Event Notification Report for December 06, 2023

EN Revision Imported Date: 12/6/2023

EN Revision Text: AGREEMENT STATE - LOST PACKAGE

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"On November 22, 2023, the Agency was contacted by G.E. Healthcare in Arlington Heights, IL (IL-01109-01) to advise of a radiopharmaceutical package missing in transit. The last known location was the Memphis, TN [common carrier] hub where it was scanned on November 21, 2023. The carrier has declared the package lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.

"The subject package is 16 centimeters square, labeled Yellow-II (TI of 0.1), UN2915 and contains a single 10 milli-Liters shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.56 millicuries. It was offered for shipment on November 17, 2023, for delivery to a customer in Ontario, Canada on November 20, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for. Tennessee program officials were notified, and the matter was reported to the HOO [NRC Headquarters Operations Officer]. This report will be updated with any available information."

Illinois Item Number: IL230033

* * * UPDATE ON 12/5/23 AT 1650 EST FROM GARY FORSEE TO ADAM KOZIOL * * *

"On 12/5/23, the licensee advised that the package was delivered undamaged to the client site. This matter is considered closed."

Notified R1DO (Werkheiser), R3DO (Szwarc), NMSS and ILTAB (email)

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 - FOUND GAUGES

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

"A Houston police officer was driving by a scrap yard on October 16, 2023, when his [personal radiation detector] PRD alarmed. He contacted his office, and another officer with radiation detection equipment went to the location and determined the radionuclide to be cesium-137. This officer contacted the Department, and on October 17, 2023, a Department investigator went to the location and located a box in a remote section of the scrap yard. The 4 foot by 4 foot by 4 foot box had several devices that appeared to be nuclear gauges in it. A service provider was contacted by the Department and put in contact with the property owner. The service provider responded to the location to remove the gauges and determine the source of radiation. Access to the area was restricted and controlled by the property owner. It does not appear that any individual would have exceeded an exposure limit. The service provider was able to determine that there was one source in the box. The source was placed in the back of a trash truck and shielded with all of the empty source holders stacked around it. The source holders all had the radioactive materials information removed.

"On October 19, 2023, a second service provider went to the site to retrieve the source. While there, they found three more shields in another area of the facility that were suspected to have sources that were very well shielded. All four sources (shields) were taken to the service provider's facility. The service provider removed the 4 sources. The service provider reached out to other individuals in an attempt to identify the manufacturer. It was determined that the sources were made by 3M and sold to Ronan Engineering, who then sold them to a DuPont plant in Wilmington, NC in 1992. The North Carolina program was contacted, and they reported that license was terminated in April of 2014. The sources were sent to a facility in South Carolina. The South Carolina program was contacted, and they provided a document showing the sources had been transferred to a Texas licensee in Sugar Land, Texas. The Texas licensee closed its facility and shipped all the sources they had for disposal. The last shipment of sources with this activity level was shipped from that facility in March of 2019. The contractor used to dispose of the sources has been contacted and will attempt to determine how the sources could have ended up at the scrap yard."

The Department will provide updated information as it is received.

Texas Incident Number: 10058
Texas NMED Number: TX230055


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 - 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

SAFETY SYSTEM MALFUNCTION

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

"[The following is a report of] reactor safety system component malfunction under Missouri University of Science and Technology Reactor (MSTR) Technical Specification (TS) 6.7.2.c)iii)

"At 1124 [CST], on December 1, 2023, with the MSTR at 180 kW, a `150 Percent Full Power' scram signal was received from one safety amplifier, and the reactor scrammed automatically. Based upon other nuclear instrumentation, at no point was reactor power at, above, or near the MSTR 300-kW Limiting Safety System Setting (LSSS), nor was any transient underway that could have yielded such a situation. Power was within the 2 percent automatic control setpoint window of 180 kW, and power dropped rapidly as expected following a scram. At the time of the event, the console operator observed that the affected safety amplifier went blank, and following an approximate 0.5 second delay, returned to a normal status tracking the decay power with a scram indicator illuminated.

"At no point was the health and safety of the public or MSTR in doubt. Due to ongoing reviews and replacement component sourcing, the MSTR has not operated since the event.

"Per MSTR TS 6.7.2.c)iii), `[the license shall make a report for] a reactor safety system component malfunction that renders or could render the reactor safety system incapable of performing its intended safety function unless the malfunction or condition is discovered during maintenance tests or periods of reactor shutdowns.' Following a thorough review of the scram logic and documented failure modes and effects analysis (FMEA) provided in the system's `Operation and Maintenance Manual' (Imaging & Sensing Technology Report 021-2103, Rev. 00), in the MSTR's opinion, the safety system malfunctioned but was able to complete its safety function. The event is being reported pending further review by facility staff and discussions with Nuclear Regulatory Commission facility project management.

"This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day. Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days. Additional replacement parts will need to be secured and repairs performed to restore operability."


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

This event has been entered into the licensee's corrective action program.

EN Revision Imported Date: 12/7/2023

EN Revision Text: 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.

* * * UPDATE ON 12/6/2023 AT 1904 EST FROM RUSSELL HESTAND TO ERNEST WEST * * *

"On 10/25/2023 the University of Kentucky (UK) reported a possible dose misadministration that occurred at the UK Chandler Medical Center on 10/23/2023. During a high dose rate (HDR) cervix/uterus treatment, the treatment was interrupted due to fluid in the transfer tubing. The authorized user directed that the transfer tubing be replaced, and treatment completed. The tubing used to complete the cycle was not cut to the correct length. This resulted in the source being 12cm out of position for the 10 seconds remaining in the planned treatment. The source was outside of the patient's body during that exposure period, causing a potential radiation exposure to the skin of the thigh in excess of reporting requirements. The worst-case assessment assumes that the patient's thigh was in direct contact with the applicator for the full 10 seconds, resulting in a localized skin dose of 300 cGy. In the judgment of treating physician, the dose is below the level likely to cause injury. However, the dose is above the reporting threshold for a Medical Event. In the most likely scenario, the patient's thigh was at least 8 mm away, resulting in a significantly lower dose of less than 50 cGy. The patient and referring physician were informed in a timely manner.

"Corrective Actions:

"1) A leak mitigation countermeasure is being trialed in an effort to prevent fluid from leaking down the catheter and potentially causing this issue in the future.

"2) Current procedures are very specific about verification of transfer catheter length before starting a treatment. However, they have not until now directly addressed a process for interruption of a procedure to make adjustments to the patient set up. These procedures have been updated and training / education is being performed on the updated processes.

"Based on the investigation by the [Kentucky Department for Public Health and Safety] Radiation Health Branch in collaboration with the University of Kentucky, we find the corrective actions to be sufficient and consider this incident closed."

NMED Item Number: 230461

Notified R1DO (Werkheiser), NMSS Division Director (Williams), and NMSS Event Notifications (Email)

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 - 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.