that the returned items were packed by other associates prior to their involvement and did not reopen the containers to recount the sources during the shipping process.

"REPORTABILITY: At this time the [4 missing] seeds cannot be attributed to implant, loss in shipment or loss at the CA facility; and is therefore being reported as lost under 32 Ill. Adm. Code 340.1210. It is unclear if the licensee met the reporting window since we are awaiting information on the nuclides involved. The Agency is making notification within 24 hours of becoming aware of the report (email wasn't retrieved until 7/21/22, due to staff absence and the automated reply was not heeded by the notifying party).

"Additional information will be provided as it becomes available."

Illinois Event Number: IL220026

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: 56012
Rep Org: Florida Bureau of Radiation Control
Licensee: TRC Engineers
Region: 1
City: Alchua   State: FL
County:
License #: 4621-1
Agreement: Y
Docket:
NRC Notified By: Chris Brosius
HQ OPS Officer: Lloyd Desotell
Notification Date: 07/22/2022
Notification Time: 17:12 [ET]
Event Date: 07/22/2022
Event Time: 16:26 [EDT]
Last Update Date: 07/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - MISSING MOISTURE DENSITY GAUGE

The following information was provided by the Florida Bureau of Radiation Control via email:

"On 07/22/22 at 1626 EDT, [the Alchua office] Radiation Safety Officer of TRC Engineers called to report that a Troxler 3440 [gauge was shipped] from the Alchua office of TRC to the West Virginia office of TRC via a common carrier. Tracking by the common carrier depicts the package to have arrived at its Memphis facility on 07/22/22 at 1125 EDT. [The package] is reported as delayed/pending per its website. The licensee is working with the common carrier to try to determine why the Troxler Gauge has not been delivered."

Florida Incident Number: FL22-084

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: 56014
Rep Org: Arizona Dept of Health Services
Licensee: Geo-Logic Associates
Region: 4
City: Ontario   State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Donald Norwood
Notification Date: 07/23/2022
Notification Time: 07:31 [ET]
Event Date: 07/22/2022
Event Time: 00:00 [PDT]
Last Update Date: 07/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Event Text
AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE LOST DURING SHIPPING

The following information was received via E-mail:

"The Department [Arizona Department of Health Services] was notified that a Humboldt 5001EZ, SN 1981, has been lost at an XPO shipping facility in Phoenix, Arizona. The gauge contains 10 mCi of Cesium-137 and 40 mCi of Americium-241.

"A reciprocity licensee, Geo-Logic Associates, dropped off the gauge at an XPO facility in Sacramento on July 15, 2022. The gauge then shipped on July 18, 2022 and arrived at the Phoenix XPO facility in Phoenix, Arizona on July 20, 2022. A company technician attempted to pick up the gauge on the afternoon of July 22, 2022 but was told that the XPO facility was unable to locate the gauge.

"Additional information will be provided as it is received in accordance with SA-300."

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: 56015
Rep Org: Maine Radiation Control Program
Licensee: Accuren Inspection, Inc.
Region: 1
City: Auburn   State: ME
County:
License #: 01221
Agreement: Y
Docket:
NRC Notified By: Tom Hillman
HQ OPS Officer: Donald Norwood
Notification Date: 07/23/2022
Notification Time: 08:44 [ET]
Event Date: 07/22/2022
Event Time: 14:45 [EDT]
Last Update Date: 07/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Schroeder, Dan (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - FAILURE OF SOURCE TO RETRACT

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

This information was reported to the Maine Radiation Control Program by the licensee at 0302 EDT on July 23, 2022. A guide tube crank-in problem occurred at 1445 EDT on July 22, 2022 in Westbrook, Maine in an area enclosed by fencing where natural gas pipe work was on-going. The problem was resolved at 0145 EDT on July 23, 2022.

During radiography operations, the guide tube was damaged and the source would not crank in. The crew did not force it and cranked it back to the collimator. The radiation safety officer was called and a retrieval team was dispatched. The tube was repaired enough to crank in the source. The activity and isotope involved was 76 curies of Ir-192. No exposures were reported and the media was not contacted.


Power Reactor
Event Number: 56023
Facility: Dresden
Region: 3     State: IL
Unit: [2] [3] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Collin Grischott
HQ OPS Officer: Bethany Cecere
Notification Date: 07/30/2022
Notification Time: 04:00 [ET]
Event Date: 07/29/2022
Event Time: 22:17 [CDT]
Last Update Date: 07/30/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(B) - Pot Rhr Inop
Person (Organization):
Peterson, Hironori (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation
Event Text
RHR CAPABILITY LOST DUE TO SUCTION BAY LEVEL

The following information was provided by the licensee via email:

"At 2217 CDT on 7/29/22, cribhouse suction bay levels were reported less than 501.5 feet due to buildup of grass on bar racks.

"Ultimate Heat Sink (UHS) is INOPERABLE due to Surveillance Requirement 3.7.3.1 not met. ENTER Technical Specification (TS) 3.7.3 condition A (Required Action (RA) A.1 mode 3 in 12 hours, RA A.2 mode 4 in 36 hours). Dresden Lockmaster reports river level normal at 504.89 feet. Commenced trash rake operations to clear grass debris off of intake bar racks.

"At 0135 CDT on 7/30/22, cribhouse suction bay levels were reported at greater than 501.5 feet. Exit TS 3.7.3 condition A. Due to this INOPERABILITY, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(B).

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

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

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 7/30/22 AT 1934 EDT FROM COLLIN GRISCHOTT TO BRIAN LIN * * *

"At 1116 CDT on 7/30/22, a repeat condition occurred where cribhouse suction bay levels were reported < 501.5 feet due to buildup of grass on bar racks. Entered TS 3.7.3 condition A (RA A.1 mode 3 in 12 hours, RA A.2 mode 4 in 36 hours). Actions are in-progress to clear grass debris off the intake bar racks.

"Due to this INOPERABILITY, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(B).

"At 1745 CDT on 7/30/22, cribhouse suction bay levels were reported at >501.5 feet. Exit TS 3.7.3 condition A. The station continues to monitor for intake grass buildup and taking appropriate actions to maintain UHS operability."

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

The licensee notified the NRC Resident Inspector.

Notified R3DO (Peterson).