Event Notification Report for September 11, 2023

UNACCOUNTED FOR IODINE-125 SEEDS

The following is a summary of information that was provided by the licensee via phone and follow-up email:

On 8/4/2023 at 1000 CDT, at SSM St. Clare Hospital in Fenton, MO, an oncologist implanted an I-125 prostate seed. After completion of the implant, a radiation oncology physicist went to the hot lab to return the backup seeds that had not been used. The first four unused needles had a single seed, which was expected. The next two had two seeds, which was expected. The last needle, was expected to have three seeds. However, when the physicist pushed the "stylette," the bone wax came out, followed by just one seed. The physicist surveyed the package, but there were no seeds in it. The final needle was still sealed in its sterile package, thus the physicist believed the seed could not have fallen out anywhere but into the sealed package itself. The physicist surveyed the hot packaging with a Geiger-Mller counter and found no radioactivity. The physicist surveyed the entire hot lab, and found no activity. An investigation is ongoing with the vendor. Unaccounted for activity was 0.504 mCi of I-125 on the date of the event.

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 - Y-90 UNDERDOSE

The following information was provided by the Wisconsin Radiation Protection (the Department) via email:

"On September 1, 2023, the department received a notification from the licensee's radiation safety officer about a Y-90 Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred the morning of September 1, 2023. The written directive stated that the activity administered should be 1.24 GBq. The estimated activity administered to the patient was 0.715 GBq, 57.7 percent of the prescribed activity. During the administration, it was identified that the spheres required increased pressure to deliver, and that the spillover vial collected a high volume of material. Post-procedure surveys confirmed that a large portion of the material had not been administered to the patient. The patient was notified, and a follow-up procedure is scheduled to deliver the remainder of the dose. The department will follow up with a site visit to investigate the incident."

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 STATIC ELIMINATION DEVICE

The following was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On September 1, 2023, the Department was notified by a general licensee that a generally licensed NRD, LLC device containing 10 microcuries (original activity on June 8, 2022) of polonium-210 was lost. This is greater than 10 times the Appendix C value of 0.1 microcuries. The device was to be disposed of after the general licensee switched to another non-radioactive material method of eliminating static. However, the device was believed to have been thrown away in municipal waste before this could happen and was last seen on May 12, 2023. The device is not expected to provide significant dose to anyone.

"The licensee does not believe this device would pose a safety or health risk to the public. Further information will be provided per SA-300."

Texas NMED: TX 230038

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 - DOSE MISADMINISTRATION

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

"The Department was notified by the licensee that on September 1, 2023, a patient was prescribed 1,800 centigray in 3 fractions using a 2.5 cm diameter vaginal cylinder. After the start of the first fraction of the treatment, the patient notified the Authorized User and Authorized Medical Physicist that she thought the cylinder was in the `wrong place.' The treatment was stopped at 111 seconds into the treatment and the licensee discovered that the cylinder was placed into the rectum instead of the vagina. The treatment utilized a Varian GammaMedplus iX with an approximate 5.2 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event."

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.

CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA

The following information was provided by the licensee via email:

"On September 6 at 15:00 CDT, Grand Gulf Nuclear Station personnel identified a bottle of vanilla extract in a kitchen area located within the Protected Area. Ingredients were listed as 'pure vanilla extract in water and alcohol. The percentage by volume of alcohol was not specified. It was subsequently determined that the alcohol by volume was likely 35 percent.

"The NRC Resident Inspector has been notified."

CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA

The following information was provided by the licensee via email:

"On September 7 at 1230 CDT, Arkansas Nuclear One personnel identified 5 bottles of vanilla extract in kitchen areas located inside the Protected Area. A total of 5 bottles were identified. The bottles ranged in sizes of 1 to 4 ounces. Ingredients were listed as vanilla extracts in water and alcohol. The percentage by volume of alcohol varied from 13 - 41 percent.

"This report satisfied the reporting criteria of 10 CFR 26.719.

"The NRC Resident Inspector has been notified."

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"On 9/9/23 at 1143 EDT, with the Unit 1 in Mode 1 at 100 percent power, all 4 turbine control valves closed resulting in a reactor protection system (RPS) automatic reactor trip on over temperature differential temperature. All control rods inserted as expected. The trip was not complex and all systems responded normally post-trip. The cause of the control valve closure has not been determined.

"Following the SCRAM, operators responded and stabilized the plant. Decay heat is being removed by the main steam system through the atmospheric relief valves and auxiliary feed water systems. Due to the RPS 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) for a valid specified system actuation.

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