Event Notification Report for September 03, 2024

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG SEGMENT OF LIVER

The following information was received via email from the Virginia Radiation Materials Program (VRMP):

"At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation."

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 - LEAKING SEALED SOURCE

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"On 3/27/24, the Cs-137 dose calibrator source was found to have 635 disintegrations per minutes (dpm) of contamination during the routine weekly swipe. Second set of swipes found 2346 dpm on the inside of the shielded container and 2559 dpm on the outside of the vial. The source was cleaned and swiped again, which brought counts to zero on the inside of the shielded container and 1018 dpm on the outside of the vial. On 4/1/2024, the swipes were counted again and found to be at the same level, showing the contamination to be a long-lived isotope. Since the area where the sealed source resides does not contain long-lived isotopes, it was assumed the source was leaking and was taken out of service and stored under the office of radiation safety's control. On 4/2/2024, Eckert and Ziegler [the manufacturer] was contacted to request instructions on returning the leaking source. Another swipe taken on 7/29/2024 found 17807 dpm and a small fracture was noticed on the vial. This swipe exceeded 5 nano Ci, and the report was made to BRC. Source will be returned to the manufacturer."

Source Information:
Manufacturer: Eckert and Ziegler.
Model: RV-137-200U.
Serial number: 1047-67-4.
Original activity: 197 micro Ci with a calibration date of 7/1/2004.

Florida Incident No.: FL24-076

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) reported the following via email:

"On August 26, 2024, an Epic Engineering gauge user was at the gym from 0700-0800 MDT. While at the gym, a Troxler nuclear density gauge was locked in the bed of the company truck. When the user returned to the truck after completing their workout, the company truck had been stolen along with the nuclear density gauge. The local police department has been contacted. The Division was notified by the company owner later that morning."

Utah Event Report ID: UT 24-0007

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 - DAMAGED MOISTURE/DENSITY GAUGE

The following was reported by the Florida Department of Health, Bureau of Radiation Control (BRC), via email:

"The BRC received notification from Universal Engineering Sciences of a Troxler gauge being hit by a passing car. The Troxler gauge was being standardized by a technician when a passing car made contact with the device. The source rod was retracted at the time and has not been exposed. The only identified damage was a crack in the plastic near the LCD screen."

Device Type: Soil Moisture Density Gauge
Manufacturer: Troxler
Model Number: 3430
Activity: 8mCi of Cs-137, 40 mCi of Am-241/Be

Florida Incident Number: FL24-077

AGREEMENT STATE - DAMAGED RADIOGRAPHY EQUIPMENT

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

"On August 27, 2024, the Department was notified by the licensee that one of its crews was working at a job site with a QSA 880D exposure device containing a 48 curie Iridium - 192 source. The crew was working in a shooting bay surrounded by concrete walls. While performing an exposure, the camera fell 18 inches from the pipe it was on, onto the guide tube, crimping the tube and preventing the crew from retracting the source into the camera. The radiographers drove the source back into the collimator and isolated the area. The radiographers contacted the radiation safety officer (RSO). The site RSO (SRSO) responded to the location. The SRSO added additional shielding to the collimator. The crimped section of the guide tube was removed, and the source was successfully retracted to the fully shielded position. The event was resolved in less than 2 hours. No individual received an exposure that exceeded any limit."

Device Type: QSA
Model Number: 880D
Activity: 48 Ci of Ir-192
Texas Incident Number: 10122
Texas NMED # TX24024

AGREEMENT STATE - MEDICAL UNDERDOSE

The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email:

The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose.

The RSO will send an official written report to the Program within 15 days.

Georgia Incident Number: 86

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 - MOISTURE DENSITY GAUGE SOURCE ROD STUCK OPEN

The Illinois Emergency Management Agency (the Agency) provided the following information via phone and email:

"Weaver Consultants Group North Centra, LLC (the licensee) notified the Agency of a source rod stuck open on a Troxler 3440 portable density gauge (8 mCi Cs-137, 40 mCi Am-241/Be). The licensee confirmed that the incident took place on August 27, 2024. The source rod was stuck out 3 inches. The [licensee's] consultant came to the jobsite to pick up the gauge for repair the same day. The consultant confirmed that they were able to retract the rod once back at their facility. The gauge is pending repair.

"Agency staff will be on-site August 28, 2024, to perform a reactionary inspection. Updates will be provided as they become available."

Illinois Item Number: IL240019

SPECIFIED SYSTEM ACTUATION - AUTOMATIC START OF DIESEL GENERATORS

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

"At 1051 CDT on 8/30/2024, during transfer of 4KV shutdown bus 1 to support Unit 1 shutdown activities, the alternate feeder breaker failed to close resulting in 4KV shutdown boards 'A' and 'B' experiencing an under voltage condition. This resulted in 'A' and 'B' diesel generators automatically starting and tying to their respective boards. This condition also caused a loss of reactor protection system (RPS) channel 'A' on Units 1 and 2, resulting in invalid actuation of primary containment isolation system Groups 2, 3, 6, and 8. The failure of the board to transfer was identified during preparation for the evolution, contingency actions were prepared and implemented as planned. The breaker failure to close has been corrected and 4KV shutdown bus 1 is energized on alternate. 4KV shutdown boards 'A' and 'B' have been restored to offsite power supplies and the diesel generators are secured.

"All systems responded as expected for the loss of voltage. This event requires an 8-hour report per 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified."

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

The change in reactor power from 70 percent to 40 percent was not as a result of the failed breaker, rather Browns Ferry Unit 1's change in reactor power was due to a scheduled reactor shutdown which was in progress. In regards to the Unit 2 loss of channel 'A' RPS, this was not a specified system actuation. The actuation of the 'A' and 'B' diesel generators were the specified system actuation. Although the 'A' and 'B' diesels are common to both Units 1 and 2, only Unit 1 credits these specific diesel generators for accident mitigation. As such, this event is only reportable from Unit 1. Unit 2 did not experience a specified system actuation.