ML22290A004

University of Missouri-Columbia Research Reactor, Reportable Event Report Pursuant to 20.2201(a)(ii) Regarding Loss of Licensed Material During Shipment

ML22290A004
Person / Time
Site:	University of Missouri-Columbia
Issue date:	10/12/2022
From:	Doenges D, Robertson J Univ of Missouri - Columbia
To:	Document Control Desk, NRC/EDO, Office of Nuclear Reactor Regulation
References
Download: ML22290A004 (5)

Text

EiJ University of Missouri Research Reactor Center

1513 Research Park Drive Columbia, MO 65211

PHONE 573-882-4211 WEB murr.missouri.edu October 12, 2022

Executive Director for Operations (EDO)

ATTN: Document Control Desk U.S. Nuclear Regulatory Commission Washington, DC 20555-0001

REFERENCE:

DocketNo. 50-186 University of Missouri-Columbia Research Reactor Renewed Facility License Operating License No. R-103

SUBJECT:

Reportable Event Report Pursuant to§ 20.2201(a)(ii)

The University of Missouri Research Reactor (MURR) submits this letter to report a condition pursuant to

§ 20.220 l(a)(ii) regarding the loss of licensed material during shipment.

On September 08, 2022, a routine shipment of research grade Lu-177 was sent from MURR to University of California San Francisco (UCSF) Medical Center (License 1725-38) via FedEx in support of the Department of Energy National Isotope Development Center (NIDC). The material had an expected delivery date of September 09, 2022. On September 12, 2022 the package was reported not to arrive by UCSF to the NIDC. After furthet: follow-up with FedEx, detailed in section (ii) and (v) below, the material was reported as lost by FedEx to MURR in a phone call on September 21, 2022 and a follow-up letter dated.

September 22, 2022 (Attachment 1 ).

Following this discovery, it was determined that. this issue needed to be reported to the NRC via § 20.2201(a)(ii). At the time of discovery of the loss on September 21, 2022 the remaining activity in the sample was approximately 27 mCi. Comparing this to the table in appendix C to part 20 (Lu-177 limit of l00uCi) the activity is more than 10 and less than 1,000 times greater than the quantity triggering a 30-day phone call.

On September 23, 2022 contact was made between MURR and NRC Project Manager and an additional call to the NRC Operations Center was made on September 26, 2022. A detailed description of the event is contained in the paragraphs below.

Since the time of this event there have been repeated shipments sent through this same method that have been delivered successfully with no loss of material.

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[:bO The following is a description of the event per 10 CFR § 20.2201(b):

(i) Description of licensed material involved, kind, quantity, and chemical and physical form:

The material being shipped in this event was Lu-177, Liquid, Lutetium Chloride Solution sent in a Type A Package of 3.89 GBq (105 mCi) per the Shipper's Declaration For Dangerous Goods. The package was labeled as UN2915, Yellow II, TI of 0.1, and an on-contact dose rate of 3.3mR/hr. This was a standard MURR package with dimensions of 23 x 16 x 16 cm. The material was packaged in a lead pig 'of.

approximately 0.4 cm in thickness.

(ii) Description of circumstances under which the loss occurred:

(v) Actions taken to recover material:

On September 08, 2022 the package was picked up from the MURR shipping dock by FedEx with intention of Priority Overnight delivery by September 09, 2022 by 10:30AM. A tracking Number of7778 8064 0260 was assigned at this time. FedEx tracking showed that the package arrived in the Memphis TN hub at 11 :35 PM on September 08, 2022. This was the last update for the tracking and the package did not arrive at its delivery destination at any point._

On September 12, 2022 UCSF reported that the material did not arrive and contacted FedEx to track the package with no success. The next day September 13, 2022, additional contact was made with FedEx and an investigation was opened in the FedEx sysf.em with code C-81474891. On September 14, 2022 MURR contacted FedEx and requested a call from the trace agent assigned to the investigation. After not receiving a call from the trace agent MURR again contacted FedEx on September 15, 2022 and was told that the tracking systems were down and that we would need to call back the next day. An additional call on September 16, 2022 was made and this time a contact of the FedEx DG Administration was given and the investigation was escalated. MURR provided the shipping documentation and photos of the package to the DG Admin at this time. On September 19, 2022 FedEx emailed MURR stating that the search for the shipment had already begun however the Memphis Hub performed a search and did not locate the package.

In a final call on September 21, 2022 FedEx stated that they could not locate the package and had ended their search. This was followed up by a letter on September 22, 2022 stating efforts to locate the package were unsuccessful and that FedEx was declaring an end to their investigation.

At this point the package was determined lost.by MURR and the reporting of the event began.

(iii) Statement of disposition, or probably disposition, of the material involved:

Based on discussion with FedEx on this and previous events it is believed that the package was misplaced within the FedEx system. This is likely due to a paperwork error and the package is assumed to be intact at one of the FedEx facilities on the original delivery path. By the time of the reported loss, the material would have undergone decay of multiple half lives and the dose rate on the external of the package would have been lower than that listed on the original shipping paperwork. The package itself was proper!y

October 12, 2022 Page 2 of 4 labeled with information that would easily allow for it to be reported or delivered if discovered in the future.

It is believed that if the package was located by the time of the letter (by any party including FedEx or UCSF) that it would have been reported to MURR..

Discussion with other FedEx users such as the DOE NIDC have confirmed that this is a reasonable assumption to make and that it should not be assumed at this time that the package is outside of the FedEx network.

(iv) Exposure to individuals to radiation, circumstances under which exposure occurred, and possible TEDE to persons:

When the package left the MURR facility the external of the package was measured at 3.3mR/hr. By the time the package was reported as lost to MURR that dose rate would have decayed to less than l.0mR/hr.

In addition, the TI for the package was 0.1 at time of shipment and would have decreased over time. The TI is more representative of dose received to an unknowing member of the public or FedEx team. Using the TI over the life of the isotope the worst-case dose to a member of the public is calculated at 23 mrem which is below the 100 mrem li~it to members of the public. In addition, it is assumed that only trained workers were in contact with the package and the on-contact dose rate would only give a dose of766 mrem over the full decay of the isotopes which is below the worker limit of 5000 mrem. The material was secured within a vial, a sealed lead pig, and a sealed box. Under these circumstances it is unlikely that any t significant dose was received during this event.

No report of exposure has been made to MURR at this time and all numbers calculated above are considered.

conservative worst case based on the assumptions of section (iii) above.

(vi) Procedures or measures that have been, or will be, adopted to ensure against recurrence of loss:

Following this event MURR has worked closely with FedEx and our customers to determine possible paths forward including advanced FedEx tracking and independent tracking. At this time, it was determined that the tracking that was in place for this package was a maximum to what FedEx would be able to provide routinely. Independent tracking systems are_ still being investigated, however the quantity of packages shipped each day by both MURR and FedEx may make this process difficult.

October 12, 2022 Page 3 of 4 Ifthere are any questions regarding this report, please contact me at (573) 882-2582. I declare under penalty of perjury that the foregoing is true and correct.

ENDORSEMENT:

Sincerely, Rev.iewed and Approved,

\\~

• Daniel Doenges J\\David Robertson, PhD Reactor Health Physics Manager Reactor Facility Director

cc: Reactor Advisory Committee Reactor Safety Subcommittee Isotope Use Subcommittee Dr. Thomas Spencer, Interim Vice Chancellor foi* Research and Economic Development Mr. Geoffrey Wertz, U.S. Nuclear Regulatory Commission Mr. Craig Bassett, U.S. Nuclear Regulatory Commission

\\

Attachments:

1. Rob Hall 777880640260

State of Missouri County of Boone

Subscribed and sworn before me this 12th ay of Octob//2022.

UJ/U/(:1_.a STEFANIE A. C My Commission Expires: April 12, 2024

October 12, 2022 Page 4 of 4 Via email hallrm@missouri.edu

September 22, 2022

Rob Hall University of Missouri 1513 Research Park Columbia, MO 65211

Re: FedEx tracking number 777880640260

Dear Mr. Rob Hall:

The situation regarding September 8th, 2022, above-referenced shipment to San Francisco, CA has been brought to my attention.

Customer satisfaction is our primary concern, and we truly regret any inconvenience caused when this shipment was not delivered. Although our tracking scans indicate that the package traveled through Memphis, TN on September 8 th, 2022, we have been unable to track its movement since. Searches of our package-research facility has been conducted; unfortunately, our efforts to locate this have proven unsuccessful.

Mr. Hall, we know our customers expect only the best possible service from our company, and I hope to assure you that this incident is not typical of our quality customer care. Should you have any other questions or concerns about this situation, please contact me at 877-477-3272 ext. 999973, and I would be happy to assist you further.

We appreciate your patience while we work to resolve this.

Respectfully,

~~-~

Sophia D. Wilson Sr. Executive Support Specialist