Event Notification Report for July 05, 2023

AGREEMENT STATE REPORT - LOST EXIT SIGN

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

On 6/23/23, the licensee discovered that a tritium exit sign was lost. The exit sign was an Isolite Corporation Model 2000 containing 7.62 Ci of tritium (H-3). This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)).

Event Report ID No.: CO230017

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 - STOLEN GAUGE

The following information was provided by the Maryland Department of the Environment via telephone:

On 6/26/23 at 1116 EDT, the licensee was working at Howard University in Washington, D.C. when a Niton XLp 300 (lead base paint analyzer containing a maximum of 50 mCi of Cd-109) was stolen out of a vehicle. The Howard University and Washington, D.C. police were notified of the vehicle break in.

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 - STUCK SHUTTER

The following information was provided by the Louisiana Department of Environmental Quality (the Department) via email:

"On June 28, 2023, Dow Chemical Company notified the Department that a fixed gauge had a stuck shutter in the open position. Vega Model SHF2B serial number: 0368CR with a 500 mCi Cs-137, source serial number: N/A.

"The facility was using BBP Sales to perform their six-month audit on the gauges. BBP Sales sprayed penetrating lubricant on the shutter which loosened the shutter. They plan to come back to re-spray the shutter and make sure that it functions as designed."

LA Event Report Number: LA20230009

OFFSITE NOTIFICATION

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

"At 1530 [EDT] on July 3, 2023, Constellation Generation Company, LLC reported to the Illinois Environmental Protection Agency and the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) that tritium concentrations in existing monitoring wells in a known [10 CFR] 50.75(g) recovery area were found higher than normal [at Quad Cities Nuclear Generating Station]. This higher than normal tritium concentration did not exceed any NRC regulations or reporting criteria and there is no indication of a liquid release beyond the site boundary. This notification is being made solely as a four-hour, non-emergency notification for a notification of other government agency in accordance with 10 CFR 50.72(b)(2)(xi).

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

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the Veterans Health Administration (VHA) National Health Physics Program (NHPP) via phone and email:

"On June 28, 2023, the VHA NHPP was notified of a medical event at the Michael E. DeBakey VA Medical Center, Houston, Texas. The medical center holds VHA permit number 42-00084-06.

"The medical event occurred on June 28, 2023. The event involved the intra-arterial administration of two vials of yttrium-90 (Y-90) microspheres to the liver of a patient. Measurements taken after the procedure of one of the vials, the administration set, and catheter showed an unusually large amount of activity remaining that had not been delivered to the patient. From the measurements, it was estimated that only 28 percent of the prescribed activity for that vial was delivered to the patient. The activity delivered from the other vial was within regulatory requirements. The causes are not certain at this time; the event is under investigation. The patient has been notified. NHPP plans to conduct a reactive inspection regarding the event.

"NHPP will send a written report to NRC Region III in accordance with 10 CFR 35.3045. NHPP has notified the NRC Project Manager for the Master Materials License of NRC Region III."

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 - SOURCE DISCONNECT

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

"On June 29, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a source disconnect had occurred on June 28, 2023, at a temporary job site. The device (camera) was a SPEC 150 exposure device containing a 43 curie Iridium-192 source. The radiographers had placed the exposure device on an I-beam 15-feet above the floor to shoot a pipe. The device was raised to the pipe using a person lift. After the last shoot, the radiographer removed the guide tube and placed the guide tube and camera in the person lift with them. The radiographer stated they had performed a survey as they approached the camera and said the reading was bouncing up and down. The radiographer stopped halfway up and verified the crank-out indicated that the source was retracted. The radiographer removed the camera and guide tube and lowered them to the floor. Both radiographers noted their self-reading dosimeters were off scale. The radiographers contacted the RSO who had them set up a 2 millirem boundary and a qualified individual then retrieved the source. The source and camera were returned to the licensee's storage location. The radiographers' badges were sent for processing. On June 29, 2023, the RSO reported both radiographers' badges read less than 100 millirem. Additional information has been requested and will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10031
Texas NMED No.: TX230029