Event Notification Report for November 23, 2022

EN Revision Imported Date: 11/23/2022

EN Revision Text: AGREEMENT STATE REPORT - GAMMA KNIFE MALFUNCTION

The following information was provided by South Carolina Department of Health & Environmental Control via email:
"The South Carolina Department of Health and Environmental Control was notified on 08/10/2022, during a follow-up of a routine inspection, that a Leksell Gamma Knife Perfexion gamma stereotactic radiosurgery unit had failed to function as designed. The licensee [Prisma Health Richland Hospital] is reporting that during routine maintenance that was conducted by the manufacturer on 11/01/2021, it was discovered that a sector was dragging and not transferring smoothly. The licensee is reporting that one of the sealed sources had slipped less than 1/8 inch within one of the source cavities of the Leksell Gamma Knife Perfexion unit. The sealed source is a Co-60 Elekta Model 43685 medical teletherapy source, with an estimated activity between 20-22 curies. The licensee is reporting the unit was repaired and source reseeded on 11/05/2021. The licensee is reporting no overexposures to workers, patients, or members of the public. All sealed sources were leak tested on 11/05/2021 and results indicated that no sources were leaking. This event is under investigation by the South Carolina Department of Health and Environmental Control."

* * * UPDATE ON 9/7/2022 AT 1158 EDT FROM ADAM GAUSE TO MICHAEL BLOODGOOD * * *
The following information was provided by South Carolina Department of Health & Environmental Control via email:

"The licensee has submitted a 30-day written report. The Co-60 Elekta Model 43685 medical teletherapy source serial number is NIW098 with an estimated activity of 20.6 Ci (0.7622 TBq) at the time of the event. On 11/05/2021, the manufacturer and service representative identified the bushing containing the source had slipped slightly from its sleeve. The bushing was visually inspected via remote camera and showed no damage. The bushing and source was reseeded into its sleeve on 11/05/2021. No patients were treated between 11/1/2021-11/10/2021. The licensee is reporting no overexposures or medical events. The licensee performed areas surveys (using a Fluke 451PYR, calibrated 04/08/21) on 11/03/21 and 11/05/21, records indicated dose rate readings that were consistent with the radiation levels in the sealed source and device registry for the Perfexion unit. The licensee also performed area contamination surveys/wipes (using a Capintec Captrac, calibrated 10/18/21) on 11/03/21 and 11/05/21, records indicated contamination levels below the licensee's removable contamination trigger limits. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

Notified R1DO (Defrancisco) and NMSS Event Notification via email.

* * * UPDATE ON 11/22/2022 AT 1501 EST FROM ADAM GAUSE TO IAN HOWARD * * *
The following update was provided by the state of South Carolina via email:

"The manufacturer (Elekta, Inc.) submitted a report dated 10/14/22. The manufacturer's estimate of the effect on the dose rate is a reduction of about 0.3 percent for the 4 mm collimator with one loose bushing in the worst angle. The manufacturer's estimate of the effect on the delivered dose was 1.5 mGy less than planned. The licensee reported the typical patient dose range is 32-85 Gy. The manufacturer performed a root cause analysis in the report dated 10/14/22. The manufacturer determined that when pushing the bushing into the sleeve, the bushing can be slightly misaligned with the sleeve making it stick without the spring being properly activated. Later the bushing can come loose due to vibrations. The manufacturer determined this is what is likely to have happened here.

"The licensee's corrective actions included determining the root cause of the event, reseating the bushing and lubricating all sectors, determining no other bushings were loose/unseated, performing acceptance testing prior to treatment of the first patient after event, and having future source loadings confirm all source bushings are properly seated prior to turning the unit over for acceptance testing. The licensee did not identify any other instances where a source/bushing slippage had occurred. This event/investigation is closed."

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

EN Revision Imported Date: 11/23/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS

The following was received from the state of South Carolina via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone on 10/31/22 that three fixed gauging device shutters were stuck in the closed position. All three fixed gauging devices are Thermo Fisher Scientific Model 5197 gauging devices, serial numbers B7842, B7847, and B7841. The activity of each gauging device is 100 mCi of Cs-137. The licensee is reporting that all three fixed gauging devices are mounted 12-15 feet above accessible areas. No elevated exposure rates are being reported. Department inspectors will be dispatched to the facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

South Carolina Event Number: To be assigned.

* * * UPDATE ON 11/22/2022 AT 1451 EST FROM ADAM GAUSE TO IAN HOWARD * * *
The following update was provided by the state of South Carolina via email:

"Department inspectors were dispatched to the facility and found the gauges as the licensee described. The gauges were expected to be repaired on 11/02/22. The licensee submitted a 30-day written report dated 11/11/22. The written report indicated the fixed gauging devices were repaired on 11/02/22. The licensee's corrective actions included repairing the fixed gauging devices and updating procedures to include examples of reporting requirements. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

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

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following information was provided by the State of Ohio via email:

"The Ohio Department of Health (ODH) received a call on November 14, 2022, concerning a Troxler model 3241-C gauge [100 mCi Am-Be source], that was damaged in a fire at a job site in Wellston (Jackson County). The gauge was stored in a trailer at a temporary asphalt plant. The plant closed last week for the winter and the gauge was going to be removed this week. The fire destroyed the trailer and melted the plastic outer shell of the device. An ODH inspector responded to the site. The source was located under the remains of the trailer but is buried in the ashes from the trailer. The highest dose rate detected was 7mR/hr which indicates that the source is shielded by the lead in the device. A licensed service provider will be on site on November 15, 2022, to retrieve the source and transport it for disposal. The licensee will provide security at the site until the source is removed."

Ohio Item number: OH220011

AGREEMENT STATE REPORT - WRONG INITIAL DOSE TO PATIENT

The following report was received via email from the Tennessee Division of Radiological Health:

"Medical Physicist for Holston Valley Medical Center reported that a patient was mistakenly given all fractions of a cervical treatment on November 14, 2022. The patient was scheduled for five 600 centigray (cGy) fractions of Ir-192 for a total of 3000 cGy. The medical physicist misread the prescription and gave the full 3000 cGy in the initial dose. As of November 15, 2022, the patient had not been notified. However, the patient will be returning on November 16, 2022, for the next treatment.

"Corrective actions or reports will be updated with a report within 30 days."

Tennessee Event Number: TN-22-069

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.

NOTIFICATION OF ENVIRONMENTAL REPORT TO ANOTHER GOVERNMENT AGENCY

The following information was provided by the licensee via email:

"On 11/22/2022, Monticello Nuclear Generating Plant initiated a voluntary communication to the State of Minnesota after receiving analysis results for an on-site monitoring well that indicated tritium activity above the [Offsite Dose Calculation Manual] ODCM and Nuclear Energy Institute (NEI) Groundwater Protection Initiative (GPI) reporting levels. The source of the tritium is under investigation and the station will continue to monitor and sample accordingly. This notification is being made solely as a four-hour, non-emergency report for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - Ra-226 DISC FOUND IN SCRAP LOAD

The following information was provided by the Massachusetts Radiation Control Program (the Agency) via email:

"On 11/1/2022, Schnitzer Steel [Docket 23-5219] in Everett, MA notified the Agency that portal monitors detected radioactive contamination in a scrap load that originated from Spiegel Scrap Metal in Brockton. A handheld meter measurement showed 0.03 mR/hr on the driver's side of the truck. DOT [Department of Transportation] exemption form MA-MA 22-28 was created to transport the load back to Spiegel Scrap Metal.

"On 11/3/2022, Atlantic Nuclear surveyed the contents of the scrap load and discovered a disc containing Ra-226. A handheld meter measured 1.5 mR/hr on contact. The estimated activity of the gauge is 2 microCuries. Spiegel is contracting Chase Environmental to dispose of the item.

"The reporting requirement is within 30 days and is of 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the licensee via email:

"During an SIR [Selective Internal Radiation] Spheres treatment on November 17, 2022, a patient was to receive 10.8 milliCuries of Y-90 [Yttrium-90]. A measurement of the residue radiological waste from the procedure indicated that the patient only received 38 percent of the intended dose or 4.33 milliCuries. The total dose delivered differs from the prescribed dose by 20 percent or more.

"The doctor drew up a dose of 11.4 milliCuries for the procedure. Static readings on the vial averaged 0.205 mR/hr. Post procedure readings averaged 0.127 mR/hr. These readings resulted in the fraction delivered of 38 percent or a total of 4.33 milliCuries. Corrective action is pending."

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 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 six exit signs (Manufacturer: SRB Technologies, Model B100 Series), containing 17.5 curies of tritium each, lost by the licensee. The incident occurred September 7, 2022.

Event Report ID No.: CO220035

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 - GAUGE SHUTTER FAILURE

The following information was provided by the Arkansas Department of Health [the Department] via email:

"On October 28, 2022, the Department received notification from Domtar, Ashdown Mill of a failed shutter on October 18, 2022. The failure occurred during a site-wide nuclear gauge shutter check being performed by a licensed third-party consultant. The failure was due to the shaft that allows for the operation of the shutter broke and the rectangular shutter control interface was no longer able to control the shutter. The licensee's immediate corrective action included shutting down the process system and closing the shutter.

"The gauge with the failed shutter, a Berthold LB 7440, serial # 1460-5-90, internal 50 mCi Cs-137 source # 012-00022 was removed and placed into the licensee's storage facility. A spare gauge, a Berthold LB 7440-D-CR, serial # 2730-8-90, internal 100 mCi Cs-137 source #012-00089 was placed in service. Leak tests for both gauges were performed which indicated no contamination. The licensee confirmed no public or employee exposure occurred. The failed gauge in storage is currently waiting to be repaired or disposed of in December.

"The reporting requirement is under the Department's 'Rules for Control of Sources of Ionizing Radiation' RH402.c.5 and 10 CFR Part 31.5 (c)(5)."

Arkansas Event Number: AR-2022-9

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 two exit signs (Manufacturer: Isolite Corp, Models 2000 and SLX60), containing 16.2 curies of tritium total, lost by the licensee. The incident occurred November 9, 2022.

Event Report ID No.: CO220038

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 - DAMAGED TROXLER GAUGE

The following information was provided by the The Arkansas Department of Health (The Department) via email:

"The Department received notification on October 7, 2022, from licensee GTS, Inc., that a Troxler gauge model 3430 had been rolled over by a bulldozer while performing routine measurements at a construction site. As a result of the incident, the source was pulled from its testing position and exposed.

"The technician created a thirty (30) foot containment barrier and notified his company's Radiation Safety Officer (RSO). The RSO mobilized to the event location and contacted the Department.

"The Department's inspectors visited the licensee on October 7, 2022, to investigate the event. Surveys at the exterior of the transport container were determined to be 3 to 5 mR per hour. Surveys performed inside of the transport container were measured to be a maximum of 27 mR per hour at a location close to the surface of the shielded source.

"The RSO returned the handle to the 'safe position' and both radiation sources were placed in the transport box. The gauge was transported back to the designated radiation storage area located at the GTS Little Rock Office in Alexander, Arkansas. The gauge was swabbed for a leak test and then sealed in its transport case and secured in the storage area. Sand and additional temporary screening were installed surrounding the area. GTS then contacted Instrotek Companies for disposal options. On November 9, 2022, the gauge was shipped back to the manufacturer. The licensee performed leak tests of the sources, surveys of the gauge transport container, and surveys of the storage location.

"The Occupational Radiation Exposure Report from October 1, 2022, through December 31, 2022, shows 0 mrem for the RSO and technicians. Leak test certificates showed no leakage.

"Upon review of the licensee's 30 day report, received November 16, 2022, it was noted that the dosimetry badge worn by the RSO during the retraction and transportation of the source showed no measurable dose.

"The report contained leak test results for the sources both on the day of the event, October 7, 2022, and after the event on November 1, 2022. The results for the leak tests in both instances were measured to be below 185 becquerel (0.005 microcuries).

"On October 10, 2022, the company conducted a thorough review of the incident and a safety session was held with the gauge operator involved in the incident prior to the operator returning to field work using a nuclear density gauge. The session included collaborative thinking and planning in performing nuclear density testing safety on unique job sites, especially those with confined work environments.

"Additional topics discussed included utilizing verbal communication with equipment operators prior to accessing a work area, utilizing a 'spotter' while performing testing, and always maintaining possession and visual observation of a nuclear density gauge while the gauge is not inside the transport case in the vehicle.

"The Department considers this event to be closed."

Arkansas Event Number: AR-2022-008

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following information was provided by the South Carolina Department of Health and Environmental Control (The Department) via email:

"The Department was notified on 11/18/22 at 1243 EST via telephone that a Troxler 3400 series portable moisture density gauge, serial number 33556, had been hit by a piece of construction equipment.

"The Troxler 3400 series portable moisture density gauge contains a maximum activity of 9 millicuries of Cs-137 and 44 millicuries of Am-241:Be. The licensee reported the source rod had been dislodged but had been successfully inserted back into the shielded position. A Department inspector was dispatched to the location on 11/18/22 and assisted the licensee in packing the damaged Troxler 3400 series device into the transport container. Dose rate readings using a ND-2000A survey instrument, calibrated 09/16/22 indicated readings as high as 30 mR/hr on the surface of the transport container and less than 1 mR/hr at 1 meter.

"The Troxler 3400 series moisture density gauge was transported and secured at the licensee's storage location and is awaiting shipment back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

South Carolina Event Number: To Be Announced