Event Notification Report for November 02, 2023

AGREEMENT STATE REPORT - LOST AND FOUND RADIOACTIVE SOURCE

The following was received from the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS)) via email:

"IEMA-OHS was contacted the morning of October 25, 2023, by GE Precision Healthcare (a Wisconsin-licensed service provider) to advise of a Ge-68 source that had been improperly shipped to Illinois. Reportedly, a positron emission tomography-computed tomography (PET/CT) unit, still containing the Ge-68 source, was removed from a medical facility in Washington state and shipped to an unlicensed Illinois facility (MAK Healthcare). The parties involved are seeking the proper removal and return of the source to the Washington licensee. It is our understanding that GE Healthcare intends to send a technician to the Illinois facility on Friday, October 27 to remove or retrieve the sources under reciprocity. Thereafter, the source will be packaged and returned to the licensee in Washington state.

"Illinois staff contacted Washington staff and advised them of the available details. In accordance with SA-300, section 5.6.2, this report is being filed with the Nuclear Regulatory Commission as a 'found source'. The matter may also be reportable under the Illinois equivalent of 10 CFR 20.2203(a)(3)(ii). IEMA-OHS staff will monitor the activities in Illinois to verify source integrity and proper return to appropriately licensed individuals.

"This report will be updated as details become available. At this time, the Ge-68 sealed source is estimated to have a maximum activity of 11 mCi and is either an IPL-model number HEGL-0132 or 0019 or 0020."

Illinois report number: IL230031

See NRC Event Notification number 56818 for a parallel report made by Washington.


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

LOST SEALED SOURCES

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

"This is a non-emergency 30-day notification for missing licensed material. This event is reportable in accordance with 10 CFR 20.2201(a)(1)(ii). On September 25, 2023, while performing the required semi-annual source leak check and inventory, radiation protection personnel could not locate seven sealed radioactive sources. Five of the sources exceed the reporting threshold of ten times the activity listed in 10 CFR 20 Appendix C. Of the five sources, four were Ni-63 sources previously utilized in security bomb detection equipment with a current source radioactivity of between 7.1 and 8.7 mCi. The fifth sealed source exceeding the reporting threshold is an Am-241 former lab calibration standard with a source radioactivity of 0.97 microcuries. These sources were last accounted for on July 6, 2022. Pilgrim's accountability process does not require leak checks or physical inventory of sources that are out of service. A search was conducted for the missing sources; however, they could not be located.

"These sealed sources are classified as Category 5 radioactive sources in accordance with the International Atomic Energy Agency (IAEA) Safety Guide No. RS-G-1.9. Sources that are less than Category 3 (Cat 4 and 5 sources) are very unlikely to cause permanent injury to individuals.

"Based on the activity of Ni-63 and Am-241 present in the sources, this 30-day phone notification to NRC is provided pursuant to 10CFR20.2201(a)(1)(ii). The required written report pursuant to 10CFR20.2201(b)(1) will be provided to NRC within 30 days. The Resident Inspector has been notified. The licensee will notify State and local authorities."


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 - POSSIBLE DOSE MISADMINISTRATION

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 10/25/23 by the radiation safety officer (RSO) of University of Kentucky (UK) Broad Scope medical license, of an incident which occurred at the UK Chandler Medical Center on October 23, 2023.

"[The UK] RSO reports, 'During a high dose rate (HDR) treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user (AU) directed that the transfer tubing be replaced and treatment completed. The tubing used to complete the cycle was not the correct length, resulting in approximately 10 seconds of source exposure at the wrong dwell position(s). The source was outside of the body during this exposure period, therefore, there is uncertainty in the dose estimates to patient skin. Likely exposure in the treatment position (legs apart) is likely below the reporting thresholds in 10 CFR 35, while conservative estimates (assuming patient's legs were closed) lead to doses above reporting thresholds. Since the exact positioning is indeterminant, the licensee did not report a dose from this incident at this time. Upper bound worse case estimates place the skin dose below the level where patient harm is expected by the treating oncologist and no changes in plan of care are anticipated from this event. This incident remains under investigation.'

"RHB is following up with the RSO for additional information not included in the initial report."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The intended organ to be dosed was the cervix/uterus. Dose estimates were not available at the time the report was received from KY RHB.

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 - STUCK OPEN SHUTTER

The following information was provided by the Tennessee Division of Radiological Health via email:

"During a scheduled 6-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was a normal operating position. A VEGA field technician has been scheduled to arrive onsite on November 7, 2023, to service the gauge.

"Manufacturer: Ohmart/VEGA
"Source holder model: SHLM-CR
"Source serial number: 4259CO
"Isotope: Cs-137, 37 mCi

"Corrective actions or reports as well as additional information will be updated with a NMED report within 30 days."

Tennessee Event Report ID Number: TN-23-079

AGREEMENT STATE - LOST AND FOUND RADIOACTIVE SOURCE

The following information was provided by the Washington State Department of Health via email:

"A positron emission tomography-computed tomography (PET/CT) unit with a Ge-68 sealed source (11 millicurie) was removed improperly from a medical facility in WA (Radia Imaging Center) and shipped to an unlicensed facility (MAK Heathcare in Woodstock, IL). Leak tests are in process to verify no spread of contamination. Currently, the plan is to ship the PET/CT scanner back to source manufacturer, Eckhert & Ziegler, in Burbank, CA on Friday, 10/27/2023."

WA Incident Report Number: WA-23-028

See NRC Event Notification number 56814 for a parallel report made by Illinois.


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

EN Revision Imported Date: 11/3/2023

EN Revision Text: FALSE NEGATIVE ON BLIND PERFORMANCE SAMPLE

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

"On October 31, 2023, at 0800 CDT, River Bend Station discovered that the results of a blind performance sample provided to an Health and Human Services (HHS)-certified testing facility were inaccurate (false negative). This report is being made in accordance with 10 CFR 26.719(c)(3). The HHS-certified testing facility has been informed of the error."

The licensee notified the NRC resident inspector.

* * * RETRACTION AT 0946 EDT ON NOVEMBER 2, 2023 FROM MICAH NAVARRO TO SAMUEL COLVARD * * *

"On November 1, 2023, River Bend Station personnel were informed by the HHS-certified testing facility that the cut-off levels used for analysis of the performance testing sample in question were the correct (higher) cut-off levels currently being used by the licensee. This resulted in a correct negative test.

"The performance testing sample sent to the HHS-certified testing facility was purchased for use based on the new lower cut-off levels in accordance with the new fit for duty (FFD) rule being implemented by the licensee on November 6, 2023. Because the higher confirmatory cut-off levels were used at the HHS-certified testing facility, the results provided were correct.

"The NRC Resident Inspector has been notified."

Notified R1DO (Eve) and FFD Group (email)

MANUAL REACTOR TRIP DUE TO TRIP OF REACTOR FEED PUMP

The following information was provided by the licensee via email:

"At 0648 EDT on 11/1/23, with Unit 2 in MODE 1 at 56 percent power, the reactor was manually tripped due to a trip of the 'B' reactor feed pump (RFP). The 'A' RFP had been previously isolated due to a leak. Closure of containment isolation valves (CIVs) in multiple systems and the actuation of high pressure coolant injection (HPCI) and reactor core isolation cooling (RCIC) occurred as a result of reaching the actuation setpoint on reactor water level as designed. The trip was not complex, with all safety systems responding normally post-trip.

"Operations responded and stabilized the plant. Reactor water level is being maintained with RCIC. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 1 was not affected.

"Due to the emergency core cooling system (ECCS) discharging into the reactor this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(A). Also, the reactor protection system actuation while critical is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, it is reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of CIVs, RCIC and HPCI.

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

The Resident Inspector was notified.

CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA

The following information was provided by the licensee via email:

"On October 31 at 1856 CDT, Prairie Island Nuclear Generating Plant personnel identified a prohibited item (alcohol) in a kitchen area located within the protected area. An 'Extent of Condition' search was performed of all other protected area kitchen areas, no additional prohibited items were found.

"The NRC Resident has been notified."

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the North Dakota (ND) Department of Environmental Quality (DEQ) via telephone and email:

"The ND DEQ received a call from Innovis Health, LLC, Fargo, North Dakota, (ND License No. 33-02604-01) at 0945 CDT on October 26, 2023, informing the ND DEQ of a possible medical event (10 CFR 35.3045(a)(1)) which occurred on October 25, 2023. The event involved a patient scheduled to receive a prescribed therapy dose of 120 Gy of yttrium-90 Theraspheres microspheres. During the line check while attempting to administer the microspheres, the licensee experienced some difficulties, stopped the procedure, and noticed a higher-than-normal radiation reading of the delivery system and associated materials. After measuring these materials, it appeared the patient received 41.7 Gy to the target site (liver). Initial imaging of the patient directly following the procedure did not show activity around the target area and surface radiation readings of the patient in this area was 0.06 mR/hr. At this time, the licensee was questioning if any of the dose was administered. The licensee contacted the manufacturer the same day regarding the event.

"The licensee also noted increased radiation activity in other materials used in the procedure. The radiation survey reading of these materials was 140 mR/hr. The license was researching a way to calculate the amount of activity that may have been in these additional materials.

"Further viewing of the images of the upper abdomen of the patient by the Interventional Radiologist (IR) demonstrated a very faint outline of the right lobe of the liver (the intended treatment area). This indicated a very small amount of the dose was delivered. The IR discussed everything with the patient before the patient had left the recovery area. There were no immediate adverse health effects, and the IR would monitor the patient for the next two weeks (about five half-lives)."

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 - LOST CATEGORY 4 SOURCE

The following information was provided by the Ohio Department of Health (ODH) via email:

"ODH received a notification last night [on 26 October, 2023], that NDC Technologies, Inc. (NDC) discovered a 25 mCi Americium-241 (Am-241) source was missing from their inventory. NDC is located in Dayton.

"The licensee has conducted three inventories of all sources, reviewed all shipping logs, and have searched (both visually and with a survey meter) areas, floors, and drawers where devices are built and stored.

"The source may have mistakenly been put into a trashcan or sent, still mounted in the sodium iodine crystal, for disposal. The last disposal was on July 12, 2023, and the licensee has contacted the disposal company and will speak with them further today.

"ODH will be sending an inspector to further investigate."

NMED report number: OH230010

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

FALSE NEGATIVE AND POSITIVE ON BLIND PERFORMANCE SAMPLE

The following information was provided by the licensee via email:

"On November 2, 2023, at 0715 CDT, it was discovered that the results of a blind performance specimen provided to a Health & Human Services (HHS)-certified testing facility were not as expected. The blind specimen results indicated a false negative for MDA/MDMA and a false positive for amphetamines.

"Investigation is ongoing to determine if the results are accurate.

"This report is being made in accordance with 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3).

"The NRC Resident Inspector has been notified by the licensee."