Event Notification Report for August 01, 2022

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 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 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 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 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.

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).

AGREEMENT STATE REPORT- LOST EXIT SIGNS

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

The Colorado Department of Public Health and Environment reported four Speclite model TP10 exit signs, containing 6.5 Curies of tritium each, lost by the licensee. The incident occurred June 8, 2022.

CO Event Report ID no.: CO220024


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: 7/28/2022

EN Revision Text: DAMAGED NUCLEAR GAUGE

The following information is a synopsis provided by the licensee via email:

An incident involving a Nuclear Gauge #26 (CPN MC1 DR serial# MD60503240) on a job site (#37: 1564-C) at about 1315 EDT on 07/22/22 in SE Washington, DC 20032. The gauge contained the following sealed sources: 370 MBq (10 mCi) Cs-137 01/17/96 and 1.85 GBq (50 mCi) Am-241/Be 03/27/96.

The gauge was damaged by an excavator while it was under the control of an authorized user (AU). The AU went to their car about 50 feet away to grab some paperwork. The operator of the excavator did not see the gauge, and hit it hard enough to crack its plastic shell. The source rod and electronics were not damaged.

The AU informed an ECS field supervisor about the incident immediately and cordoned off the 15 foot radius of an area around the damaged gauge. The back-up radiation safety officer (RSO), was contacted and came to the site to evaluate the damage. The gauge's plastic case was broken due to the impact, but the sources were in the shielded position. Several surveys were made using a survey meter (RADIATION Alert M4, calibrated on 12/22/21) at one meter distance, and the readings were found to be less than 0.4 mR/hr range.

In addition to contacting the NRC Operations Center on 7/22/22, the Virginia Department of Health was informed at 1755 EDT the same day.

All the pieces of the gauge were placed in a box and it was hauled back to the designated storage area in the Chantilly, VA office around 1700 EDT. After performing a leak test and once an all-clear report is received, the damaged gauge will be returned to the authorized distributor in the area, for them to repair it properly.

All authorized users will be informed about the incident immediately, and this will be discussed in detail at our safety meetings to reiterate and stress the importance of maintaining physical control of gauges when the gauge is not otherwise secured using two independent physical locking systems to prevent unauthorized access or removal.

NON-AGREEMENT STATE REPORT - DOSE ABOVE THE PRESCRIBED DOSE

The following is a summary of a phone call with the licensee:

On 7/14/22, a patient received more dose than the written prescription for delivery to their bone surfaces. The prescription was for 57.5 microCi of radium-223 and the patient received 184.9 microCi. The patient was intended to receive 184.9 micro Ci, however a clerical error resulted in the prescription only listing 57.5 microCi.

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.