Event Notification Report for February 17, 2023

AGREEMENT STATE REPORT - STUCK SHUTTER GAUGE

The following summary was obtained via phone and email from the South Carolina Department of Health & Environmental Control [the Department]:

On February 9, 2023, at 1534 EST, the Department was notified by WestRock Charleston Kraft, LLC of a shutter on an Ohmart SH-F1 gauging device (serial number 67584) containing 10 mCi of Cs-137 that was stuck in the open position. The shutter was found during the licensee's six month inventory and shutter check. The gauge is in an isolated area not heavily trafficked.

The vat that the gauge is attached to leaks directly onto the gauge, so it was previously recommended that the gauge be covered. The recommendation did not help. The contractor surveyed the gauge and got no higher than 2 mR/hr at a foot. The inspector concurred after using his [model] 14-C [detector] (serial number 99961). The numbers were approximately 4 mR/hr on the outside surface of the covering. It has been decided by the licensee that because it is in a very unobtainable location, they will leave it in the open and operating position until they remove the entire vat from service in March or April.

South Carolina Event Number: (pending)

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the Wisconsin Radiation Protection Section via email:

"On February 10, 2023, the licensee reported a medical event which had occurred the previous day. A patient was being treated with a high dose rate remote after loader unit and the fraction required 17 needles. After the first 15 needles had been treated, the licensee noticed that the patient's needles had been pulled out approximately 2 cm from where they had been placed due to unexpected movement of the patient's bed. The licensee has not yet determined how the patient's bed moved, as the patient was sedated during treatment. Needles 16 and 17 were re-inserted and the dose to those needles was delivered as intended. The authorized user had prescribed 13.5 Gy to the treatment site for this fraction, and the licensee estimates that only 30 percent of the treatment volume received the prescribed dose. The referring physician and the patient's family have been notified."

Event Report ID No: WI230001

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.

OFF-SITE NOTIFICATION OF AN ON-SITE FATALITY

The following information was provided by the licensee via email:

"On February 16, 2023 at 0859 EST, a contract worker at McGuire was transported off-site for treatment at an off-site medical facility. Upon arrival at the off-site medical facility, medical personnel declared the individual deceased at 0915 EST.

"The fatality was not work-related and the individual was inside the Radiologically Controlled Area. An on-site survey confirmed that neither the individual nor the individual's clothing were contaminated. A notification will be made to the Occupational Safety and Health Administration.

"This is a four-hour notification, non-emergency for an on-site fatality and notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified."

FAILED FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

At 0743 EST on February 16, 2023, it was determined that a contract supervisor failed a random fitness-for-duty (FFD) test. The individual's authorization for site access has been terminated.

The NRC Resident Inspector has been notified.