Event Notification Report for April 07, 2023

AGREEMENT STATE REPORT - DOSE ABOVE PRESCRIBED DOSE

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

"On 3/29/2023 at 1353 EDT, the Radiation Safety Officer (RSO) at Tufts Medical Center reported a medical event, misadministration, to the MA Radiation Control Program.

"On 3/28/2023 at 2230 EDT, the licensee discovered that a patient was administered, on the same date shortly before the discovery, a therapeutic activity of 37.9 mCi of Y-90 microspheres to the right lobe of the liver instead of the intended total of 11 mCi in a two-step successive administration per written directive. The patient and the referring physician have been notified.

"It was reported by the RSO that the administering physician determined that there will be no adverse effect to the patient as a result of the event. The cause of the event has initially attributed to human error by the administering technologist. The error was the improper application of a dose calibrator correction factor for the administration of Y-90 microspheres. A correction factor of 10 was not applied as per procedure. As a result, the technologist drew an activity of 60.3 mCi into the vial instead of 6.03 mCi as per the written directive for the first dose in an intended two step successive administration up to 11 mCi. The actual stasis administration was 37.9 mCi, which is the portion actually delivered to the right lobe of the liver via the delivery apparatus resulting in overloading. No further administrations to the patient occurred.

"At 1538 EDT on 3/29/2023, the Tufts RSO was contacted to discuss the facility's immediate corrective action. MA RCP recommended that the technologist responsible for the event not be allowed to perform any further therapeutic or diagnostic procedures at this time due to their failure to follow procedures (written directive). The Tufts RSO agreed. It was also agreed that he would contact the administering physician and forward the request for the dose conversion from mCi to rads or Grays to the target tumor.
Tufts will provide any additional immediate corrective actions and the delivered dose estimate to the Radiation Control Program in a preliminary summary report on 3/30/2023."

MA Event Number: TBD

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/STOLEN TRITIUM EXIT SIGN

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

"On March 29, 2023, RHB was notified by the Manager of Regal Manchester Cinemas 16 number 1820 via email that a second tritium exit sign was stolen from the movie theater hallway leading towards auditorium number 8. It appeared that it was pulled out forcefully from the wall. Please note that the first exit sign was stolen on March 8, 2023 (see EN56399). The facility has not provided RHB with the model, serial number, or quantity for the exit signs."

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 SOURCE

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

A customer shipped a package containing an AirSentry II-IMS unit with a 10 mCi nickel-63 source to Particle Measuring Systems. On February 16, 2023, the customer emailed that the package should have arrived. Particle Measuring Systems contacted the common carrier, whose tracking system showed the package was delivered on February 7, 2023. The site conducted an extensive search but could not locate the package. The Radiation Safety Officer was informed on March 1, 2023, that the package was lost. The Colorado Radioactive Materials Unit was subsequently notified of this event on March 10, 2023."

Colorado Event Number: CO 230009

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

LOST RADIOACTIVE SEED

The following is a synopsis of information that was provided by the licensee via phone:

On 27 March, 2023, the Brooke Army Medical Center discovered a missing I-125 radioactive seed containing between 144 and 209 microcuries of activity missing during a routine inventory. The seed was last accounted for on 24 February, 2023, when it was distributed to histology/pathology. The seed was intended to be used in radioactive seed localization. The licensee interviewed the responsible providers and conducted a search of the hospital with negative results. The licensee checked the alarm log and found none to have been activated. The licensee contacted the land fill and they had no radiation alarms from hospital waste during this time period. The licensee is continuing to search for the seed and will update the NRC with the results of their investigation.

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 - RADIOACTIVE SOURCE LOST IN SHIPMENT

The following information was received from the Louisiana Department of Environmental Quality via email:

"On February 17, 2023, the [Alpha-Omega] Radiation Safety Officer (RSO) shipped a high dose rate (HDR) source through [a common carrier] for shipment to Radiation Oncology, Elk Grove Village, IL 60007. The shipment's last known location was the [common carrier's] Memphis Hub. Alpha-Omega contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a HDR Ir-192 source was lost in transit with [a common carrier] on March 30, 2023.

"The source serial number is 02-01-1027-001-021523-11023-87. The activity of the Ir-192 source on 2/17/23 was 400 GBq when it was shipped. The current activity on 3/31/23 is 7.292 Ci (269.8 GBq).The [common carrier's representative] in Dangerous Goods Administration stated that, '[the common carrier's] position is that an exhaustive manual search was completed and the parcel is no longer in our control.'"

Louisiana Event Report ID No.: LA20230006

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

DAMAGED DENSITY GAUGE

The following information is a summary of the information provided by the licensee via email:

"On March 22, 2023, the subcontractor was performing grading and compaction of crushed concrete aggregate on the west half of the proposed building pad. The subcontractor had several active pieces of heavy equipment on the jobsite at the time, including a large excavator, a bulldozer, a skid steer loader, a large smooth drum roller, and dump trucks.

"While waiting to perform the compaction testing, the gauge operator stepped forward (east) approximately 10 feet to inspect a small excavation where the subcontractor had removed wet soils. At this time, the foreman operating the bulldozer had turned facing the south and began reversing the dozer north along the west edge of the pad. The gauge operator heard the dozer moving closer along the west edge of the building pad and turned to retrieve the gauge. Due to concerns for his safety, the gauge operator was not able to retrieve the gauge prior to the bulldozer's back left track making contact with the gauge.

"At the time of contact, the gauge's source rod was in the locked and shielded position. The gauge operator contacted the GME Testing's Radiation Safety Officer (RSO) and was instructed to follow operating and emergency procedures. The gauge operator responded immediately and had the foreman drive the bulldozer 15 feet north of the area to begin establishing the 15 foot perimeter around the gauge. The gauge sustained visible damage, with the yellow plastic shell cracking and the source rod falling over sideways onto the ground while in the locked and shielded position. The gauge operator quickly inspected the gauge and noted that the source rod remained in the locked position and undamaged inside the lead housing within the gauge, as well as the lead housing showing no signs of damage.

"The gauge operator remained with the gauge while securing the 15 feet perimeter and contacting the on-site foreman for the subcontractor, the superintendent for the contractor, and GME Testing's RSO.

"Readings were taken at the edge of the 15 foot radius around the gauge, the 3 foot radius, the 1 foot radius, and on the surface of the gauge. All readings gathered were within the acceptable range when compared to the the radiation profile of the gauge, as provided by the manufacturer. The damaged gauge was securely locked in its shipping case and transported to the GME Testing office."

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was provided by the New York State Department of Health via email:

"The New York State Department of Health (NYSDOH) conducted a routine inspection of lnficon, Inc. on March 30, 2023, and were made aware of a Ni-63 (2.4 mCi as of March 2, 2023) source that exceeded the 0.005 microcurie leak testing threshold and is considered leaking. Information on the source is below:

"Make: NRD, LLC
"Model: N1001 (SSDR: NY-0502-S-103-U)
"Serial Number: INF732
"Date of Sample Collection: 3/2/2023
"Leak Test Result: 1.47E-2 microcuries
"Analysis Report Date: 3/7/2023

"In accordance with lnficon's license, this source was obtained for secondary manufacturing and assembly into Micro Argon Ionization Detector (MAID) cells. lnficon detected this leaking source immediately following assembly prior to distribution in accordance with all regulatory requirements and the conditions of their license. Once it was determined that this source was leaking, personnel were notified, and the device was immediately quarantined. lnficon conducted removable contamination surveys around the device in question, however, they do not believe that any personnel or equipment may have been contaminated from this leaking source. Wipe test results are pending to date.

"Following the results of these wipe tests, the facility plans to dispose of this source and equipment. New York State Department of Health is in continued discussion with lnficon regarding next steps for this event.

"New York State Department of Health also contacted NRD, LLC (source manufacturer) to inform them of the leaking source and request an internal investigation to validate that this leaking source is an isolated occurrence. No information from NRD, LLC has been obtained prior to the date of this notification. New York State Department of Health continues to track this event with lnficon and NRD, LLC.

"No further information on the device, source or incident is available at this time. Any updates to this event will be provided as soon as feasible. This incident is tracked under Incident No.1433 by NYSDOH."

Event Report ID number: NY-23-01

AGREEMENT STATE REPORT - RADIOACTIVE SOURCE LOST IN SHIPMENT

The following information was provided by the New York State Department of Health via email:

"New York State Department of Health received a phone call from United Memorial Medical Center to report a Co-57 flood source that was sent to International Isotopes on January 11, 2023. This flood source was picked up by [the common carrier] and never arrived at International Isotopes. The technologist that shipped this source back checked the status of the delivery and noticed that the shipment had been delayed and noted that the location of the package was at the Rochester NY [common carrier] hub for several weeks. The technologist called [the common carrier] on March 30, 2023, and was informed that the package was determined as lost. Information on the source is below:

"Make: International Isotopes
"Model: BM01L10 (SSDR: NR-1235-S-104-S)
"S/N: BM01L1021298203
"Isotope: Co-57
"Est Activity (as of 3/30/2023): 2.66 mCi

"NYS Department of Health contacted [the common carrier] independently on March 31, 2023, and was also informed that the package was lost and unlikely to be recovered. 10 CFR 20 Appendix C states a value of 100 microCi for Co-57, therefore this loss is 26.6 times this value, requiring a 30-day notification in accordance with 10 CFR 20.2201(a)(l)(ii). United Memorial Medical Center has been instructed to contact New York State Department of Health with any updates regarding this package. New York State continues to monitor this event under Incident No. 1434.

"Provided the estimated activity as of March 31, 2023, unshielded exposure rate at one meter from the package is expected to be approximately 147.8 microR/hr, which does not constitute any immediate risks to [the common carrier] staff or workers.

"No further information on the device, source or incident is available at this time. Any updates to this event will be provided as soon as available."

New York Event Report number: NY-23-02

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 - RADIOACTIVE SOURCE LOST IN SHIPMENT

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
"BRC Tallahassee received notification this afternoon from QC Laboratories, Inc. that tracking has been lost on a 16.8 curie (below Cat 2) Iridium 192 sealed source. The source was shipped out of country (St. Thomas, Virgin Islands) and was on return shipment. Per [the common carrier]: 'Our records reflect that this package was tendered to [the common carrier] on March 16 with the expectation of delivery by 1030 EDT on March 17, barring delays in Customs. These records indicate that this shipment arrived at our port of entry at our central sorting facility in Memphis on March 17 and went into the customs clearance process. After Customs delays resulting from clearance paperwork issues, the paperwork was resolved. Customs clearance was completed on March 27, and the package was removed from the cage; however, we are unable to verify its status past that point.'"
Florida Incident Number: FL23-045

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

MANUAL REACTOR TRIP

The following information was provided by the licensee via email:

"At 0651 EDT on April 5, 2023, with Unit 1 in mode 1 at 85 percent power, the reactor was manually tripped due to loss of main feedwater pump 'C'. The trip was not complex, with all systems responding normally post-trip. Main feedwater pump 'B' had previously been removed from service in preparation for a planned shutdown as a part of refueling outage RF27.

"Operations responded and stabilized the plant. Decay heat is being removed by the emergency feedwater system.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) resulting from valid actuation of the reactor protection and emergency feedwater systems.

"There was no impact on the health and safety of the public or plant personnel."

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

The licensee continues to investigate the loss of main feedwater pump 'C'.

The licensee notified the NRC Resident Inspector.

MAIN STEAM LINE 'B' LEAKAGE IN EXCESS OF TECH SPEC LIMITS

The following information was provided by the licensee via phone and email:

"On March 4, 2023, it was determined that the main steam line (MSL) local leak rate test results for MSL 'B' were in exceedance of technical specification (TS) surveillance requirement (SR) 3.6.1.3.10 limits. Additionally, the leakage at the outboard main steam isolation valve (MSIV) 'B', was indeterminate due to a gross packing gland leak. An engineering calculation dated April 6, 2023, showed that this leakage, in conjunction with a design basis loss of coolant accident, would result in the radiological dose exceeding Updated Safety Analysis Report limits to the exclusion area boundary, the low population zone, and the control room. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B) as a condition that results in the power plant being in an unanalyzed condition that degrades plant safety.

"Both inboard and outboard 'B' MSIVs have been reworked and are within the TS SR limits.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."