Event Notification Report for July 03, 2024

DAMAGED DENSITY GAUGE

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

At 1146 CDT on 7/3/2024, the radiation safety officer at Midwest Subsurface Testing reported a gauge was damaged on a construction site. An InstroTek MC1 Elite moisture density gauge containing 10 millicuries of cesium-137 and 50 millicuries of americium-241/beryllium was backed over by a skid loader. The source was stuck in the shielded position. A radiological survey was conducted, which verified there was no contamination. The damaged gauge was recovered and transported to a vendor facility to conduct a leak test.

This event was reported under 10 CFR 30.50 (b)(2).

AGREEMENT STATE REPORT - LOST GAUGE

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

"On July 3, 2024, a technician for American Testing Services, Inc. (ATS), completed a job at a temporary jobsite. They placed the gauge on the tailgate while they completed the paperwork. Then, they left the jobsite but failed to put the gauge in the transportation box and secure the gauge for transport. Reportedly, the gauge was in the shielded position when on the tailgate. It is unknown if was locked in the safe position or not.

"The technician drove away from the site and made a stop down the road. When they left that location, they noticed that the gauge and the transportation case were no longer on the vehicle, but the chains were still on the truck. They retraced the route but did not find the gauge. Afterwards, the technician reported the gauge missing to the radiation safety officer (RSO).

"The RSO reported the incident to the Department. The only information given at that time was that a gauge was lost. There was no information regarding where the incident occurred, what isotopes and activity were involved, information regarding what happened, etc. The RSO was informed to get more information regarding the details for the incident and provide the information to the Department as soon as possible."

Utah Event Report ID number: UT240005

EN Revision Imported Date: 7/22/2024

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the Pennsylvania Department Bureau of Radiation Protection (the Department) via email:

"On July 3, 2024, the licensee informed the Department of a medical event involving a treatment with SirSpheres [Y-90 resin microspheres].

"A patient was about to undergo a treatment with SirSpheres when the physician noticed a globule on the vial septum. They cleared the globule and began the treatment. At the beginning of treatment, the tube became occluded immediately, resulting in the patient receiving only 0.2% of the prescribed dose. The procedure was stopped. The physician and patient have been informed. No harm to the patient is expected from this event."

PA Event Report ID: PA240014

* * * UPDATE ON 7/15/2024 AT 1050 EDT FROM JOHN CHIPPO TO SAMUEL COLVARD * * *

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"On July 11, 2024, the Authorized User (AU) for the event was interviewed and provided the following additional information:

"The treatment used Y-90 SirSpheres administered through the `SIROS' apparatus. The treatment location was the right lobe of the liver. When the vial was placed into the apparatus the `C' and `D' lines were not in the right location and no spheres were at the bottom of the dose vial where they usually are. The AU saw the spheres clumped at the top of the dose vial, so they agitated the vial to try to suspend the spheres. The vial was then connected to the `SIROS' unit. The AU started the procedure by trying to push a 20 mL syringe of saline solution through the `D-Line' which connects to the dose vial. After many attempts the AU could not get any solution through the `D-line' which he thought may be occluded. The AU then checked the patient's catheter line with contrast and tried to slightly move the catheter. The AU then connected a 3 mL syringe to the `D-line' to create more pressure to try to push the solution to the dose vial, but the line remained occluded. The treatment was then terminated. The patient was retreated on July 10th, 2024, successfully.

"The Department will perform a reactive inspection."

Notified R1DO (Schroeder), NMSS Events Notification (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.

* * * RETRACTION ON 7/18/2024 AT 1407 EDT FROM JOHN CHIPPO TO JORDAN WINGATE* * *

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"After the licensee's physicists performed all calculations and consultation with the NRC, it was determined that no dose was delivered and since no material was administered the dose threshold would not be met and there would not be a radiation protection concern to the patient. Therefore, this is not considered a medical event and DEP wishes to formally retract the submission."

Notified R1DO (Schroeder), NMSS Events Notification (email).

NONCOMPLIANCE WITH TECHNICAL SPECIFICATION

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

"On July 3, 2024, at 0907 EDT, a reactor operator (RO) was in the process of commencing a routine startup. During the startup, the RO switched on the ventilation fans for less than 1 second with the key in the console.

"[With the key in the console] the reactor did not meet the definition of 'reactor secured' and thus the confinement requirements of technical specification (TS) 3.4.2 were still required to be met. [Ventilation fans running in this condition violates the confinement requirements of TS 3.4.2.]

"The RO notified the director of radiation facilities and logged the action. Throughout the duration of the event all control rods were fully inserted.

"The director notified the NRC project manager."