Event Notification Report for July 31, 2023

AGREEMENT STATE REPORT - DAMAGED GAUGE HANDLE
The following information was provided by the South Carolina Department of Health and Environment (the Department) via email:
"On July 20, 2023, at 1507 EDT, the Department was notified by the licensee that while performing semi-annual shutter checks the licensee discovered that the handle on a Berthold LB7440D had broken off which prevented the shutter from being locked. The licensee cordoned off the area and was able to rotate the shutter to the closed and shielded position. The gauge is a Berthold Model LB7440D s/n FT314 and contains a 30 mCi Cesium-137 source. On July 21, 2023, BRH [Bureau of Radiological Health] on-call duty officer met licensee's RSO at 0800, to perform a visual inspection and radiation survey of the gauge. The highest radiation measured was 0.2 mR/hr. The licensee has contacted a licensed vendor to schedule the repair of the handle. "

DOSE TO AN EMBRYO

The following information is a summary of a phone call with the North Kansas City Hospital Radiation Safety Officer (RSO):

On May 10, 2023, a nuclear medicine tech administered 125.7 mCi of I-131 to a patient for the thyroid cancer ablation at North Kansas City Hospital. The patient had received a pregnancy test on May 8, 2023, which was negative.

On July 21, 2023, the hospital was notified that the patient was pregnant with an estimated fetal age of 7-10 weeks which would have had the patient pregnant at the time of administration, or shortly thereafter. This event is being reported because of the potential for a dose to the embryo.

At this time there are no known negative effects to the patient.

AGREEMENT STATE REPORT - MEDICAL EVENT (UNDERDOSE)

The following information was provided by the PA Bureau of Radiation Protection (the Department) via email:

"On July 21, 2023, the licensee informed the Department of an underdose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable as per 10 CFR 35.3045(a)(1). It was determined that 76 percent of the prescribed dose to the target tissue was delivered for the above treatment.

"This is believed to have happened for possibly the following reasons: The spheres were attached to the bottom / interior portion of the septum and remained there even through 4 flushes of the system; There was clumping of spheres in the microcatheter connector, which did not clog the lines, that remained in the microcatheter connector.

"Possible reasons for these theories or reasons for the above theories are, there was no contamination in the room, or interior / exterior of box. The required alarming Rados personal dosimeter on the back of the box read zero as expected after the original 3 flushes. The authorized user (AU) had no indication from pushing the line that anything was wrong with the flow and in total 4 flushes went into the patient with no problem. All procedures and policies were followed, and this was directly observed by the Radiation Safety Officer (RSO) and the Boston Scientific Corporation, Incorporated (BSCI) company rep who was in the room.

"It was observed on the optional, additional, personal dosimeter that was used on the steel arm coming from the box, that the dose rate did not decrease as expected after the original first 3 flushes. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD 1007 EDT ON 7/25/2023 * * *

The source was 1.09 GBq of Yttrium 90 TheraSpheres (Lot # 2399334, vial # 8). The patient was prescribed 120 Gy, but it is calculated they received 91.4 Gy. The material was collected in the standard waste container. No one other that the patient received any dose.

Notified R1DO (Biickett) and NMSS Events Notification email group.

Pennsylvania Event Report ID Number: PA230019

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 - LOSS OF CONTROL (LOST THEN FOUND) OF RADIOACTIVE MATERIAL

The following is a synopsis of information received from Oregon Health Authority, Radiation Protection Services (RPS):

At 1845 PDT this evening a caller contacted the Oregon Emergency Response System (OERS) to report a yellow package with a radioactive placard that was found in a parking lot at their location.

RPS followed up on the OERS report (Incident Number: 2023-1825) and it appears that an employee from Weston Solutions, an EPA contractor, discovered a box with a Yellow II DOT label in the middle of a parking lot outside of their warehouse in Portland. The box appeared structurally sound and intact.

The caller had a survey meter on-site (a Ludlum 2241 with pancake probe) and measured approximately 11,000 cpm at 1 inch away from the package. The employee called 911 and the police notified the National Response Center and sent officers to respond.

The police inspected the package and discovered it belonged to Cardinal Health. Cardinal Health Nuclear Pharmacy, a licensee, shares a parking lot and occupies an adjacent warehouse to Weston Solutions. The police then hand-carried the box to the Cardinal Health building. A representative from Cardinal Health (police verified credentials) accepted the package and took it inside their facility.

RPS called Cardinal Health Nuclear Pharmacy Services and spoke with the on-call pharmacist / RSO of the facility. At the time of the call she was on-site at the pharmacy to investigate the situation after being contacted by the employee that accepted the package from the police.

The pharmacist / RSO explained that she had immediately leak tested the package and the readings were typical. The box was labeled as containing I-131. There was no sign of a breach or disturbance to the package. The package was then transported to a locked storage vestibule and the pharmacist / RSO then notified the courier of the misplaced material.

The courier used to transport the radionuclides to the nuclear pharmacy was PNW Trade Winds. RPS called and spoke with the lead courier to gather more information about the circumstances that could have led to losing the package.

The lead courier had spoken with the driver involved and their best guess is that while the driver was segregating packages for the different delivery locations at his vehicle, he must have dropped a box and it landed underneath the vehicle. All the material that was supposed to arrive at Cardinal Health was accounted for, so the driver was not aware of the missing package. The driver most likely would not have realized it was lost until performing a physical inventory at a subsequent location.

As far as timing, the lead courier explained that the driver had left Cardinal Health at approximately 1800 PDT and the package was discovered by Weston Solutions at 1820 PDT. When talking with the Weston Solutions employee, he had mentioned that they were in the parking lot area at 1745 PDT and did not see the package at that time, confirming the timeline. Therefore the material was in the parking lot for only about 20 minutes before it was discovered.

RPS Incident Number: 23-0035

FUEL ELEMENT INSPECTION FAILURE

The following information was provided by the licensee via email:

"This notification is being made per the requirements of technical specification 6.7.2

"During the facility's routine 2023 fuel inspection on July 27th, 2023, it was discovered that a stainless steel clad standard TRIGA 20/20 element did not pass its visual inspection. The visual inspection of the element, made via an underwater camera with approximately 2 times optical magnification, showed inward pitting and unusual discoloration in the cladding of the fueled section of the element. The elongation and transverse bend of the element were measured and were within tolerance per the facility's technical specifications. The cause of this pitting is unknown at this time. The element has been permanently retired from service and placed in an in-tank fuel storage rack. No unusual radiation readings were observed leading up to the inspection or during the inspection. Therefore, it is very likely that the integrity of the cladding has not been compromised and no fission products have escaped as a result of the pitting.

"Though not required by the facility's technical specifications, [McClellan Nuclear Research Center] (MNRC) staff is proceeding with the inspection of all adjacent fuel elements and all other standard elements that have not been inspected within the last year. This inspection corresponds to approximately 85% of all in-core elements. The expected completion date of this inspection is August 2nd. Detailed results of this inspection will be provided in an incident report to the NRC no later than August 10, 2023."

CONTROL ROOM ENVELOPE INOPERABLE

The following information was provided by the licensee via email:

"On July 30, 2023 at 1119 CDT, Waterford Steam Electric Station Unit 3 declared the control room envelope inoperable in accordance with technical specification (TS) 3.7.6.1 due to the control room envelope doors failing a door seal smoke test creating a breach in the control room envelope.

"Operations entered TS 3.7.6.1 Action b.

"Mitigating actions were implemented and tested satisfactorily by 1215 CDT.

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

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(v)(D), as an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident, due to the control room envelope being inoperable.

"The NRC Resident Inspector has been notified."

MANUAL REACTOR TRIP DUE TO LOW MAIN TURBINE ELECTRO-HYDRAULIC CONTROL (EHC) OIL LEVEL

The following information was provided by the licensee via email:

"On July 30, 2023 at 1526 EDT, with unit 1 in mode 1 at 100 percent power, the reactor was manually tripped due to low main turbine electro-hydraulic control oil level. The trip was uncomplicated with all systems responding normally post-trip. Operations stabilized the plant in mode 3. Decay heat removal is being accomplished using the steam dumps in steam pressure mode to the main condenser. Emergency Feedwater actuated due to low-low steam generator level as expected.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 8/1/2023

EN Revision Text: ECCS POTENTIALLY INOPERABLE

The following information was provided by the licensee via email:

"At 0449 [EDT] on 7/12/2023, Millstone Unit 3 declared the 'B' train of the emergency core cooling system (ECCS) inoperable due to a degraded damper associated with the ventilation support system for the 'B' charging pump. At the time of this event, the 'A' train of service water was already inoperable due to planned maintenance on a breaker that would have prevented an 'A' service water valve powered from this breaker from closing on a safety signal. This configuration resulted in the possibility that the 'A' train of ECCS would not have been available to fulfill its design function under all postulated accident conditions. This event is being reported under 10 CFR 50.72(b)(3)(v)(B), '[any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (B) remove residual heat].'

"Subsequently, the 'A' train of service water was restored to operable at 0548 on 7/12/2023. Repairs and investigation continue on the 'B' train ECCS damper. The NRC resident has been notified. This event did not impact Millstone Unit 2. There was no impact to the public."


* * * RETRACTION ON 7/31/2023 AT 1400 EDT FROM JAMES KELLY TO JOHN RUSSELL* * *

The following information was provided by the licensee via email:

"The condition was reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(B), via an 8-hour report as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.

"A subsequent engineering review of the conditions that existed at the time determined that, based on area temperature response, any impact on ventilation flows into and out of the `B' charging pump cubicle did not generate an observable change in the temperature trend. Based on this, it is concluded with reasonable assurance that the functional requirement of the support system was maintained and the `B' charging pump would have continued to perform its safety function until the `A' train of service water was restored to operable and as a result safety function was not lost.

"Therefore, this condition is not reportable and NRC Event Number 56620 is being retracted.

"The basis for this conclusion has been provided to the NRC Resident Inspector."

Notified R1DO (Bicket).

AGREEMENT STATE REPORT - DAMAGED ASH/MOISTURE GAUGE

The following information was provided by the Utah Division of Radiation Control (the Division) via email:

"There was a partial roof collapse in a coal mine, resulting in a damaged, beyond repair AshScan coal analyzer. The Division was notified of the incident by voicemail the afternoon of July 24, 2023 (State of Utah Holiday). The Division contacted the licensee's radiation safety officer (RSO) at 0630 [MDT] on July 25, 2023 after listening to the voicemail.

"Received from the licensee (by the Division):

"The device referenced was an AshScan serial number AS16-157, utilizing 300 mCi of Am241 and 5 mCi of Cs137. The roof fall occurred on the morning of July 16, 2023. After notification of the incident, the licensee began the process of developing a plan and getting an approval from the Mine Safety Health Administration (MSHA) to begin the work of removing rubble and uncovering the belt and device. The approval allowed the licensee to work their way through approximately 150 feet of rubble, removing rubble and bolting the roof every 5 to 6 feet according to the roof control plan. The area was pre-shifted twice a day with the pre-shifter using a radiation detector to ensure that there was no errant radiation.

"The RSO was notified on July 19, 2023, that the device was visible but not yet accessible due to the roof not being bolted. That morning, the licensee had a brow collapse in the same area, effectively setting them back to where they started. The process of mucking and bolting the brow took priority until the morning of July 24, 2023 when they were able to safely access the gauge. Once they were able to access the gauge and assess its condition, the licensee determined that the gauge was not repairable and would need to be decommissioned. The licensee moved the gauge with a scoop into Crosscut 38 which is about 100 feet away from the original position of the gauge. It was filled with rock on one end. The licensee taped off the other end and placed radiation warning signs to keep personnel from entering the area. The licensee is arranging for a technician to come and decommission the device and will then forward the appropriate paperwork once that work is completed.

"The Division will investigate this matter and update the record upon completion of the investigation."

Utah Event Report Number: UT23-0006

MEDICAL EVENT - DOSE TO UNINTENDED ORGAN

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

A patient was prescribed Y-90 microsphere implants to the liver. The procedure occurred on 4/20/23 with no abnormal outcomes reported. The patient returned to the hospital on 7/24/23 reporting stomach pain which was diagnosed as an ulcer. A biopsy of the ulcer revealed microspheres. Due to the tissue damage, it was assessed that the dose to the stomach lining exceeded 50 Rem. This event is being reported per 10 CFR 35.3045(a)(3).

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 SEED

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

"A patient at Sisters of Charity Hospital in Buffalo, RAM license 2911, was implanted with a Best Medical International model 2301, serial no. 56305C, I-125 localization seed (108.76 microcurie) on 6/23/23 for a surgical removal scheduled on 6/26/23. The seed was in the breast specimen when it arrived in pathology on 6/26/23 (Activity was 105.08 microcurie) and was supposedly removed, bagged, and stored in the proper storage area. Personnel from nuclear medicine retrieved the seeds from the pathology storage unit on 7/3/23 and filled out the log sheet and the chain of custody paperwork. While bringing the seeds to the nuclear medicine decay closet, a nuclear medical technician (NMT) noticed that one of the bags with seeds in it (they retrieved 4 seeds that day from pathology) had a seed that seemed thicker than the others. Upon further investigation, it was noted that there was a clip and not an I-125 seed in the one bag. NMT staff Immediately went and monitored all areas in pathology (floor, work areas, sharp containers, garbage of the remaining specimen and the patient slides). No activity was noted. Staff contacted the boiler house, and no radioactive waste has been discovered leaving the premises. The licensee believes that the seed possibly went down the drain in the pathology lab. As a precaution, the licensee plans to set up a dedicated area to survey the biohazard bag with the seed in it and the sink drain will be covered during dissection. This seed is considered lost with no reasonable probability of recapture."

New York State Event Report Number: NY-23-06

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 - MISSING STATIC ELIMINATOR

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

"Tesla reported that one of their Polonium-210 static eliminators is missing. The device is a NRD model P-2021-Z705, s/n A2ME848. The device was shipped to Tesla on 2/23/21. The device has been through more than six half-lives so the activity at this point should be below 0.1 millicurie."

New York State Event Report Number: NY-23-07

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