Event Notification Report for September 26, 2024

AGREEMENT STATE REPORT - LOST I-125 SEED

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

"The Department received notification from the licensee of a lost I-125 seed used for localization. A patient was implanted with two, approximately 0.050 mCi I-125, seeds on September 20, 2024, with the placement of the seeds verified by x-ray. The patient returned to the hospital on September 26, 2024, to have the tissue, including the seeds, removed. The seeds were then sent to pathology where only 1 seed was found. The operating room and patient were surveyed but the seed was not located. The Department has requested additional information and continues to investigate the event.

"Arizona License Number- 07-478

"Additional information will be provided as it is received in accordance with SA-300."

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 - DAMAGED MOISTURE DENSITY GAUGE

The following information was provided by the Colorado Department of Public Health and Environment (the Department) via email:

"On 09/26/2024, the Department was notified by the CTL/Thompson, Inc. radiation safety officer (RSO) that a possible incident with a moisture density gauge occurred at a job site in Granby, CO. The RSO stated he had no further information to provide [about the event]. The Department compliance lead spoke with the RSO over the phone and identified the assistant RSO (ARSO) over that job site. [When contacted] the ARSO stated that a technician was driving on a job site when the incident occurred. The latches were closed on the transportation case, but not fixed with locks since additional testing was going to be performed. While driving over the uneven terrain of the job site, the truck jostled causing the tailgate to open and the transportation case flipped over towards the edge of the truck bed. The latches on the transport case released and caused the gauge (Troxler model 3430, 8 mCi Cs-137, 40 mCi Am-241/Be) to come out and land on the ground, resulting in damage to the gauge."

Colorado Event Report ID: CO240024

AGREEMENT STATE REPORT - LEAKING SEALED SOURCES

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

"On September 26, 2024, the radiation safety officer at Bard Brachytherapy, Inc. (the licensee) notified the Agency of a contamination event within a restricted area presumably resulting from the receipt of leaking Pd-103 brachytherapy seed or seeds. Seventy-one (71) Pd-103 seeds (solid/sealed sources, Theragenics Corp. Model 200 TheraSeed), each with an approximate activity of 1.6 mCi, were received on September 26, 2024, from Theragenics Corporation for loading into a Mick applicator. No contamination was noted on the incoming package and the [transportation information] on the package label was verified. As a result, no exposures to the carrier or members of the public are anticipated. However, upon working with the Pd-103 seeds within the restricted area, personnel surveys evidenced contamination on PPE. At the time of notification, the process of assessing the extent of contamination and decontaminating had begun. Personnel surveys had been performed and indicated contamination on clothing/shoes, with no skin contamination reported.

"Agency staff performed a reactive inspection on September 27, 2024. Inspectors verified that contamination was limited to the restricted area (loading room) and that no contamination to the skin was identified. The licensee is working to quantify the contamination and assess any potential skin dose to workers. At this time, Agency staff do not anticipate any occupational exposures in excess of regulatory limits as a result of this incident. No public exposures resulted from this incident and all contamination was limited to restricted areas. All 71 seeds had been placed in secured storage and radiation safety staff had successfully cleaned contaminated areas (floor, bench top, equipment, chairs) and had placed contaminated clothing (shoes, lab coats, gloves, a shirt, a pair of jeans) for decay-in-storage. Regarding reportability, the licensee committed [to Illinois] to performing leak tests of the sources once assembled. Therefore, [Illinois-specific] reporting requirements apply. There may not be an equivalent NRC requirement. There was no limit on contamination within the restricted area exceeded by the licensee. It is unlikely the potential for uptake of more than one annual limit on intake (greater than 3 seeds) would have been feasible within 24 hours. Therefore, unless there is a reportable occupational exposure, this matter may not be NRC reportable. Regardless, the incident will be shared with Georgia program staff as well. This report will be updated with the information obtained from the licensee's written report."

Illinois item number: IL240022

EN Revision Imported Date: 11/25/2024

EN Revision Text: PART 21 - DEFECTIVE THERMAL OVERLOAD RELAY DISCOVERED DURING TESTING

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

"This notification is a 10 CFR 21.21(a)(2) interim report for General Electric thermal overload relay, model CF124G011, part number DD317A7861P003.

"A sample of overload relays were sent to PowerLabs for parts quality initiative testing. The results were reviewed by James A. FitzPatrick Nuclear Power Plant (JAF) and a deviation in one relay component was discovered. Testing identified a failure to latch on trip, which is a deviation from the performance characteristics of the relay. Under normal operation, the relay would latch in the tripped state requiring a manual reset of the relay. If the relay with the deviation were installed, the relay would trip when required; however, it would automatically reset. The unexpected reset could result in unintended cycling of associated equipment including repeated exposure to inrush current and potential damage.

"Bench testing would be expected to identify this condition prior to installation. Based on a review, this potential condition does not affect installed equipment. The affected relay was stored at JAF since July 1998.

"The cause of the deviation cannot be investigated because the part is not available; however, the evaluation of the potential effect of the condition on equipment where the relay could have been used at JAF is ongoing, and it is expected to be completed by February 28, 2025. This notification is being submitted as an interim report per 10CFR21.21(a)(2)."

"The NRC resident inspector has been notified."