Event Notification Report for November 25, 2022

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.

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

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."