Event Notification Report for May 09, 2024

UNPLANNED CONTAMINATION
The following information was provided by the licensee via telephone:
On March 26, 2024, at 0800 EDT, a spill occurred outside of the Cardinal Health facility's hot-cell. The spill was an aqueous thorium suspension containing 0.5 microcuries, Th-229 and 1.0 microcuries, Th-228. The spill was confined to the licensee's facility.
On March 29, 2024, the licensee became aware of a potential airborne radioactivity hazard posed by the spill and directed personnel to wear respiratory protection in the area of the spill. Personnel dosimetry reports indicate that all external radiation exposures were below regulatory limits. Bioassay samples were taken and preliminary bioassay results were below the analytical minimum detectable concentration. Final bioassay results are pending more sensitive analysis.

Decontamination activities were completed on April 12, 2024.

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On April 30, 2024, the Agency was notified by Northwestern Memorial HealthCare's radiation safety officer of an yttrium-90 (Y-90) TheraSphere underdose. There were no adverse patient impacts reported, and the treatment is scheduled to be repeated the following week. The initial information indicated an underdose of Y-90 TheraSpheres of near 100 percent. Additional information is forthcoming, and Agency staff will be on-site to perform a reactive inspection on May 5, 2024. Updates will be made when available."

IL Event Number: IL240009

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 - OVEREXPOSURE TO AN EMBRYO / FETUS

The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was contacted on April 30, 2024, by Advocate Illinois Masonic Medical Center in Chicago, IL, to advise a patient was administered a therapeutic dose of iodine-131 on March 7, 2024, and was confirmed pregnant on April 29, 2024. The licensee estimates the pregnancy began 3-7 days after the iodine administration. Negative pregnancy test results were confirmed prior to the administration. Both the patient and the referring physician were notified on April 29, 2024. Using dose modeling (ICRP-88) methodology, and assuming conception was 3 days post-administration, the Agency estimates dose to the embryo/fetus over the term of the pregnancy to be 19.8 rem. This is based on an effective half-life of 5.5 days over the 3 days from administration. The patient has had a thyroidectomy which complicates the use of available biokinetic models, but likely also alters the effective half-life. The licensee is researching to determine an appropriate value for the effective half-life (which may range down to 14.4 hours and result in a 900 mrem effective dose).

"Agency inspectors will conduct a reactionary inspection, and this report will be updated as additional information becomes available."

IL Report Number: IL240010

RADIOGRAPHY SOURCE DISCONNECT

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

On May 1, 2024, while conducting radiography on a weld using a QSA D880 with a 90 curie iridium-192 source, the source became disconnected from the cable when attempting retrieval. Surveys showed the source was still in the collimator. The radiation safety officer (RSO) set up boundaries and contacted the manufacturer for guidance. After about three hours, the RSO was able to return the source to its shielded container in the radiography camera. Pocket dosimetry indicated that the RSO received a dose of 178 mrem and the assistant RSO received a dose of 12 mrem. Film badge dosimeters will be read to confirm the exposures.

AGREEMENT STATE REPORT - LEAKING ELECTRON CAPTURE DEVICE

The following was received from the Washington State Department of Health via email:

"The University of Washington has indication that an electron capture device (ECD) containing nickel-63 (Ni-63) is leaking.

"The ECD (G1223A, serial number F7283) had been removed from the gas chromatograph (Hewlett Packard 5890) for disposal. Previous leak testing had been performed with the ECD installed in the GC, and no contamination had been identified that required reporting. The ECD contains Ni-63 that is plated onto an inner surface of the cell body. The current activity is approximately 11.9 millicuries.

"On April 26, 2024, a health physicist performed a leak test by taking a wipe sample on the detector inlet. The wipe from the detector inlet showed contamination of 44,536 dpm using a machine calculated efficiency of approximately 72 percent. The detector inlet indicates a contamination level of 44,536 dpm or approximately 742 Bq (0.02 microcurie). This value exceeds the limit of 185 Bq (0.005 microcurie).

"The ECD will be returned for recycling/disposal of the source."

Washington Incident Report No.: WA-24-011

TECHNICAL SPECIFICATION VIOLATION

The following information was provided by the licensee via phone:

Per the licensee's Technical Specifications (TS) 6.1.3.a, "The minimum staffing when the reactor is not secured shall be: . A reactor operator or the senior reactor operator on duty in the control room."

On May 7, 2024, following the reactor shutdown, there was an indication that one control rod was not fully inserted. Both the reactor operator and reactor engineer left the control room to investigate and discovered that one control rod was not fully inserted. The reactor operator leaving the control room violated the minimum control room staffing requirements of TS 6.1.3.a.

On May 8, 2024, the licensee determined that the cause for the control rod not being fully inserted was a dislodged plastic buffer at the bottom of the control rod barrel.

The NRC Project Manager has been notified.