Event Notification Report for March 17, 2023

EN Revision Imported Date: 3/17/2023

EN Revision Text: AGREEMENT STATE REPORT - STOLEN EXPOSURE DEVICE

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On March 9, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a Source Production and Engineering Company (SPEC) 150 exposure device containing a 121 curie iridium-192 source was stolen from one of the company's trucks. The radiography crew stated they left their job site to get some food at around midnight and stopped at a fast-food restaurant. They went into the restaurant to eat. The radiographers stated they failed to set the alarm on the dark room. They also stated they had left the key for the exposure device transport box in the dark room. The radiographers completed their meals and went back to the job site.

"When they went to get the exposure device they found it was missing. The radiographers contacted the RSO and a search was conducted for the device. It was not found. The RSO reviewed security footage at the location the radiographers were working and confirmed the exposure device was not on the tailgate of the truck. They reviewed security footage at the fast-food restaurant, but the cameras were not pointed in the right direction to see the truck. The RSO stated there is a restaurant across the street from where they believe the exposure device was stolen that has security cameras. They will go there when it opens to see if the theft was captured by their cameras. The RSO stated that personnel will be sent back to the area where they believe the theft occurred for additional searches. The RSO stated they have sent people out to contact local pawn shops and scrap dealers and notify them of the theft and provide their contact information. Local law enforcement have been notified of the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: I-10000

Notified DHS SWO, FEMA Operations Center, CISA Central, USDA Operations Center, HHS Operations Center, DOE Operations Center, EPA Emergency Operations Center, FDA EOC (email), FEMA NWC (email), and NuclearSSA (email).

* * * UPDATE ON 03/11/23 AT 0652 EST FROM ART TUKCER TO KERBY SCALES * * *

The following update was provided by the Texas Department of State Health Services (the Agency) via email:

"On March 9, 2023, at 1935 [EST], the Agency's radiation safety officer and an incident investigator arrived in the area where the exposure device was reported stolen. They searched the area using the Agency's [Radiation Solution Inc] (RSI) RS-700 mobile radiation monitoring system. They did not find the missing device or source. They intend to meet with the licensee's RSO this morning and search a broader area."

Notified R4DO (Gepford), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Ulses), INES Coordinator (Smith), CNSNS (Mexico) via email.


* * * UPDATE ON 03/11/23 AT 1929 EST FROM ART TUKCER TO OSSY FONT * * *

The following update was provided by the Texas Department of State Health Services (the Agency) via email:

"The Agency personnel have completed their search in the Houston area and are returning to Austin. They did not locate the missing exposure device. The licensee will continue looking for the device."

Notified R4DO (Gepford), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Ulses), INES Coordinator (Smith), CNSNS (Mexico) via email.

* * * UPDATE ON 03/16/23 AT 1730 EST FROM ART TUKCER TO BILL GOTT * * *

The following update was provided by the Texas Department of State Health Services (the Agency) via email:

"On March 15, 2023, the Agency conducted interviews with the licensee and individuals involved in the event. Using the licensee's GPS records, it was determined that the theft occurred between 2314 and 2355 CST the night of March 8, 2023."

Notified R4DO (Kellar), and NMSS Events Notification, ILTAB (MacDonald), IRMOC (Crouch), INES Coordinator (Smith), CNSNS (Mexico) via email.

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf*

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION EVENT

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

"At approximately 1400 MST on March 7, 2023, while performing a meta-iodobenzylguanidine (MIBG) infusion of 266 mCi of I-131 in a patient at Children's Hospital Colorado, an unplanned contamination event occurred on the floor of the hot lab. The floor contamination was discovered at approximately 1730 MST on March 7, 2023, by the licensee. The hot lab has been secured from entry. The licensee believes the amount spilled is greater than 5 times the annual limit on intake (ALI). CDPHE will be receiving more information from the licensee. The licensee will be performing bioassay soon and will provide more information at that time."

Colorado Event Report Number: CO 230006

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:

"On Wednesday, March 8, 2023, at approximately 1000 PST, the Radiation Safety Officer (RSO) of Converse Consultants, Inc. (Redlands), radioactive materials license number 8057-36, contacted the RHB Brea office concerning a Troxler moisture/density gauge (Cs-137 0.296 giga-becquerels (8 millicuries), Am-241 1.48 giga-becquerels (40 millicuries)) that had been damaged when driven over by a vehicle at a construction site in Moreno Valley, CA. The gauge handle was in the shielded position when the gauge was struck and was bent during the incident. The area was cleared until the gauge was surveyed by the RSO and Assistant RSO to assess if the Cs-137 source was still in the lead shielding. The survey by the licensee confirmed the source remained in the shielded position based on exposure rate levels being in the normal range for a shielded source. The locking mechanism on the source rod is not functional. Due to the extent of damage to the gauge, the gauge was then taken to Maurer Technical Services, LLC., radioactive materials license number 6163-30 for leak test analysis and disposition.

"A copy of the incident report from the authorized user of Converse Consultants will be forwarded to the RHB Brea office and will be included as part of this investigation."

California NMED Number: 030823

AGREEMENT STATE REPORT - LOST/STOLEN TRITIUM EXIT SIGN

The following was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:

"On March 8, 2023, the Regal Cinemas general manager contacted RHB to report a stolen tritium exit sign from their movie theater in Fresno, CA. Based on the general manager's statement, the theater has installed 90 tritium (H-3) exit signs. Every morning the assigned theater employee performs a daily exit sign inventory by going through the exit doors and the hallways. On Monday March 6, 2023, before the theater was opened to the public, one of the exit signs, located in the hallway leading to the auditorium number 5, was noted as missing. It appeared that it had been pulled out of the wall. The management and employees checked all possible dumping places, and were unable to locate the sign. RHB has requested additional information (model and serial number) regarding the exit sign."


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

EN Revision Imported Date: 3/16/2023

EN Revision Text: AGREEMENT STATE REPORT - MISAPPLICATION OF MEDICAL DOSE RESULTING IN UNDERDOSING

The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email:

"Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable."

Reference Number OH 2023-006

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 GAUGE

The following was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:

"On March 6, 2023, the Radiation Safety Officer for G3 Quality, Inc. contacted a Licensing Health Physicist (instead of an Inspection Health Physicist) within the California Radiologic Health Branch regarding a moisture density gauge that was stolen from a jobsite in Moreno Valley, California. The gauge is a Troxler model 3450, serial number 72761 (8 millicuries of Cs-137 (nominal) and 40 millicuries of Am:Be-241 (nominal)). On March 4, 2023, after arriving at the jobsite, the gauge operator took the gauge out of the transport case, placed the gauge on the bed of their vehicle to perform a standard count. After that was completed, the operator then walked over to the site supervisor to discuss the job, leaving the gauge sitting on the bed of the truck, outside of its transport case and without a lock on the handle. When he returned to the vehicle, the operator discovered the gauge was missing. After searching the area for the gauge, the operator contacted their supervisor. The Moreno Valley Police Department was contacted and a police report was made. The licensee has offered a reward for return of the gauge. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health.

"The reporting of this event was delayed due to a communication issue within the CA Radiologic Health Branch."

California NMED Number: 030623




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

MEDICAL EVENT - DOSAGE NOT IN ACCORDANCE WITH THE WRITTEN DIRECTIVE

The following information was obtained from the licensee via telephone in accordance with Headquarters Operations Officers Report Guidance:

On March 8, 2023 at 1230 CST, three of nine catheters of a Venezia applicator with 6.8 Ci of Ir-192 were incorrectly mapped to channels in the after loader. This resulted in a dose to the patient that was not in accordance with the written directive. This was discovered on March 9, 2023. The patient and ordering physician were notified.

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 - FOUND SOURCE

The following was received from the state of Wisconsin Department of Health Services (WI DHS) via phone and email:

"On 2/16/2023, WI DHS was notified that a citizen was in possession of a package labeled radioactive on their farm and that they had been in possession of the package for almost a year. The label on the package indicated that it contained 8.15 GBq (220 milliCuries) of Mo-99. The label on the box indicated that the intended destination was Medi-Ray. The shipper was unknown.

"On 03/01/2023, WI DHS took possession of the package and determined that it contained a Lantheus Mo-99/Tc-99m generator. The generator label indicated that it originally contained 277.5 GBq (7.5 Curies) Mo-99, with a calibration date of 04/03/2022. WI DHS confirmed that the package contents are no longer radioactive. WI DHS consulted with the NRC and determined that the event was not reportable based on the information known at the time, the lack of radioactive contents, an unidentified licensee, and an unknown common carrier.

"On 03/09/2023, WI DHS was contacted by a Lantheus representative who determined, based on the lot number, that the package was most likely originally distributed to the Medical College of Wisconsin (WI RAM license number: 079-1104-01). On 03/09/2023, WI DHS contacted the licensee to confirm if they had shipped the recovered package. On 03/09/2023, the licensee confirmed that they had possessed a generator from the identified lot number and that their records indicated a return shipment containing that generator should have been picked up for transfer to Medi-Ray by the common carrier on 04/17/2022. On 03/09/2023, Medical College of Wisconsin made an official telephone notification of a reportable event of the loss of 220 milliCuries of Mo-99.

"This investigation remains open and WI DHS is working with Medi-Ray to dispose of the generator."

Wisconsin Report ID: W1230003

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 - LOST FIXED GAUGES

The following information was received from the Arkansas Department of Health via email:

"The Arkansas Department of Health, Radiation Control Section (the Section), was notified on February 28, 2023, via a letter received from Anchor Packaging Company in Paragould, Arkansas, of two generally licensed fixed gauges that were determined to not be located on-site (GL-0010). The Section called the manufacturer on March 1, 2023, then received information on March 10, 2023, that they had no record of the gauges ever being returned to them. These gauges each contain 5.55 GBq (150 milliCuries) Am-241 -- NDC device model 102 (device SN 2844) and NDC device model 103X (device SN 13264, source SN 3576CW).

"Causes of the event are the following: the lack of effective procedures that stress the general licensee requirements, specifically those that aid accountability of sources; failure to ensure the appointing and support of the individual responsible for having knowledge of the regulations/requirements; and lack of training (though not required) needed to identify radioactive material/general license labeling and then to know what steps to take. The Section is currently working with the licensee regarding corrective actions due to a previous missing devices event, 55793."

Event Number: AR-2023-001

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 - MEDICAL EVENT

The following information was provided by the Tennessee Division of Radiological Health via email:

"The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and [the physician] connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows:

"1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy
"2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy

"Corrective actions will be sent with the follow-up NMED report."

State Event Report ID NO.: TN-23-013

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.

REACTOR COOLANT SYSTEM (RCS) BOUNDARY DEGRADED CONDITION

The following information was provided by the licensee via email:

"At 2257 [CDT] on 3/14/2023 during the 2R22 refueling outage on Browns Ferry Nuclear Plant Unit 2, it was determined there was RCS boundary leakage from five of eight sensing lines that pass through containment penetrations X-30 and X-34 that did not meet the requirements of Section XI, of the ASME Boiler and Pressure Vessel Code. The condition will be resolved prior to plant startup. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

OFFSITE NOTIFICATION OF INADVERTENT ACTUATION OF EMERGENCY SIRENS

The following information was provided by the licensee via email:

"At 0950 [EDT] on 3/15/23, the Ottawa County emergency warning siren system was activated. The county issued a press release to state that the intent was to sound the sirens next week on Wednesday, 3/22/23, as part of Severe Weather Awareness Week. All 49 of the Davis-Besse Nuclear Power Station Offsite Emergency Notifications sirens in Ottawa County were sounded as part of the county's activation of the emergency warning siren system (of the 82 sirens total). This notification is being made solely as a four hour, non-emergency notification for a notification of other government agencies in accordance with 10 CFR 50.72(b)(2)(xi). All emergency notification sirens functioned as required. The NRC Resident Inspector has been notified of the issue."

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 2157 EDT on 03/15/2023, with Unit 3 in Mode 1 at 18 percent power, the reactor automatically tripped due to the loss of two reactor coolant pumps when their electrical buses failed to transfer after a main generator excitation protective relay tripped.

"Operations responded and stabilized the plant. Decay heat is being removed by steam generator power operated relief valves. Units 1, 2, and 4 are not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, nonemergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 3/17/2023

EN Revision Text: FAILED FITNESS-FOR-DUTY (FFD) TEST

The following information was provided by the licensee via email:

At 0845 EDT on March 16, 2023, it was determined that a contract employee supervisor failed a for-cause FFD test. The individual's authorization for site access has been terminated.

The NRC Resident Inspector has been notified.