Event Notification Report for August 14, 2024

EN Revision Imported Date: 8/14/2024

EN Revision Text: AGREEMENT STATE REPORT - BRACHYTHERAPY MISADMINISTRATION

The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:

"The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024. The licensee is reporting that the total source strength administered differed by 20 percent or more from the total source strength documented in the post-implantation portion of the written directive."

SC Event Number: 240003


* * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

"For the medical event, the licensee is reporting that the total source strength documented in the post-implantation portion of the written directive is 5.54 millicuries per seed, and 221.6 millicuries total (forty seeds implanted). At the conclusion of the initial procedure on May 16, 2024, the licensee is reporting that all seeds as documented in the post-implantation portion of the written directive were administered. As of May 30, 2024, all seeds had been removed from the patient due to medical complications."

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

* * * UPDATE ON 8/13/24 AT 0901 EDT FROM ADAM GAUSE TO TENISHA MEADOWS * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

On June 20, 2024, the licensee submitted a 15-day written report regarding the medical event. Department inspectors conducted an on-site visit between July 24 and July 31, 2024. Interviews with the licensee's representatives were consistent with the details outlined in the written report. The licensee has provided additional training to neurosurgery department staff. The investigation is considered closed.

Notified R1DO (Ford), 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.

EN Revision Imported Date: 8/14/2024

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEEDS

The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:

"The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024.

"The licensee is reporting that on May 27, 2024, the seven (7) Cs-131 seeds that were removed from the patient are lost or missing. The other thirty three (33) seeds are accounted for."

SC Event Number: 240003

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

The exact source strength of the lost seeds was not provided, however, the licensee reported that the quantity was greater than 10 times but less than 1000 times the 10CFR20 Appendix C value for Cs-131.


* * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

"For the seven (7) Cs-131 seeds that were lost on May 27, 2024, the licensee is reporting the estimated activity at the time of removal and loss was approximately 2.5 millicuries per seed and approximately 17.5 millicuries total."

Notified R1DO (Bickett), NMSS Events Notification (email), ILTAB (email).

* * * UPDATE ON 8/13/24 AT 0901 EDT FROM ADAM GAUSE TO TENISHA MEADOWS * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

On June 20, 2024, the licensee submitted a 30-day written report regarding the loss of seven (7) Cs-131 seeds. Department inspectors conducted an on-site visit between July 24 and July 31, 2024. Interviews with the licensee's representatives were consistent with the details outlined in the written report. The licensee has provided additional training to neurosurgery department staff. The investigation is considered closed.

Notified R1DO (Ford), NMSS Events Notification (email), 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 - MEDICAL UNDERDOSE

The following report was received by the California Department of Public Health, Radiation Health Branch (RHB) via email:

"The University of California, Los Angeles (UCLA) reported a medical event that had occurred on Monday, August 5, 2024, during a Y-90 Sirtex SIR-Sphere liver cancer treatment.

"The target organ was the patient's left liver lobe. The authorized user prescribed an activity of 0.71 GBq (19.14 mCi).

"Unfortunately, the target organ only received 7.72 mCi or 40.33 percent of the prescribed dose.

"The interventional radiologist reported that the cause of the under-delivery was a leak in the SIR-Sphere tubing system (delivery box and covered table). All contaminated equipment is being held for decay by UCLA.

"UCLA will submit a 15-day written report to the RHB."

California Event Number: 080524

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 - LOST SOURCE

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

"On August 7, 2024, the Department was notified by the licensee that they had lost a Humboldt model 5001 EZ moisture density gauge. The gauge contains a 40 millicurie americium - 241 source and an 8 millicurie cesium - 137 source. The gauge was used at a temporary job site and had been placed in the back of a pickup truck to transport back to its storage location. The technician failed to secure the gauge in the truck and did not raise and secure the tailgate. When the technician arrived at the office, they found the gauge was missing. The technician drove the route they had taken looking for the gauge but did not find it. They then notified their radiation safety officer (RSO). The licensee has contacted the Houston Police Department and notified them of the loss. The licensee stated the cesium source rod was locked in the fully shielded position. The RSO stated that the technician and a district RSO are still out looking for the gauge at the time of this report. The RSO stated the gauge would not create an exposure risk to any individual. Additional information will be provided in accordance with SA 300."

Texas Incident #: I-10119


* * * UPDATE ON 08/09/24 AT 2019 EDT FROM ARTHUR TUCKER TO JOSUE RAMIREZ * * *

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

"On August 9, 2024, the licensee reported that they had recovered the gauge. An individual was driving on the road where the gauge had fallen out of the truck and recognized what it was and picked it up. He found the contact information on the gauge container and called the licensee. The licensee has the gauge in its storage location. The licensee inspected the gauge and stated that the gauge was in good condition."

Notified R4DO (Vossmar), NMSS Events Notification, ILTAB, and CNSNS (Mexico) via 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

EN Revision Imported Date: 8/14/2024

EN Revision Text: ALERT - FIRE IN SAFETY-RELATED TRANSFORMER

The following information was provided by the licensee via phone:

"At 1200 EDT on August 13, 2024, with Unit 2 in Mode 1 at 100 percent power, Vogtle Unit 2 declared an ALERT per emergency action level (EAL) SA9 due to a fire that caused visible damage to a safety system component needed for the current operating mode. At 1151 EDT, the fire was extinguished. The equipment affected was the safety-related regulating 480V transformer which supplies power to the Unit 2 'B' engineered safety features chiller.

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

"Units 1, 3, and 4 are unaffected.

"State and local officials were notified. The NRC resident inspector was notified."

The NRC decided to remain in the Normal mode of operation at 1234 EDT.

Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, EPA Emergency Ops Center, USDA Watch Officer, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC THD Desk (email), FEMA NRCC SASC (email), FERC RMC (email), CWMD Watch Desk (email).

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

The fire alarm was received at 1145 EDT. A fire was confirmed at 1149 EDT. The switchgear was de-energized and a fire extinguisher was used to put out the fire.

* * * UPDATE ON 8/14/2024 AT 1448 EDT FROM JEFF COX TO BRIAN SMITH * * *

The licensee terminated the ALERT emergency action level at 1436 EDT.

Notified R2DO (Lopez-Santiago), IR MOC (Grant), NRR EO (Felts), DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, EPA Emergency Ops Center, USDA Watch Officer, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC THD Desk (email), FEMA NRCC SASC (email), FERC RMC (email), CWMD Watch Desk (email).