Event Notification Report for December 05, 2022

EN Revision Imported Date: 12/5/2022

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.

* * * UPDATE ON 12/02/2022 AT 1500 EST FROM SHEREE BUTLER TO WILLIAM GOTT * * *

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

The licensee notified the Georgia Radioactive Material Program that the leaking source was returned and received by the manufacturer. The Georgia Radioactive Material Program has closed this report.

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

EN Revision Imported Date: 12/5/2022

EN Revision Text: 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."

* * * UPDATE ON 12/2/2022 AT 1257 EST FROM THE DEFENSE HEALTH AGENCY TO BILL GOTT * * *
"Following administration of Y-90 Sir Spheres on November 17, 2022, the treatment team determined that the faction of the assayed dose delivered to the patient was only 38 percent. The remaining 62 percent of the assayed dose of 11.4 mCi remained within the delivery system. This represents a delivery of 40 percent of the prescribed dose of 10.8 mCi. The microcatheter used was size 2.4F, which was appropriate for the clinical situation. The vascular access to the treatment location was unusually torturous. Two representatives from Sirtex advised during the procedure, rotating out part way through the procedure so one was present at all times, with no noted deviations from the recommended protocols.

"The event likely occurred due to microsphere blockage in the microcatheter, resulting from a torturous path to the delivery point required by the patient's vascular anatomy. Sirtex indicated that the spheres must have attached to the catheter walls due to a torturous path (excessive bends in the line)."

Notified R1DO (Cahill) and NMSS Events Notification via email.

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 - PATIENT UNDERDOSE

The following information was received from the Georgia Radioactive Materials Program via email:

"We received an emailed report of a misadministration, where there was over 50 percent deviation of the prescribed dose. The patient received only 10 percent of the [redacted] prescribed fractioned dose due to equipment malfunction. The patient is scheduled to receive the remainder of the dose at a later time. The licensee will conduct a thorough investigation and provide a formal report as soon as possible. We are still pending the source activity information and event date. We will update as more information comes in."

Georgia incident no.: 61

* * * UPDATE ON 12/01/2022 AT 0751 EST FROM THE GEORGIA RADIOACTIVE MATERIALS PROGRAM TO IAN HOWARD * * *

The following is a synopsis developed from information provided by the Georgia Radioactive Materials Program via email:

Was source able to be retracted to safe position? Yes
Manufacturer and Model number of HDR: Elekta's Flexitron
Serial number: 00625
Source activity (8.9 Ci); Prescribed dose (750 cGy); Delivered dose (12.7 cGy)

Root Cause: Equipment failure.
Assessment by Elekta's field service engineer determined that the Flexitron selector assembly should be recalibrated including lubrication of all brackets on the assembly.

Corrective Action: Recalibration.
Following recalibration of the Flexitron selector assembly, the treatment unit functions correctly. Spot checks performed by physics confirmed normal operation of the treatment unit. The treatment unit reentered clinical service the following day and this patient was successfully treated on 11/21/22 for their third fraction and they finished treatment on 11/23/22.


Notified: R1DO (Cahill). Notified via email: NMSS Event Notification.

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 - STOLEN MOISTURE DENSITY GUAGES

The following information was provided by the Colorado Department of Public Health and Environment (the Department) via email:

"At approximately 0715 MST on November 28, 2022, the Department was contacted by the [Company Radiation Safety Officer] CRSO of Kleinfelder, Inc. (CO 958-01) to inform the Department that two Troxler 3430 (SN 35349 & SN 35335) moisture density gauges were discovered to be stolen from their temporary job site. Each gauge had sealed sources containing not more than 9 mCi of Cs-137 and 44 mCi of Am-241:Be or 66 micro curies of Cf-252. An authorized user arrived at the temporary job site around 0530 MST to pick up supplies when they noticed the door to the container express (conex) box was open. Upon further investigation, it was discovered that both gauges were missing. The site was secured by a security fence and under video surveillance, and that footage is currently under review. The thieves broke the exterior lock to the conex box door and they broke a lock to a job box in the conex box that contained both gauges in their locked transport cases. The job box was also bolted to the ground but those bolts were left intact. The CRSO estimates that the gauges were last seen/used on November 23rd or 24th, but the date of the theft is unclear at this time. Additionally, multiple other contracted companies were targeted in this theft that presumably occurred during the Thanksgiving holiday weekend."

Colorado Event Report ID No.: CO220040

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 - STUCK SHUTTER

The following report was received via email from the Texas Department of State Health Services [the Agency]:

"On November 28, 2022, the licensee notified the Agency that it had discovered that the shutter on one of its Ohmart-Vega SH-F1A gauges had been stuck in the closed position since November 23, 2022. The gauge had been closed and locked out on November 22nd for work on the vessel. On November 23rd the gauge was placed back into service. Over the holiday weekend the unit operations had continued to get high readings which would indicate a buildup in the system or a closed shutter. On November 28th the gauge was checked. The licensee's radiation safety officer found the two bolts on the shutter handle were sheared and the shutter was in the fully closed position. No exposures have resulted from this event. An investigation is ongoing. Source: Cesium-137, 5 millicuries, SN: OV-0050 (this SN serves also as the gauge source holder SN). More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9966

PART 21 - DEVIATION TO QUALIFIED DESIGN

The following is a summary of information provided by Flowserve - Limitorque via email:

Entergy Waterford 3 informed Flowserve - Limitorque on 10/5/2022 that it discovered that a Peerless 125 volt, 25ft-lb, 56 frame direct current (DC) motor had two fasteners securing the brush holder ring assembly to the motor frame. However, the DC motor assembly used in the qualification test program was assembled with 4 fasteners. Therefore, the use of two fasteners is a deviation to the qualified design. Flowserve is submitting this report as an interim report and is evaluating this deviation to determine whether this condition could potentially affect the safety related function of DC powered Limitorque actuators.

Flowserve is continuing to work with the motor original equipment manufacturer (OEM) to refine the scope of potentially affected motors. Limitorque actuators equipped with Peerless - Winsmith DC electric motors with start torque ratings of 40 ft-lb and larger are not affected by this issue. Limitorque actuators equipped with alternating current (AC) powered electric motors are not affected by this issue.

The evaluation is expected to be completed by 01/27/2023. If there are questions, or addition information is required, please contact Chris Shaffer, Quality Assurance Manager, Flowserve Corporation, Ph: (434) 522-4136.

Known affected plant: Waterford 3 Nuclear Generating Station

FUEL CYCLE FACILITY - LOSS OR DEGRADATION OF SAFETY ITEMS

The following information was provided by the licensee via email:

"It was discovered on 12/2/2022, that an Item Relied on For Safety (IROFS) had failed because it was determined to not be available and reliable in the sinter test grinder (STG) dust collection system. On 11/29/2022, a mass of dry uranium oxide powder greater than expected was identified in the grinder swarf collection can, prompting a shutdown of the STG and further investigation. Subsequent equipment cleanout identified approximately 28.4 kilograms of dry uranium oxide compared to the system safety limit of 43.39 kg. The investigation determined that the safety limit could have been challenged. The failed IROFS resulted in a failure to meet performance requirements. The STG operation remains shut down.

"Additional controls on moderation remained intact, and at no time was an unsafe condition present.

"Additional corrective actions, extent of condition, and extent of cause are being investigated.

"This event is being communicated to meet the reporting requirements of 10CFR70, Appendix A (b)(2)."

DEGRADED CONDITION DISCOVERED ON SHUTDOWN COOLING TEST LINE

The following information was provided by the licensee via email:

"On 12/2/2022 at 2330 [CST] during the planned F311 outage on Browns Ferry Nuclear Plant Unit 3, personnel entered the Unit 3 drywell for leak identification. Personnel discovered a through-wall piping leak on a 0.75 inch test line between the two test line isolation valves. This 0.75 inch test line is located on the residual heat removal (RHR) loop 1 shutdown cooling and RHR return line to the reactor vessel. On 12/3/2022 at 1000 CST, Engineering determined this location is classified as ASME Code Class 1 piping.

"This constitutes an 8-hour NRC notification in accordance with 10 CFR 50.72(b)(3)(ii)(A) - Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.

"The NRC Resident Inspector has been notified."