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| Entered date | Event description | |
|---|---|---|
| ENS 56309 | 12 January 2023 08:26:00 | The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On January 11, 2023, a patient was administered a Y-90 Therasphere treatment to segments 5 and 8 of the liver. The prescribed dose was intended to be 1.377 GBq. The patient only received a dose of 0.903 GBq. At the time of notification, the licensee suspects that a low flow rate caused an occlusion in the catheter, resulting in less than the prescribed dose of Y-90 being administered to the patient. There were no reported adverse effects for the patient. 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. |
| ENS 56284 | 23 December 2022 17:02:00 | The following information was provided by the licensee via email: At 1513 EST on 12/23/22, a Technical Specification required shutdown was initiated at the Davis-Besse Nuclear Power Station Unit 1. Technical Specification (TS) Action Limiting Condition of Operation (LCO) 3.7.9 for Ultimate Heat Sink water level minimum requirements was not met and condition 'A' was entered on 12/23/22 at 1412 EST with a required action to `Be in Mode 3' with a completion time of 6 hours and `Be Mode 5' with a completion time of 36 hours. This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. At 1640 on 12/23/22, the NRC granted enforcement discretion for the shutdown requirements of TS LCO 3.7.9 and the shutdown was terminated with the unit remaining in Mode 1. |
| ENS 56135 | 30 September 2022 17:13:00 | The following information was provided by the licensee via email: At 1608 (EDT) on September 30, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw inside containment detected during plant pressurization in preparation for startup following a refueling outage. St. Lucie Unit 2 was not affected and remains at 100 percent power. This event is being reported pursuant to 10CFR50.72(b)(3)(v)(D). The NRC Resident Inspector has been notified.
The following information was provided by the licensee via email: The purpose of this notification is to retract a previous report made on 09/30/2022 at 1713 EDT (EN 56135). Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage. Subsequent to the initial report, FPL (Florida Power and Light) has concluded that the flaw identified in line 2"-CH-109 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was operable but degraded for the period of concern. Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified. Notified R2DO (Miller). |
| ENS 56132 | 29 September 2022 21:58:00 | The following information was provided by the licensee via email: On Thursday 9/29/2022 at 1605 PDT, SONGS (San Onofre Nuclear Generating Station) notified Cal OES (California Office of Emergency Services) of the Monday, 9/26/2022, NPDES (National Pollutant Discharge Elimination System) oil exceedance. Cal OES # 22-5744. The NPDES oil exceedance concerned a liquid discharge to the ocean from the oily waste sump on Monday, 9/26/2022. It was confirmed to exceed the NPDES permit limits for Total Suspended Solids (TSS) and Oil & Grease (O&G). Actions taken: - Discharge terminated at 1818 on Monday, 9/26/2022. - (The licensee) notified the San Diego Regional Water Quality Control Board via telephone voice mail at 1638 on 9/27/2022 (SDRWQCB acknowledged receipt of the Voice Message at 1755 on 9/27/2022). The total volume of oil and suspended solids that was released was approximately 19 gallons of oil and 25 pounds of solids. There was no significant effect on the health and safety of the public or the environment. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee will notify NRC Region IV inspection staff. |
| ENS 56133 | 30 September 2022 14:19:00 | The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On September 29, 2022, a patient was administered an I-131 treatment to the thyroid. The patient did not receive the additional administration of Thyrogen, a hormone meant to enhance the uptake of I-131 to the thyroid. This resulted in dose delivered to other areas of the body and an underdose to the thyroid of preliminarily greater than 20 percent. Additional preliminary calculations showed that the bladder received approximately 17 Rem and the patient received a whole body dose of 39 Rem. 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. |
| ENS 56080 | 31 August 2022 11:56:00 | A contract supervisor refused to provide a specimen during a fitness-for-duty test. The employee's access to the plant has been terminated. The licensee notified the NRC Resident Inspector. |
| ENS 56063 | 23 August 2022 18:32:00 | The following report was received via email from the Texas Department of State Health Services (the Agency): On August 23, 2022, the licensee notified the Agency that a string of well logging tools containing a 1.5 curie cesium-137 source and a 15 curie americium-241 source was lodged downhole in a well in Starr County, Texas. The sources are at 8,772 foot depth. Efforts to remove approximately 1,800 feet of wireline cable from above the tool were unsuccessful. The abandonment plan has been submitted to the Agency and to the Texas Railroad Commission for review. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: I-9950 |
| ENS 56082 | 31 August 2022 17:03:00 | The following information was received from the Wisconsin Department of Health Services (the Department) via email: On August 31, 2022, the licensee notified the Department that they had lost control of licensed radioactive material. Per the licensee's report, on or about August 10, 2022, four sharps containers with yttrium-90 microsphere waste were inadvertently taken from the licensee's decay-in-storage room and placed in a locked room in the hospital's shipping department for disposal as biohazardous material. On August 15, 2022, the four sharps containers (approximately 60 millicuries of yttrium-90) were picked up by the hospital's biohazardous waste vendor, where they are assumed to have been autoclaved and disposed in a landfill. The licensee became aware of the loss on August 29, 2022. Based on the current activity of the sources (less than 1 millicurie) no attempt will be made to retrieve the material. No members of the public are expected to exceed public dose limits. A Department investigation is ongoing. WI incident no.: WI220020 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 |
| ENS 56034 | 5 August 2022 16:56:00 | The following information was received from the Massachusetts Radiation Control Program (the Agency) via email: Licensee reported employee weekly finger ring exposure exceeding 50 rem (67.569 rem for wear period, 7/4/22-7/10/22) a situation reportable within 24 hours per 105 CMR 120.282 (B) (1) (c). The other finger ring dosimeter worn by the subject employee received 31.509 rem exposure for same wear period. Exact cause of exposure not yet known. Licensee investigation ongoing. Licensee, a radiopharmaceutical manufacturer/distributer, stated that subject employee does perform work involved with F-18 radiopharmaceutical manufacturing operations. The Agency considers this matter still open. MA Event Number: 20-5102
On August 17, 2022, An Agency investigation was performed at the PETNET facility. The inspector determined that the root cause of the event was insufficient training of staff. The licensee submitted sufficient corrective actions to prevent recurrence. The Massachusetts Radiation Control Program considers this incident closed. Notified R1DO (DeFrancisco) and NMSS (email). |
| ENS 56031 | 4 August 2022 16:42:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: On August 4, 2022, this Agency received information that a former licensee was trying to obtain 500 microCi of Am-241 without a license. The material would reportedly be used for calibration. The issue was reported to the appropriate Agency in California because that is where the seller is located. An informal report was made to the NRC in Arlington, Texas. It was decided that this needed to be reported to the FBI which was accomplished on this same day. The seller has reported that they will not provide a quote to the former licensee and hence will not be supplying the material. It is not clear if this is a misunderstanding or an attempt to gain material while bypassing regulations. This Agency will not investigate this matter immediately but will give the FBI some time to investigate. No further information is expected in the near future, but information will be provided when obtained per SA-300. Texas Incident Number: I-9944 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 |
| ENS 56021 | 28 July 2022 15:51:00 | The following information was provided by the Florida Bureau of Radiation Control (BRC) via email: Indian River County (Radiological Emergency Preparedness) (REP) (employee) called this afternoon regarding a small cardboard box, about half the size of a shoebox, with several sources inside being stored in a small, unlocked metal storage shed on property of the Emergency Operations Center. Inside the small cardboard box are six small cylindrical containers three of which are labeled `Unrefined uranium minerals emit alpha, beta, and gamma radiation', one 'No Salt' container, and the other three are smaller metal containers not labeled. Also in the box are several typical plastic check sources inside plastic bags and one wooden gamma standard check source. REP reported an 'on contact' reading with the box a dose rate of around 280 microR/hr and with a gloved hand, removed all the items inside the box and reported a contamination reading of just over 400 cpm. REP has requested a response from the BRC to handle. The Central Inspection Office has been notified and will respond. Florida Incident Number: FL22-086 |
| ENS 56020 | 28 July 2022 15:12:00 | The following report was received via email from the VA National Health Physics Program (NHPP): Tibor Rubin VA Medical Center, Long Beach, California, which holds Permit Number 04-00689-07 under the VA master materials license, reported the discovery of a medical event to NHPP at approximately 1450 CDT, July 27, 2022. A radium-223 dichloride (Xofigo(R)) therapy administration was performed at approximately 1115 PDT on July 27, 2022. The prescribed dosage was 211 microcuries, to be administered intravenously. Due to leakage at the IV 3-way stopcock, approximately only 160 microcuries was administered, resulting in about 75 percent of the prescribed dosage being delivered. This meets the reporting criteria of 10 CFR 35.3045 (a)(1)(i) and (a)(1)(i)(B). The patient and the referring physician have been notified. No harm is expected to the patient. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP notified our NRC Region III Project Manager, Bryan Parker. 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. |
| ENS 56019 | 26 July 2022 16:09:00 | The following is a summary of a phone call with the licensee: On 7/14/22, a patient received more dose than the written prescription for delivery to their bone surfaces. The prescription was for 57.5 microCi of radium-223 and the patient received 184.9 microCi. The patient was intended to receive 184.9 micro Ci, however a clerical error resulted in the prescription only listing 57.5 microCi. 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. |
| ENS 55979 | 6 July 2022 12:20:00 | The following summary was received from the Wisconsin Department of Public Health (the Department) via email: During a recent routine inspection, the licensee told the Department that they disposed all their tritium exit signs in 2021; however, the licensee had no disposal records for six tritium exit signs which were distributed to the licensed location in 2012 and 2017. The licensee has thoroughly searched its facility and nearby buildings owned by the licensee but the signs could not be located. The licensee suspects the signs were discarded when the storage cabinet they were in was repurposed. Five of the signs were Isolite Model SLX60 (s/n 12-14613, 12-14615, 12-14616, 12-14617 and 12-14618, each originally containing 6.2 Ci of tritium). One sign was an Isolite Model 2000 (s/n H76360, originally containing 7.5 Ci of tritium). The Department considers this matter to be closed. Wisconsin Event Report ID No.: WI220013 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 |
| ENS 56022 | 29 July 2022 12:52:00 | The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: On 7/1/22 a 200 microCurie I-125 implant seed was lost. The seed was discovered to be missing on 7/5/22. Licensee staff verified that the seed had arrived in the pathology lab. A survey of the lab was performed and showed that the seed was not in the lab, in the trash, in the sample, and did not remain in the patient. The licensee believes the seed was most likely washed down a drain. 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 |
| ENS 55955 | 22 June 2022 02:26:00 | The following information was provided by the licensee via email: At 2240 on 06/21/2022, it was discovered that both required trains of Control Room Ventilation and Control Area Chilled Water System were simultaneously inoperable; therefore, this condition is being reported as an eight-hour, nonemergency notification per 10 CFR 50.72(b)(3)(v)(d). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The 'B' train was restored at 2315. |
| ENS 55956 | 22 June 2022 08:12:00 | The following information was provided by the licensee via email: The plant is in a safe condition. On June 21, 2022, while performing a routine management observation, an employee noticed that only a single individual was performing the administrative actions required to implement both (items relied on for safety) IROFS 50b and IROFS 50c. These IROFS are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61. Since only one individual was performing the administrative action, the independence of the IROFS was not being maintained and the performance requirement of 10 CFR 70.61 was not being met. At the time of the event, there were not any heavy vehicles that threatened damage to equipment. (Urenco USA) (UUSA) is reporting this event per 10 CFR 70. Appendix A(b)(2). All work that requires utilizing person(s) to control the proximity of vehicles to equipment that could release UF6 has been stopped. This issue has been entered in UUSA's corrective action program as EV 152996. The licensee will notify the NRC Regional inspector. |
| ENS 56017 | 26 July 2022 12:21:00 | The following summary was received from the Colorado Department of Public Health and Environment via email: The Colorado Department of Public Health and Environment reported four Speclite model TP10 exit signs, containing 6.5 Curies of tritium each, lost by the licensee. The incident occurred June 8, 2022. CO Event Report ID no.: CO220024 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 |
| ENS 55840 | 12 April 2022 19:47:00 | The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email: The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045. California Event Number: 041222 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. |
| ENS 55842 | 13 April 2022 13:10:00 | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: The Radiation Safety Officer for Northwestern Memorial HealthCare, contacted the Agency on 4/12/2022 to advise of a Y-90 microsphere administration in which the patient received only 70 percent of the prescribed dose. Of note, the (authorized user) noticed sluggish flow during the first flush of saline through the device, possibly due to a kink in the micro catheter as it exits the base catheter. No contamination or other issues were identified. No adverse patient impacts are expected. The (authorized user) was satisfied that the dose was adequate as delivered and will assess with MRI in 1 month as per protocol. The Agency will dispatch inspectors to review procedures and determine a root cause. Item Number: IL220012 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. |
| ENS 55850 | 20 April 2022 09:36:00 | The following is a synopsis of an email received from the state of Georgia: On April 14, 2022, the state of Georgia received the following complaint from the licensee's Assistant Radiation Safety Officer (ARSO): the licensee had a shipment of Y-90 seeds that was supposed to be delivered from Sirtex on the morning of April 11, 2022 for a procedure. The package did not arrive. The ARSO was notified on April 12, 2022 and reported the information to the state of Georgia on April 13, 2022. The package contained 81 milliCi of Y-90 spheres. The ARSO was unable to obtain any information about the location of the shipment from the common carrier. Georgia Incident Number: 53
The following is update was received from the state of Georgia via email: On April 25, 2022, Georgia received notice that the package had been located and is being returned to Sirtex. Georgia has closed the incident. Notified R1DO (Young) and ILTAB and NMSS Events Notification 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 |
| ENS 55833 | 11 April 2022 11:20:00 | The following was received via an email from the state of North Carolina: A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box. An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report. North Carolina Tracking Number: 220003. 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 |
| ENS 55836 | 11 April 2022 21:01:00 | The following information was provided by the licensee via email: The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard. Name and address of the individual informing the Commission: Camille T. Zozula Westinghouse Electric Company 1000 Westinghouse Drive Cranberry Township, Pennsylvania 16066 (412) 374-2577 zozulact@westinghouse.com Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018. The (FVRs) are designed and qualified to open and close on demand. The FVR contactors sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position. Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related FVR contactors that are potentially affected between 2014 and 2022. Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022. Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding. Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available. Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts. Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022. The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event. Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements. |
| ENS 55803 | 28 March 2022 04:45:00 | The following event was received from the South Carolina Department of Health (the Department) via email: On 3/27/2022, the Department was notified by the licensee's (radiation safety officer) RSO that one of its fixed gauges was damaged during a fire at the plant. The fixed gauge is a TN Technologies Model 5206 containing 200 mCi of Cs-137. The licensee took radiation readings around the gauge and has contacted System Services. Systems Services is arriving on the evening of 3/27/22 to service the gauge. The licensee's radiation readings were 3 mR/hr on the surface of the bottom of the gauge, 250 mR/hr on the top of the gauge. The licensee also took a radiation reading on the walkway three feet above the gauge and the reading was 0.3 mR/hr. The licensee also took a reading at the bottom of the ladder, and it was 0.1 mR/hr. The licensee has barricaded roped off areas on the walkway and at the bottom of the ladder. The gauge is located approximately 12 feet off the floor and is not readily accessible by employees. |
| ENS 55795 | 18 March 2022 16:45:00 | The following was received via email from the Massachusetts Radiation Control Program: At 1338 EDT today (3/18/2022), QSA Global, Inc. contacted the Radiation Control Program to report a potential missing package containing radioactive material. The package is a QSA Global 880 source changer and overpack containing a single Ir-192 source with an activity of 6.6 curies (assay date 2/15/2022), (serial number) SN: 31468M. The 880 source changer SN is C010. The package was shipped via common courier from Acuren Group, Inc. in Edmonton, Canada on February 15, 2022. On March 3, 2022, package was scanned at the common courier terminal in Memphis, TN (last known location). On March 9, 2022, Acuren contacted QSA Global, Inc. in Baton Rouge, Louisiana to inform them that the package could not be located. On March 11, 2022, Acuren contacted QSA Global, Inc. in Louisiana and the common courier for a status. The common courier initiated a search on March 11, 2022, that included the common courier main hub in Memphis, TN. The package could not be located. At 0930 EDT this morning (3/18/2022), common courier contacted the QSA Global Baton Rouge office and notified them that the package could not be located. At 1206 EDT today (3/18/2022) the Baton Rouge office contacted QSA Global, Inc. in Burlington, MA to notify them of the missing package. The Massachusetts Radiation Control Program considers this event as open pending further investigation.
The following received via email from the Massachusetts Radiation Control Program: Upon Agency (Massachusetts Radiation Control Program) discussion with state of Tennessee, who had contacted the common carrier's Dangerous Goods Administration, the carrier reported on March 22, 2022, the package to be located at the carrier's Custom clearance area at its hub in Memphis, TN and the package is not missing. Notified R1DO (Jackson) and NMSS Events Notification, ILTAB, and CNSNS via email. THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 55783 | 11 March 2022 11:37:00 | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted on 3/11/22, by the Radiation Safety Officer for Heuft USA, Inc to advise that a package scheduled to arrive at their Downers Grove, IL facility on or before 3/10/22, had not arrived. This was reported as missing in transit. The 6"x6"x6" excepted package contains approximately 86 mCi of Am-241. The carrier could not immediately locate the package and advised it had not been checked into any of their processing facilities. Last known location was an industrial facility (S.C. Johnson) in Sturtevant, WI on 3/3/22, when it was packaged for transit and picked up by the carrier. The package contained (2) special form model AMC-25 sealed sources containing approximately 43 mCi of Am-241 each. Source serial numbers were 3676CW and 7256LQ. Both sources were contained in the 6"x6"x6" brown cardboard box. As it is an excepted package, it will bear only the terms `UN2910' and `RQ' (reportable quantity), and not radioactive labels. Should the package be opened, there is an aluminum 5"x5" round can filled with foam and two zip lock bags. Each bag contains a shielded source holder with the Am-241 capsules therein. The bags and the can are labeled with a trefoil and the words `Radioactive Material'. Unshielded, the two sources would yield a combined exposure rate of about 15 mR/hour at one foot. This is not an immediate hazard to workers or members of the public that locate the package. There is no indication of intentional theft or diversion. Item Number: IL220009 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 |
| ENS 55794 | 18 March 2022 12:01:00 | The following is a synopsis of an email received the Georgia Radioactive Materials Program (the department): On March 10, 2022, the department received an email from the licensee's radiation safety officer (RSO), reporting a failed shutter on one of their sealed nuclear sources that occurred during their routine, semi-annual gauge inspection. The gauge contained 5 mCi Cs-137. The licensee performed a surface survey with readings in a 1 ft. radius. The readings ranged from 0.01 mR/hr to 0.1 mR/hr. The licensee also performed a leak test with results still pending. The licensee plans to dispose of the faulty gauge. No one was exposed during this incident. Georgia Incident Number: 51 |
| ENS 55759 | 1 March 2022 10:17:00 | The following information was provided by the Texas Department of State Health Services (the Agency) via email: March 1, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that the shutter on a Vega model SHLD-1 gauge was stuck in the closed position. The gauge contains a 100 millicurie (original activity) cesium - 137 source. The gauge was tested while it was on the side of a vessel and functioned normally. The gauge was removed from the vessel and during that process the shutter was damaged and will no longer open. The gauge has been placed in storage. The manufacturer was contacted, and repair parts have been ordered. The RSO stated no individual received any additional exposure due to the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9919 |
| ENS 55740 | 16 February 2022 10:38:00 | The following report was received from the Pennsylvania Department of Bureau Radiation Protection (the Department) via email: The Department (DEP) received notification from a licensee on February 15, 2022, of medical event involving dose to an incorrect treatment site. An Elekta/Nucletron Remote Afterloader containing 6.421 Curies of iridium 192 (serial number V3/ 10799) with a Valencia skin applicator was to treat the lower third nasal dorsum with 600 cGy. However, the prescribing physician specified the right nasal sidewall. Therefore, the patient received 600 cGy to her lower 3rd nasal dorsum and not right nasal sidewall. The patient and prescribing physician were informed on February 14, 2022. The patient is being monitored and at this time no adverse effects are evident. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided. Pennsylvania Event Report Number: PA220007 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. |
| ENS 55726 | 3 February 2022 11:04:00 | The following was received from the state of Texas (the Agency) via email: On February 3, 2022, the Agency was contacted by the licensee's service company and notified that while removing a Vega SH-F1B nuclear gauge from its mounted position it was dropped about 2 feet and the operating arm for the shutter was bent. The shutter was locked in the closed position and remained closed. The gauge contains a 20 millicurie (original activity) cesium - 137 source. Dose rates taken on the gauge housing after the gauge was dropped were normal. A leak test was performed on the source and the results were satisfactory. The gauge was placed in storage. The manufacturer is being contacted to repair the gauge. No overexposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # I-9909 |
| ENS 55784 | 11 March 2022 15:17:00 | The following is a synopsis of information received via facsimile: Three defects were identified on an N7030 temperature transmitter, and all sub-models, manufactured by Ultra Energy. The first two defects were identified during product testing and are dependent on component tolerances and fabrication, these may not exist in all units. The third defect was identified during the safety investigation. First, for transmitters configured to indicate a failed resistance temperature device (RTD) via an over-range signal, the transmitter could return an in-range reading when operating at a temperature near the bottom of the specified temperature range. Second, for transmitters configured to indicate a failed RTD via an under-range signal, the transmitter could return an in-range reading when operating near the bottom of the specified loop voltage range. Third, transmitters with a disconnected RTD could output noise in the presence of very high impedance (mega-ohm range) at the input terminals and in specific narrow temperature ranges (less than 10 degrees Celsius). The first two defects could cause a sensor, which had failed, to appear to be functioning, although the reading would likely be obviously false and thereby highly unlikely to result in any risk to safety. The third condition might, depending on sensor noise filtering, result in a false temperature reading which was not obvious. This however requires multiple parameters to be in the correct ranges to trigger the latent defect and is also highly unlikely to result in any risk to safety. Corrective actions include: a reduction in specified operating temperature and loop voltage range, a field fix for the high impedance condition, and supplying impacted facilities with an engineering bulletin. Additionally, devices in the process of being manufactured have been segregated and will be scrapped. Design modifications will be made prior to continuing manufacturing these temperature transmitters. The facilities listed as being impacted are: Oconee Nuclear Station, Quad Cities NPS, and Prairie Island Nuclear Generating Plant. Contact Gary Hawkins , Vice President Engineering, or Diane Steen, Director of Quality, with questions. (512) 434-2800. Ultra Energy 707 Jeffrey Way P.O. Box 300 Round Rock, Texas 78665 |
| ENS 55673 | 24 December 2021 14:32:00 | The following was received from the Tennessee Division of Radiological Health via email: A dozer ran over a density gauge at a construction site in Oneida, TN. Source was in the shielded position. Licensee was able to fit gauge back into the case and return to their facility. Corrective actions will be updated with a report within 30 days. The gauge contains a 40 mCi Am:Be-241 and an 8 mCi Cs-137 source. State Event Report ID Number: TN-21-120 |
| ENS 55670 | 22 December 2021 20:52:00 | The following information was received from the state of Kansas via email: Initial notification from State of KANSAS that we have a radiography licensee reporting that they have a source that is unable to retract. The licensee is a fixed radiography licensee and the source is exposed inside one of their main shops. The shop is not occupied, their (standard operating procedure) (SOP) is to have radiography work after hours when the work spaces are vacant. The area is secured by the radiographer/(assistant radiation safety officer) (ARSO) and his assistant. It appears the stand the guide tube was on fell (and) it is assumed the tube was damaged by the fallen stand. This is an initial report, more information will follow. The device contains a 24.8 Ci selenium-75 source. |
| ENS 55729 | 4 February 2022 10:30:00 | The following was received via email from the Massachusetts Radiation Control Program: On 01/18/22 the Massachusetts Radiation Control Program (the `Agency') received a telephone report of a missing shipment of radioactive material. The package contained 28 mCi of S-35 (half-life of 87.3 days) in liquid form, in 4 vials at 0.561 mL per vial, in one White-I package, and was sent by PerkinElmer, Inc. (the `licensee') to Associated Regional and University Pathologists, Inc. (the `customer') via (common courier). The package was sent from the licensee on 12/15/21 and tracking information showed it arrived at the courier's facility on 12/16/21 but never left. The customer notified the licensee on 12/21/21 that they never received the package. The licensee was periodically contacting the courier for status updates in an attempt to recover the package. The licensee informed the courier of the importance of maintaining custody of radioactive material shipments until they are delivered. On 02/02/22 the licensee notified the Agency that their internal investigation to locate the package was closed and that the licensee considers the package lost for good. The licensee estimates that no person received greater than 1 mrem TEDE (total effective dose equivalent) as a result of the missing package. The Agency considers this event to be closed. 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 |
| ENS 55667 | 20 December 2021 21:52:00 | The following information was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email: On 12/17/2021, the licensee notified RHB of an incident in which an INC IR-100 (S/N 7362) radiography exposure device, containing a 54.2 Ci Ir-192 QSA Global source (S/N 55806M), failed to actuate its safety latch plate upon retracting the Ir-192 source to the fully shielded position. The incident occurred on 12/16/2021, at approximately 1900 PST, at the PBF refinery in Martinez, CA. The radiography site was approximately 150 ft. above grade, on temporary staging, and accessed by an adjacent permanent deck. The RSO ((radiation safety officer)) stated that the device was used all day without issue prior to the safety latch plate's actuation failure. The initial personnel during the incident consisted of a radiographer trainer and an assistant radiographer. The radiographer trainer noticed the failure when attempting to 'crank out' after fully retracting the source. After attempting to fully retract the source, the latch plate maintained a visibly depressed position and the source was not fully secured and free to move. The radiography trainer contacted the RSO for further assistance during which an additional radiographer trainer assisted with maintaining security of the barricaded area until the RSO and staff arrived on the site. The RSO stated that he was able to secure the source by flushing the locking mechanism with brake cleaner and that there was no excessive exposure to any personnel involved. RHB will be investigating this incident further. CA 5010 Number: 121721 |
| ENS 55652 | 15 December 2021 20:53:00 | The following is a summary from a phone call with the licensee: At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.
The following retraction was received from the licensee via email: On December 15, 2021, (the licensee reported) telephonically about a leaking radium-226 source at the TS-1 site at Kirtland AFB, which prompted a radioactive material incident report. After further examination, the suspected radium dial was identified as a `Delco-Remy Ignition Unit.' Upon re-surveying the unit, only background readings were identified. Due to the newly discovered information, the ((Radioisotope Committee Secretariat)) RICS and Kirtland AFB request to retract the incident. Notified R4DO (Josey) and NMSS Events Notification via email. |
| ENS 55643 | 14 December 2021 15:38:00 | The following is a summary of a phone call with the licensee: A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
The following is a summary of a phone call with the licensee: Following discussions with an NRC inspector, the licensee determined that the correct activity had been implanted into the correct area. As such, a medical event did not need to be reported and the licensee retracted the event. Notified R4DO (Roldan-Otero) and NMSS Event Notification. 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. |
| ENS 55647 | 15 December 2021 14:08:00 | The following was received from the Tennessee Division of Radiological Health via email: A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational. Corrective actions will be updated with a report within 30 days. The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source. State Event Report ID Number: TN-21-116 |
| ENS 55650 | 15 December 2021 15:48:00 | The following was received from the Tennessee Division of Radiological Health via email: During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows: Manufacturer: BEST Model: 2301 Isotope: I-125 Activity: 1.6 mCi Corrective actions will be updated with a report within 30 days. State Event Report ID Number: TN-21-117 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 |
| ENS 55628 | 6 December 2021 18:30:00 | The following was received from the Massachusetts Radiation Control Program (the Agency) via email: On December 6, 2021 at 1435 EST the Massachusetts Radiation Control Program received a call from the (Radiation Safety Officer) RSO at Amherst College reporting a leaking sealed source. The source is an open-window reference source (RM Corp, s/n R8023) containing 0.001 milliCi of Am-241 and the RSO believes he accidentally wiped the window while collecting the leak test sample of the source, the analysis of which showed 0.0908 microCi of removable activity which is in excess of regulatory limits. The RSO collected the leak test sample on November 29, 2021 at 0930 EST and sent it the same day to RSCS, Inc. for analysis. The leak test results were transmitted to the RSO by email on December 2, 2021 but the RSO was on vacation from December 2 through December 3 and was unable to review the email. The RSO was back at work on December 6, 2021 and reviewed the email at 1230 EST due to previous work commitments in the morning. The area where the source was handled was surveyed and no contamination was found. The RSO assumes the source window was damaged due to being wiped therefore the source will be secured and properly disposed of in accordance with the regulations. The Agency considers this event open. Massachusetts Event Number: TBD |
| ENS 55626 | 6 December 2021 17:17:00 | The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73. At 1203 MST on December 6, 2021, the Unit 3 reactor automatically tripped on low departure from nucleate boiling ratio. A part-strength control element assembly was being moved at the time of the trip. Unit 3 is stable and in Mode 3. In response to the reactor trip, all control element assemblies inserted fully into the core. Safety-related electrical power remains energized from off-site power sources and reactor coolant pumps continue to provide forced circulation through the reactor. Decay heat is being removed by the steam bypass control system and main feedwater system. Required systems operated as expected. No emergency classification was required per the Emergency Plan. The NRC Senior Resident Inspector has been informed. Units 1 and 2 were unaffected by this transient. |
| ENS 55620 | 2 December 2021 13:36:00 | This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided in 30 days. On November 10, 2021, Callaway Plant received written notification from Paragon Energy Solutions, LLC, pursuant to 10 CFR 21.21(b), which identified a deviation associated with the DC/DC converter in two power supplies, NLI-STM15-15M20 (15 VDC) and NLI-STM48-14M20 (48 VDC) that had been sent to Paragon for evaluation and failure analysis following failures of individual components within the power supplies at Callaway Plant. The notification identified the following failed components: For the NLI-STM15-15M20 (15 VDC) power supply, the failed components were the Vicor Module, P/N: V150A28C500BL, and the DC/DC Converter, Murata P/N: NKE1212SC, Date code: G1511 For the NLI-STM48-14M20 (48 VDC) power supply, the failed component was the DC/DC Converter, Murata P/N: NKE1212SC, Date code: G1511 Fourteen of these power supplies (in total) are used in three Balance of Plant Engineered Safety Feature Actuation System (BOP-ESFAS) cabinets and two Load Shed and Emergency Load Sequencer (LSELS) cabinets. Based upon the 10 CFR 21.21(b) transfer from Paragon Energy Solutions, Callaway Plant has determined that a Substantial Safety Hazard could be created by the failure of the power supplies. The responsible officer was notified on December 1, 2021. The NRC Resident Inspector at Callaway Plant has been notified. |
| ENS 55618 | 1 December 2021 17:10:00 | The following was received from the Arizona Department of Health Services (the Department) via email: On November 30, 2021, the Department received notification from the licensee of a leak test (0.0129 microCi) that exceeded the regulatory limit of 0.005 microCi. The licensee is going to return it to the manufacturer for repair. The Department has requested additional information and continues to investigate the event. Particle Measurement System, Inc. Air Sentry II Ion Mobility Spectrometer unit SN# 59369 Cell SN5935 10 mCi of Ni-63 Arizona Incident Number 21-011 |
| ENS 55621 | 2 December 2021 18:12:00 | The following was received from the Arizona Department of Health Services (the Department) via email: On December 1, 2021, the Department was notified by the licensee of one missing I-125 radioactive seed for breast tumor localization. According to the licensee, one IsoAid Advantage I-125 breast localization seed (approximately 0.4 mCi) was removed by surgery on 11/30/2021 and was verified to be included in the specimen. The specimen with the seed was delivered to pathology on the afternoon of 11/30/21. When a nuclear medicine technologist went to retrieve the seed from pathology, the technologist noticed only a marker and not an actual seed. Nuclear Medicine performed surveys of pathology, pathology staff, the operating room and hallways leading from surgery to pathology. The licensee was unsuccessful in locating the missing I-125 seed. The Department has requested additional information and continues to investigate the event. Arizona Incident Number 21-012 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 |
| ENS 55708 | 21 January 2022 10:25:00 | The following information was provided by the licensee via email: This telephone notification is provided in accordance with 10 CFR 50.73(a)(1) to report an invalid actuation of secondary containment relays in accordance with 10 CFR 50.73(a)(2)(iv)(A). On November 29, 2021, the `B' Fuel Pool radiation monitor spiked high during restoration following the performance of the 0068 procedure `Spent Fuel Pool & Reactor Building Exhaust Plenum Monitor Calibration' due to cable to radiation monitor connector degradation from handling. This resulted in a Partial Primary Containment Group II isolation (gas systems), initiation of Standby Gas Treatment system, and isolation of the Reactor Building Ventilation system. All systems responded as designed to the actuation signal. Operations reset the Partial Primary Containment Group II isolation signal, shutdown Standby Gas Treatment System, and restored Reactor Building Ventilation system per procedures. At the time of the occurrence, the `A' Fuel Pool radiation monitor was reading normal at approximately 1.5 mr/hr. The `B' Fuel Pool radiation monitor spiked above the 50 mr/hr setpoint and continued to read erratically. Work was performed to clean and reconnect the connector and testing per 0068 procedure verified the condition was corrected. The `B' Fuel Pool radiation monitor returned to service. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. |
| ENS 55613 | 29 November 2021 10:24:00 | The following was received from the Virginia Department of Health, Radioactive Materials Program (the agency) via email: On November 24, 2021, the agency was notified by the (radiation safety officer) at the University of Virginia, by email at 1347 EST and by phone at 1355 EST, that a medical event involving an HDR (high dose rate brachytherapy) had occurred that day. During a prostate HDR Iridium-192 case, the patient was treated without any issues through the first channel. At the start of the second channel run, an error was received indicating that the source position slipped while at the 0.0 cm mark. The procedure was paused with no treatment to the patient through the second channel. A dummy wire test was run with no errors indicated. A second attempt at treatment with the source through the second channel was made and the same position error was indicated. The treatment was cancelled at that point. Having only received the first channel treatment, the patient received less than 5 percent of the total prescribed dose. The HDR unit is a Varian VariSource iX, serial number V3509. The source is an Alpha Omega Iridium-192, serial number 02-01-3798-001-191421-11617-25 with a current activity of 5.98 Ci. The licensee contacted Varian and stated that they believe it is likely an issue with the afterloader itself. The source was verified to be in the unit and no additional exposure to the patient or staff was received from the event. The licensee is working with Varian to schedule a repair visit. This report will be updated when the licensee submits their final investigation report. Virginia Event Report ID No.: VA-21-0007 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. |
| ENS 55653 | 16 December 2021 13:04:00 | The following is a summary of a phone call with Lester E. Cox Medical Center: On November 23, 2021, the licensee was performing a radiography procedure on a patient's lymph node. The procedure involved the use of a Co-57 marker rod source, approximately 13.1 microCi. During the procedure the shielding cap was removed, reference mark was made, the cap was replaced, and the rod was placed back onto a medical cart. At some point following the procedure the licensee recognized that the source was missing. A search of the lab, linen area, and trash was conducted and did not identify the missing source. 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 |
| ENS 55588 | 17 November 2021 17:23:00 | The following was received from the Wisconsin Radiation Protection Section (the State): On November 17, 2021, the licensee reported to the State a medical event involving Y-90 SIR-Spheres that was discovered that same day and occurred on November 16, 2021. Two administrations were prescribed to different segments of the left lobe of the liver, one of 0.4 GBq and one of 1.6 GBq. A calculation error occurred while converting these doses from GBq to milli-Ci which resulted in administered doses of 0.51 GBq and 2.3 GBq respectively; both of which are 27 percent above prescription. The State will continue to follow-up on the event. No deleterious effects to the patient are expected. All dose was delivered to the intended organ. Wisconsin Event Report ID Number: WI210008 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. |
| ENS 55562 | 5 November 2021 12:24:00 | The following was received from the Louisiana Department of Environmental Quality (DEQ) via email: Louisiana DEQ was notified by Source Production & Equipment (SPEC) Radiation Safety Officer, via the DEQ Radiation Hotline at approximately 1045 CDT on November 5, 2021, concerning an industrial radiography camera shipment from Nigeria. According to the RSO, Dynaquest Energy Limited in Nigeria wanted to exchange three Industrial Radiography Ir-192 sources. When the package was received, two of the drums had the Industrial Radiography cameras (SPEC 150) and the other drum did not have a camera just the unshielded source. The unshielded source was in the type B container without a camera. The source is an Ir-192 with 0.06987 Ci. The reading on the side of the drum was 300 mR/hr and the reading from the top of the drum with the lid off was 40 - 50 mR/hr. SPEC retrieved the source and put it in a shield. The individual that was handling the package and retrieval received 5 mR exposure. The two cameras were a SPEC 150 (s/n 2619) with Ir-192 source s/n AF2815 and SPEC 150 (s/n 2618) with Ir-192 source s/n AF2814 and were locked. SPEC 150 (s/n 2618) did not have a locking cap on it even though the camera was locked. SPEC stated that they will hold on to the devices and terminate their relationship with Dynaquest Energy Limited. Louisiana Event Report ID Number: LA 202100010 |
| ENS 55561 | 4 November 2021 09:12:00 | A non-licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified. |