Event Notification Report for April 28, 2023

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following information was received from the South Carolina Department of Health and Environmental Control (the Department) via email:

"The Department was notified via telephone at 1511 EDT on 04/19/23, that during a routine inspection of the licensee's fixed gauging devices, the source window of one device was discovered to have been damaged. The licensee is reporting that the fixed gauge is a Thermo Fisher Model ASC-185 gauging device, housing a Kr-85 Isotope Products Laboratories Inc. sealed source Model NER-588 with an activity of 46.25 giga-becquerel (1250 millicuries). The licensee is reporting that no immediate health and safety concerns have been identified. The licensee is reporting that the manufacturer of the gauging device has been contacted for repair, and this repair was initiated upon discovery on 04/19/23. A Department inspector will be dispatched to the facility. This event is still under investigation by the Department."

SC Event Report ID No.: EN 56479

MEDICAL EVENT - PATIENT UNDERDOSE

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

"Per 10 CFR 35.3045(c), Veterans Health Administration (VHA) National Health Physics Program (NHPP) is reporting a possible medical event.

"Southern Arizona VA Health Care System [the facility], Tucson, Arizona, which holds Permit Number 02-06186-01 under the VA master materials license, reported discovery of a 'possible' medical event to NHPP at approximately [1500] CDT, April 19, 2023.

"A yttrium-90 microsphere therapy administration for liver cancer was performed on April 19, 2023. The intended treatment site was hepatic segment 4 of the right lobe of the liver. During the administration, performed under fluoroscopy guidance, the Authorized User (AU) / administering Interventional Radiology physician noted a change in the catheter position and elected to stop the administration. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity [15.06 mCi delivered vs. 21.6 mCi prescribed]. Post implant single-photon emission computerized tomography (SPECT) imaging verified that the dosage had been delivered to the correct location.

"The AU believes that the movement of the catheter qualifies as an emergent patient condition. The written directive was modified to include the reason for not administering the intended activity, the signature of an AU for yttrium-90 microspheres, and the date signed. NHPP in coordination with the facility and NRC will conduct further evaluation of this event to determine if the regulatory definition of emergent patient condition was met.

"The patient and the referring physician have been notified.

"At this time, short term harm to the patient is not expected.

"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.

"NHPP has notified the NRC Region III Project Manager."

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 I-125 SEED

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

"On 4/20/2023, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, one IsoAid Advantage I-125 breast localization seed (containing approximately 0.158 mCi of activity) was removed by surgery on 4/17/23 and was verified to be included in the specimen. The specimen with the seed was delivered to pathology on the afternoon of 4/17/23. The seed was removed from the specimen by pathology on 4/17/23. When nuclear medicine came to retrieve the seed, the jar was empty and the licensee was unsuccessful in locating the missing I-125 seed. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."



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 CAN NOT BE CLOSED DUE TO BROKEN LEVER
The following information was provided by the Texas Department of Health Services (the Department) via email:
"On April 21, 2023, the Department was notified of a gauge with a shutter that could not be moved into the closed position because the lever which moves the shutter broke off. The owner of the gauge reports the lever broke because of corrosion and vibrations. The gauge is a Texas Nuclear 5204 with 8 curies of cesium-137. It is on the side of a dredging vessel that is dredging the entrance channel in Corpus Christi in a 24 hours of work per day operation. During dredging operations, the gauge is normally in the open position and the beam is directed inwards towards the ship. The crew of the vessel normally avoid that side of the vessel and will continue to do so. A survey of the gauge was performed and there is no change. The owner of the gauge reports that they expect the gauge to be repaired by a servicing company on May 9, 2023.
"The Department discussed the possibility of the vessel being docked with the gauge still in the open position and will continue to monitor the situation. Further information will be provided per SA-300.
"The Department will also forward this to the Florida Radiation Control Program as this is a Florida licensee operating in Texas under reciprocity."

Texas incident number: 10013

OFFSITE NOTIFICATION - SPILLED SODIUM HYPOCHLORITE

The following information was provided by the licensee via email:

"On 4/25/2023 at approximately 2315 [MST] it was reported that there was possible sodium hypochlorite actively leaking near the 'A' essential spray pond (ESP). Upon investigation, it was determined that the 'low flow' line of sodium hypochlorite supply to the 'A' spray pond had developed a leak. Sodium hypochlorite had pooled at the leak location and subsequently run down the ESP apron, into the road, and into the storm drain located in the protected area fence. An estimate of approximately 300 gallons of spilled sodium hypochlorite was determined based on the time frame that the sodium hypochlorite was scheduled to start injecting into the 'A' spray pond and the time the leak was isolated. The leak was isolated on 4/25/2023 at approximately 2330.

"The leak was contained in the storm drain with the storm gates closed, therefore nothing was released offsite. The cleanup effort in progress includes diluting the sodium hypochlorite with domestic service water, collecting it into the storm drain, pumping it to a tank truck, and transporting it to the Palo Verde Water Resources Facility for neutralization.

"Condition Report 23-04519 was generated to document the leak. The Palo Verde Senior Environmental Scientist was notified and subsequently informed the Environmental Protection Agency (EPA) National Response Center (NRC#1365638) on 4/26/23 at 0005 in accordance with the 91DP-0EN03 Environmental Spill Response [local procedure]. The NRC Senior Resident Inspector was also notified.

"No personnel were injured and no equipment was damaged as a result of the spill. The Palo Verde Fire Department was notified and the area was barricaded off to prevent personnel from entering the area during the cleanup effort.

TECHNICAL SPECIFICATION DIRECTED SHUTDOWN

The following information was provided by the licensee via email:

"Violation of Limiting Condition of Operation per Nuclear Science Center Reactor (NSCR) technical specifications (TS) 3.5.1. Report made in accordance with TS 6.7.2.

"At approximately 1300 [CDT], April 25, 2023, it was determined there was a Limiting Condition of Operation that required a remote display for a single Area Radiation Monitor (ARM) on the reactor bridge in the Emergency Support Center. That display had been inoperable for two weeks. The ARM was operable, and the displays in the reactor control room and on the reactor bridge at the ARM location were active. The remote display is located in a different building from the reactor confinement building.

"Upon discovery of the situation, the reactor was shut down. This notification to the [NRC] Headquarters Operations Officer is required by NSCR TS 6.7.2 within one working day.

"Corrective actions underway:

"The display of the ARM is being repaired and will be confirmed to be in operation prior to the restart of the NSCR, and for each successive start up."

FITNESS FOR DUTY REPORT

A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.