Event Notification Report for November 28, 2023

AGREEMENT STATE REPORT - PARTIALLY STUCK OPEN SHUTTER

The following information was provided by the Iowa Department of Health and Human Services (HHS) via email:

"Arconic Davenport possesses an [Isotope Measuring Systems] IMS model 5221-02, profile thickness gauge for measuring thickness of aluminum on the production line. The C-frame gauge contains 5 independent source housings, with each housing containing a 5 curie, Americium-241 sealed source. The C-frame gauge is constructed from steel and is suspended from a monorail which allows the device to be moved off-line to a restricted access calibration area. The shutter is opened and closed by a pneumatic cylinder that is controlled from a remote location. In the afternoon of November 28, 2023, it was determined that shutter number 1 of the C-frame gauge had failed to fully close. This was determined when an automated attempt to close all 5 shutters on the gauge [failed], and the computer indicated that shutter number 1 was not fully closed. Per the licensee's procedures, the C-frame gauge was removed from the line using the monorail to the secured calibration house.

"Radiation surveys of the outside wall adjacent to the shutter 1 position were above background with a maximum dose rate of approximately 0.1 mR/hr. The licensee has contacted their service provider to perform repair work (identify and fix the equipment problem) which is tentatively scheduled for November 29, 2023. No reported overexposures and no release or contamination of radioactive material occurred because of this incident (most recent negative leak test was November 2, 2023). Iowa HHS will update this report once additional information is provided (cause, corrective actions, etc.)."

Iowa Item Number: IA230004

AGREEMENT STATE REPORT - Y-90 UNDERDOSE

The following information was received from the Arizona Department of Health Services (the Department) via email:

"On November 29, 2023, the Department received notification from the licensee about a medical event involving Y-90 TheraSpheres that occurred on 11/28/2023. A patient was prescribed a dose of 1.766 GBq, but was delivered 1.019 GBq. The dose delivered was 57.7 percent of the prescribed dose. 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.

FOUND DEPLETED URANIUM PROJECTILE

The following information was provided by the licensee via email:

"In accordance with 10 CFR 20.2201 (a)(1)(ii), the US Army is (telephone) reporting the recovery of a 120 mm depleted uranium (DU) projectile from a landfill in York, PA. [10 CFR 20.2201(a)(1)(ii) - Within 30 days after the occurrence of any lost, stolen, or missing licensed material becomes known to the licensee, all licensed material in a quantity greater than 10 times the quantity specified in appendix C to Part 20 that is still missing at this time.]

"An M829 120 mm DU projectile has 4000 grams of DU, which equates to approximately 1,520 microcuries of U-238. The M829 DU projectile was manufactured in the 1970's - 1980's.

"The Part 20 App C limit for U-238 is 100 microcuries. 100 microcuries times 10 equals 1,000 microcuries.

"The specifics on retrieving the 120 mm DU projectile are as follows:

1. A military explosive ordnance disposal (EOD) team was contacted (Nov 28) and requested to respond to a possible unexploded ordnance (UXO) device at the York County Resource Recovery Center, York, Pennsylvania.
2. The EOD team arrived (Nov 28) and identified the UXO as a 120 mm DU projectile (projectile with tailfin, no propellant, no cartridge case, no explosives, no tracer).
3. EOD placed the item in an ammo storage container and transported the item to Joint Base McGuire-Dix-Lakehurst, New Jersey for safe storage.
4. US Army Joint Munitions Command DoD Low Level Radioactive Waste (LLRW) Lead Agent was notified on or about December 1.
5. A member of the LLRW team is at Joint Base McGuire-Dix-Lakehurst on December 27-28 to package and ship the DU projectile to our Morris Consolidation Facility (NRC License 12-00722-15), Rock Island Arsenal, Rock Island, IL, for safe storage and eventual disposal.
6. At this time, we have no further information or evidence to determine how the item arrived at the Pennsylvania landfill.
7. There are no clear identification markings that we have viewed on pictures (so far) that will help us to determine where the device was stored or possessed. We will conduct a more thorough visual exam once we have the item in our possession at our Rock Island Arsenal facility (Morris Consolidation Facility).

"In accordance with 10 CFR 20.2201 (b), a written report will be provided to the NRC within 30 days after making the telephone report."

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

Swipe test of the ordinance revealed no loose contamination. Dose rate on contact is 1-2 mrem/hr, so exposure exceeding limits to public is unlikely.

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