Event Notification Report for June 09, 2023

AGREEMENT STATE REPORT - LOST MEDICAL SOURCE

The following is a summary of an email received from the North Carolina Department of Health and Human Services:

The Breast Center of Greensboro reported one lost brachytherapy seed (Iodine-125 in a preloaded 7 cm syringe, initial activity 255 microcuries, final activity 176 microcuries, order number 202385558, lot number 85558, satisfactory leak test on April 4, 2023) to the North Carolina Department of Health and Human Services on May 12, 2023. The lost source was identified during an inventory performed on May 9, 2023. An extensive search was performed but the seed was not located. The seed was most likely thrown away in a sharps container and is not believed to be stolen. Each medical procedure performed with this specific seed lot was audited with no abnormalities noted. Corrective actions include identifying each seed with a unique tracking number, updating use procedures, designating waste containers for seed use only, daily seed tracking when seeds are used, and retraining for all seed technicians.

North Carolina Event Number: NC230009

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 IODINE LOCALIZATION SEED

The following was received by email from the Minnesota Department of Health:

"An Iodine-125 localization seed (approximately 270 microcuries) was lost following removal from the specimen. The seed is suspected to have been placed on a surgical towel and never put into the source vial. Prior to discovery of the missing seed, the pathology department linens were taken to a laundry facility where the towel was washed. The licensee surveyed the pathology department and the laundry facility and were not able to find the seed."

State event report number: MN230003

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 - LOST BRACHYTHERAPY SOURCE
The following was received by email from the South Carolina Department of Health and Environmental Control (The Department):

"The Department was notified on 05/09/23, that that one (1) Iodine-125 manual brachytherapy sealed source was lost or missing. The sealed source is a Bard Brachytherapy, Inc. Model STM 1251 with an activity of 0.34 mCi (12.58 MBq). The licensee reported that during a prostate seed implant procedure that occurred on 04/21/23, a single seed was possibly lost and remains unaccounted for. The licensee reported that during the procedure, an incorrectly configured strand was identified in the QuickLink device. This strand was ejected into the transfer device then pushed out into the sterile shielded shipping container so that the loose seeds could be counted. When assessing the seeds in the container, it was observed that one of the two I-125 seeds in this strand was missing. The medical physicists used a Geiger-Mueller counter to immediately survey the sterile cart and surrounding areas. The cart, floor, physician hands, nurse hands, and scrubs were all surveyed and no exposure was detected above background. Several other area surveys were also performed after the procedure was completed. The manual brachytherapy sealed source could not be accounted for.

"Department inspectors were dispatched to the facility on 05/17/23, and were unable to locate the missing sealed source. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

SC internal ID number is: SC230011



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

FITNESS-FOR-DUTY REPORT

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

A non-licensed supervisor was found to have falsified fitness for duty reports for a period of two months. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

AUTOMATIC ACTUATION OF "B" EMERGENCY DIESEL GENERATOR EMERGENCY POWER SEQUENCER

The following information was provided by the licensee via email:

"On April 12, 2023, with Seabrook Station Unit 1 in Mode 6 at zero percent power, a valid actuation of the 'B' emergency diesel generator (EDG) emergency power sequencer occurred due to a loss of power to the 'B' train emergency bus. The 'B' EDG was removed from service for scheduled maintenance during this time.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) for a valid actuation of the 'B' EDG emergency power sequencer.

"The NRC Resident Inspector has been notified."

ACTUATIONS OF REACTOR PROTECTION SYSTEM

The following information was provided by the licensee via email:

"On 05/06/2023, at 1552 [EDT] with Seabrook Unit 1 in Mode 3 at zero percent power, while performing digital rod position indication system surveillance testing, shutdown bank 'E' stopped withdrawing. In response, the reactor trip breakers were manually opened, initiating a valid actuation of the reactor protection system (RPS).

"Subsequently, at 2253 while continuing to perform digital rod position indication system surveillance testing, shutdown bank 'C 'stopped inserting. Reactor trip breakers were manually opened, initiating a valid actuation of the RPS.

"The RPS responded as designed during both events, and both actuations are being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident Inspector has been notified."

TEMPORARY LOSS OF CONTROL OF RADIOGRAPHY EXPOSURE DEVICE

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

On 6/7/23 at 1040 ADT, the licensee (Mistras Group, Inc.) was providing gamma radiography services in Prudhoe Bay, Alaska when an industrial radiography source (QSA 880 Delta, SN 73648M, Ir-192, 115.6 Ci) cable failed to retract. The device was moved safely to a location where repairs were made to the cable. No overexposures were associated with this event or during recovery operations. No radiation exposure was received by the general public.