Event Notification Report for September 14, 2023

EN Revision Imported Date: 9/14/2023

EN Revision Text: UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS

The following is a synopsis of information provided by the licensee via email:

Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.

This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.

This issue has been entered into the licensee's corrective action program as IR-2022-9728.

* * * UPDATE ON 09/13/23 AT 1219 EDT FROM STEPHANE SUBOSITS TO THOMAS HERRITY * * *

The following is a synopsis of information provided by the licensee via email:

On 9/12/2023, while offloading additional barrels of Hematite Ash from the the 2003 shipment, A URRS operator identified that the tag for a drum showed the contents have a higher enrichment than that which is recorded in the Chemical Area Manufacturing and Process System (ChAMPS) and on the original paperwork provided by Hematite Fuel Operations. The unloading activity was stopped, and URRS Management and Nuclear Criticality Safety were notified. The unopened pail was placed back in the drum and the drum was segregated from other items in the area. Environmental Health and Safety requested that the remaining seven drums be opened and the contents tag for each be checked against the information in ChAMPS and the original paperwork from Hematite Fuel Operations. This was done.

This report is conservatively being made as an update to Event Notification 56199 under reporting criterion 10 CFR 70 Appendix A (b)(1) as an event that resulted in the facility being in a state that was not analyzed in the Integrated Safety Analysis, and resulted in a failure to meet the performance requirements of 10 CFR70.61 similar to the 9 drums of Hematite Ash that were discovered in November 2022 due to it being an unanalyzed condition.

Westinghouse believes it is likely that the enrichment listed on the tag of the drum is inaccurate. The issue has been entered into the corrective action program as IR-2023-8953.

Notified R2DO (Endress) and NMSS_EVENTS via email.

AGREEMENT STATE REPORT - PATIENT RECEIVED 29 PERCENT OVERDOSE

The following was received from the Colorado Department of Public Health and Environment via email:

"The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023."

Colorado Event Report ID No.: CO230028

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.

SURFACE CONTAMINATION LEVELS OF PACKAGE EXCEEDED LIMIT

The following information was provided by the licensee via telephone:

On September 6, 2023, Adventist Health Castle received an expected package of TC-99M from Cardinal Health. During a wipe test that was conducted at 0737 HST, it was determined that the package had removable surface contamination levels of 17836 disintegrations per minute (dpm) per 300 centimeters squared (cm^2). The radiation safety officer (RSO)'s determination was that this exceeded a limit that he stated was 2400 dpm per 100 cm^2. The RSO notified the Headquarters Operations Officer and the carrier for follow-up. The package was stored in a secure location for the contamination level to decay. Adventist Health Castle plans to return the package to the originator following its decay to a suitable level.

TROXLER GAUGE DAMAGED

The following summary information was provided by the PA Bureau of Radiation Protection (PA DEP) via email"

"On September 6, 2023 a Troxler gauge, model 3411, serial number 6829 was hit by a vehicle while on a job site. This gauge contained a 9 millicurie Cesium-137 source and a 44 millicurie Americium 241:Be source. The area was secured, and the PA DEP responded to the site. The owner/radiation safety officer (RSO) retrieved the sources with long handled pliers and secured them in the transportation box for the gauge. The area and gauge were surveyed and smears were taken for contamination. The case was also surveyed and the owner/RSO has contacted a consultant/vendor to leak test the sources and arrange for disposal."

Pennsylvania Event Number: PA230024

AGREEMENT STATE - LOST AND RECOVERED TROXLER GAUGE

The following information was provided by the Florida Bureau of Radiation Control (the Bureau) via email:

"On or about 1715 [EDT], 9/7/23, [the licensee's] Assistant Radiation Safety Officer (RSO) notified [the Bureau] of a missing soil moisture density gauge. Operator [deleted] believed the gauge to be absent due to the storage/transport box 'feeling light' when the box was moved at 1700 EDT. Sanford Police Department (PD) was notified by the licensee. [A Bureau investigator] was notified. The NRC was notified.

"Upon a subsequent thorough search of job site with Sanford PD, [the licensee] called the [Bureau's] duty officer at approximately 1800 EDT to report the gauge was located in the storage/transport box, which was within a locked and fenced area."

Florida Incident Number: FL23-141

* * * UPDATE ON 09/08/23 AT 0930 EDT FROM ROBERT LATHAM TO TOM HERRITY * * *

"Just to clarify, I talked to the RSO this morning and he said the gauge user assumed the gauge was left at the job site that morning because when he got back to the office that evening to remove his samples, he had to move the gauge case and it felt light. It wasn't until they went back to the job site to meet with the PD that someone actually looked in the case and then realized the gauge was still in there. So the gauge was never out of their possession or control, they just assumed it was.

"I will be submitting an investigation and incident report, but not a radioactive material license inspection report since there was no violation for loss of control."

Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.

* * * RETRACTION ON 09/08/23 AT 1037 EDT FROM MONROE A. COOPER TO TOM HERRITY * * *

"On 9/8/23, at 1026 EDT, the Bureau spoke with Tierra and it was explained that the gauge was misidentified as missing. This occurred because a user determined the Troxler case felt light, and reported the object missing without ensuring the gauge was not present."

Notified R1DO(Young), NMSS_EVENTS_NOTIFICATION via email.