Event Notification Report for September 07, 2022

AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL PACKAGE LOST IN TRANSIT

The following information was received via email:

"The Illinois Emergency Management Agency (the Agency) received notice of a missing radiopharmaceutical package lost in the care of a commercial carrier while in transit from Arlington Heights, IL to Dallas, TX. The package was initially damaged and identified at the carrier's Memphis, TN location on 8/5/22. At that time, it was accounted for and was not reported as lost. As of 8/25/22, the carrier declared the package as lost after attempts to overpack and return to the shipper, GE Healthcare. The carrier reports they lost the overpack with the package inside at their Memphis, TN facility. The 1.0 millicuries of Indium-111 [originally contained in the package] has now decayed beneath 20 microcuries. As a result, this does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. TN program staff have been copied on the notification. All reporting timelines were met. Unless additional information is provided, this matter is considered closed."

Illinois Reference Number: IL220030


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 - DOSE LESS THAN PRESCRIBED

The following information was provided by the Oregon Health Authority, Radiation Protection Services via email:

"During preparation for a hepatic microsphere (ThereSphere) treatment, the oncology nurse primed the system but when the needle assembly was snapped into the dose vial a series of bubbles appeared. The nurse attempted to remove the bubbles from the tubing that was to be connected to the patient's catheter but was unsuccessful. The procedure physician was made aware of the bubbles and since the physician did not want to push them through the patient's catheter, the bubbled liquid was expelled into gauze which was subsequently added to the waste container. Working through this issue added approximately 10 minutes to the time between assay and administration.

"In addition, the assayed activity of Y-90 was 96.5 percent of the prescribed dose of 440 Gy and 95.6 percent at time of administration after the 10-minute delay due to the bubbled liquid issue. Normally, 95-99 percent of the assayed activity is delivered to the target (liver), however, with the loss of activity through expelling bubbled liquid, the delivered activity dropped to 351.8 Gy which is greater than the 20 percent lower limit of 440 Gy (352 Gy) at 20.4 percent and makes this a reportable medical event.

"[The physician notified the patient, documented this on the patient's chart, and stated there are no adverse effects from this under-dosing.] No additional dose is needed.

"Cause and corrective actions:

"It was stated the oncology nurse prepped the system 'correctly'. The licensee informed the TheraSphere representative regarding this issue with the needle assembly. At this time, we are unable to determine whether this event is considered human error or defective product.

"It is worthy to note that if one of the two issues (delay of 10 minutes or starting with 96.5 percent) was absent, the under-dosing of greater than 20 percent probably would not have occurred."

Oregon Event Report Number: 22-0038

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.

EN Revision Imported Date: 9/7/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified by the Radiation Safety Officer (RSO) at Arkema via voicemail and email on 8/30/2022 at 1501 EDT, that on August 30, 2022, one fixed gauging device (Ronan Engineering SA1-F37, Serial Number M8107), containing 5 Ci of Cs-137 (source Serial Number not reported, assay date 08/1991) had developed a problem in that that the shutter arm was not moving freely to the closed position. The technician eventually moved the shutter arm to the closed position and verified radiation levels to be normal. The gauge is mounted on a tank, manned entry is currently restricted, and plant personnel have been notified that there is no access allowed to the vessel. No overexposures were reported due to the malfunction. All operational and maintenance activities related to the vessel will be delayed until the manufacturer (Ronan Engineering) repairs the shutter mechanism. The licensee has contacted the manufacturer/service provider to remediate this situation."

Kentucky Event ID Number: KY220004

*** UPDATE ON 9/2/22 AT 1031 EDT FROM KENTUCKY RADIATION HEALTH BRANCH TO BILL GOTT ***
The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email:
The KY RHB was informed by the new RSO that the actual date that the shutter malfunction was discovered was April 29, 2022."
Notified R1DO (Gray). Notified via email: NMSS Event Notification

AGREEMENT STATE REPORT - LOST Y-90 MICROSPHERES

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

"On August 31, 2022, the licensee notified the Department that they had lost control of licensed radioactive material. Per the licensee's report, on or about August 10, 2022, four sharps containers with yttrium-90 microsphere waste were inadvertently taken from the licensee's decay-in-storage room and placed in a locked room in the hospital's shipping department for disposal as biohazardous material. On August 15, 2022, the four sharps containers (approximately 60 millicuries of yttrium-90) were picked up by the hospital's biohazardous waste vendor, where they are assumed to have been autoclaved and disposed in a landfill. The licensee became aware of the loss on August 29, 2022. Based on the current activity of the sources (less than 1 millicurie) no attempt will be made to retrieve the material. No members of the public are expected to exceed public dose limits. A Department investigation is ongoing."

WI incident no.: WI220020

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

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

The following information was provided by the licensee via email:

"At 2345 CDT, Unit 1 Reactor tripped due to a turbine trip. All auxiliary feedwater pumps started due to steam generator Lo Lo levels.

"Unit 1 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IPO-007A. The Emergency Response Guideline procedure has been exited. Decay heat is being rejected to the main condenser via steam dump valves.

"The cause of the Turbine Trip is currently under investigation."

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

NRC Resident Inspector has been notified. Unit 2 is unaffected by this event.