Event Notification Report for November 10, 2022

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the licensee via phone:

New Haven Hospital performed stereotactic radiosurgery treatment plan on brain lesions using a gamma knife. Following the procedure, it was determined that up to 6 of the 10 targets could have been missed resulting in up to a 50 percent underdose to the intended targets. There was no indication of unintended damage to neighboring tissues, organs, or structures.

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: 11/9/2022

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE

The following information was provided by the Georgia Radioactive Material Program via email:

"On 10/18/2022 at 0630 EDT, a Cs-137 vial source was being used to measure dose calibrator constancy. The nuclear medicine [NM] technologist noticed a crack in the bottom of the sealed source vial and possible contamination surrounding the vial.

"The sealed source was placed in a leak proof container, the Radiation Safety Officer (RSO) was notified, and decontamination protocol was followed. A leak test of the vial confirmed there was more than 0.005 microcuries of removable Cs-137 contamination.

"Post-decontamination surveys and wipe tests of the staff and department indicated that there was no contamination in the department, but there was detectable contamination on the hands of one staff member. The staff member is the individual who was handling the sealed source and discovered the crack in the source. He repeatedly scrubbed his hands - first with lukewarm soap and water, then with Bind-It brand radioactive decontamination hand soap until there was no improvement in the surveys of his hands.

"A final survey of the individuals hands hands showed there was no detectable contamination on his left hand. A small area on his right-hand thumb still measured 1000 [Counts Per Minute] CPM above background, and another small area on his right-hand index finger measured 700 CPM above background using a GM probe. Measurements of the contamination on his fingers using the on-site well counter indicated it was Cs-137 contamination.

"Both the Radiation Safety Officer and Medical Director were notified of the incident. The RSO came on-site to supervise decontamination efforts and to secure the leaking source and decontamination waste.

"Dose calibrator measurements of the source by the RSO indicated the source had leaked approximately 6 microcuries total. Since 6 microcuries of Cs-137 is less than 10 percent of the annual limits on intake (ALI) for Cs-137 (100 microcuries ALI for oral ingestion as defined in Appendix B of 10 CFR 20), [the Program's] understanding is no individual bioassay monitoring is required for the individual.

"The sealed source has been placed back within its shielded container, sealed with tape, and marked as leaking and out-of-service. The waste generated during the decontamination process was placed in a leakproof plastic bottle and marked as containing Cs-137. Both items are currently stored in [a secure area]. We are contacting waste disposal companies to arrange disposal of both the leaking sealed source and decontamination waste. The NM staff was re-educated on the requirement to wear disposable gloves at all times while handling radioactive materials, which includes sealed radioactive sources, per the Model Rules for Safe Use of Radiopharmaceuticals."

Georgia Incident Number: 60

* * * UPDATE ON 11/08/2022 AT 1323 EST FROM SHEREE BUTLER TO BRIAN LIN * * *

The following information is a summary of information received via email:

The licensee supplied an updated report to the state of Georgia. Georgia Radioactive Material Program employees will finalize and close out the report after disposal of the leaking source and contaminated waste.

Notified R1DO (Werkheiser) and NMSS Events Notification email group.

UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS

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

Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.

This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.

This issue has been entered into the licensee's corrective action program as IR-2022-9728.

AGREEMENT STATE REPORT - LEAKING CS-131 BRACHYTHERAPY SOURCE

The following information was received via email from the Washington Office of Radiation Protection:

"On 11/2/2022, a licensee, IsoRay Medical - License Number: WN-L0213-1 reported a Cs-131 Brachytherapy source, model CS-1, leaking at customer's facility. A customer detected contamination on equipment used during a procedure with Cs-131 seeds. The customer was not initially able to identify the isotope of the contamination using their equipment, however they were able to perform a half-life estimation using dose measurements on a collimated container loaded with all the contaminated items from the procedure. The decay rate was roughly in line with Cs-131. The customer indicated that as part of their own procedures, the order, which arrived as a non-sterile mick pig, was opened and surveyed. No contamination was found at that time. A thorough investigation is ongoing."

Washington Incident Number: WA-22-021

FITNESS FOR DUTY REPORT

A non-licensed supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.