Event Notification Report for October 04, 2023

MEDICAL EVENT - DOSE TO UNINTENDED PART OF ORGAN

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

On September 21, 2023, a female patient received the first of three scheduled doses using a vaginal cylinder containing 5 curies of Iridium 192. The cylinder shifted inadvertently during the administration by about 3.5 centimeters outward causing the dose to the intended site to be different than the intended dose. The patient was informed.

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 - DAMAGED TROXLER GAUGE

The following information was provided by the Utah Division of Waste Management and Radiation Control via email:

"At approximately 1400 [CDT] on September 27, 2023, a Troxler 3440 portable gauge (serial number 37345) was run over by a water truck. The Troxler 3440 gauge has an 8 mCi Cs-137 source and a 40 mCi [Am-241/Be] source. The Utah radiation safety officer inspected the gauge at the job site and determined that the sources appeared to be undamaged and remained in the shielded position.

"The licensee took the gauge to another Utah licensee, Construction Materials Technologies (doing business as Precision Calibration) [with license number] UT1800143, for evaluation and repair."


Utah Event Report ID: UT23-0008

AGREEMENT STATE - RADIOGRAPHY SOURCE DISCONNECTED

The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:

"On September 27, 2023, the Department received a report of a source disconnect incident from a licensee that occurred on September 26, 2023, at around 1000 [CDT]. The source is 63.6 curies of iridium-192 in an Industrial Nuclear Corporation (INC) IR-100 camera. The licensee could not give a narrative or a dose estimate for the trainee who was working the source. They did report that the drive cable was not broken, and it seems that this may be a misconnect. They were not able to provide a time estimate for the exposure to the trainee, but they were talking about minutes. They have taken the trainee to a medical facility for blood tests with no results yet. This Department recommended that they send bloodwork to [Radiation Emergency Assistance Center/Training Site] (REAC/TS) and provided contact information for REAC/TS. The Department has also asked that the licensee take daily pictures of the trainee's hands. His dosimetry badge has been sent in overnight for processing. The trainer was reportedly not close to the source and his dose was reported as not significant.

"An experienced consultant has been hired by the licensee and will begin work in the morning reconstructing what happened. A meeting with the Department is set up for 1100 [CDT] to discuss a dose estimate as well as get a narrative.

"The source retrieval was performed by the associate radiation safety officer and another individual. Licensee has reported that both are trained to retrieve sources. Each person received about 90 mR. An update will be provided to the [NRC] Headquarters Operations Center (HOC) tomorrow afternoon. Further information after that will be provided per SA-300."

Texas Incident Number: I-10055
Texas NMED Number: TX230046

* * * UPDATE ON 9/28/2023 AT 1832 EDT FROM RANDALL REDD TO BETHANY CECERE * * *

The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:

"On September 28, 2023, the Department received additional information from both the licensee and the consultant hired by the licensee following a reenactment of the incident.

"It was reported that, after setting up and taking two shots, the trainee noticed that the source got stuck in the guide tube. The trainee did not have his alarming dosimeter turned on, and he did not have his survey meter close by. The trainee believed the source was back in shielding, and he continued to work. He replaced the film, repositioned the tip of the guide tube, and cranked the source back out although it was already out. He repeated this a total of four times before he noticed that the source lock indicator was not in the shielded position. The trainee then checked his dosimeter and found it off scale. He immediately reported this to the trainer which began the source retrieval event wherein they expanded the boundary, maintained security, and waited for the associate radiation safety officer to arrive.

"The film for the first two shots came out as expected, but the film for the last four shots came out black indicating that the source was near the film long enough to overexpose those four. This would indicate the source did become disconnected after the second shot.

"Based upon measured times and distances during the re-enactment, a whole-body dose of 38 R to the trainee has been reported TO this Department. The estimate for dose to each hand was reported to be 18 R. The trainee had left his badge in the truck so it will not be helpful in verifying these values. Dose to the trainer was 5 mrem. The trainer was 50 feet away during this event.

"Based upon this information, this Department is adding the following reporting criteria to this event: 20.2202(a)(1)(i) - Overexposure event involving byproduct, source, or special nuclear material possessed by the licensee that may have caused or threatens to cause an individual to receive a total effective dose equivalent greater than or equal to 25 rems (0.25 Sv).

"This Department will be reviewing the dose calculations and will provide an assessment with the final NMED report."

Notified Young (R4DO), Einberg (NMSS), and NMSS Events by email.

AGREEMENT STATE - DAMAGED GAUGE

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

"During a routine radioactive materials inspection on September 27, 2023, the Division was informed that a gauge was damaged by a piece of equipment which cracked the gauge's casing in May of 2023. The incident was not reported to the Division by the licensee as they believed the event was not reportable. The Division is waiting for additional information pertaining to the incident and will provide an update once the information is received."

Utah Event Report ID number: UT 230007


The following additional information was obtained from the Utah Division of Waste Management and Radiation Control in accordance with Headquarters Operations Officers Report Guidance:

The location is listed as 'Unknown' since the location where the portable gauge was in use when it was damaged is currently unknown but will be provided once that information is received.

DEGRADED CONDITION
The following information was provided by the licensee via email:

"At 1154 EDT on 10/03/23, investigation into a boric acid indication was determined to be through a leak on a weld-o-let upstream of a pressurizer level transmitter isolation valve. Unit 2 is currently in MODE 6 with reactor coolant system (RCS) operational leakage limits not applicable. The leak is not quantifiable as it only consists of a small amount of dry boric acid at the location. The failure constitutes welding or material defects in the primary coolant system that are unacceptable under ASME Section XI.

"Therefore, this is a degraded condition reportable under 10 CFR 50.72(b)(3)(ii)(A). This condition does not affect the health and safety of the public or station employees."

The Resident Inspector was notified.