Event Notification Report for April 19, 2023

EN Revision Imported Date: 4/19/2023

EN Revision Text: AGREEMENT STATE REPORT - POTENTIALLY DAMAGED GAUGE

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

"At 1730 CST on 2/23/2023, the IEMA was contacted by the radiation safety officer (RSO) for Rubino Engineering to advise of a portable moisture/density gauge involved in an accident at a temporary jobsite. Reportedly, a Troxler 3400 series gauge was in use at a construction site in Maple Park, IL when it rolled down an embankment and was struck by a skid steer. The licensee's technician remained on scene and assessed minor damage to the case. The source rod was not extended at the time of the accident. Both sources were reported as intact and the area secured until the RSO could arrive within an hour with a survey meter. No exposure concerns were reported or anticipated. The RSO arrived on site approximately an hour later to assess, survey, package, and return the device to safe storage. The IEMA advised that they were available to respond if contamination was suspected or if there were complications in retrieving and returning the sources to storage. At approximately 1900, the RSO advised IEMA that the device had been returned to storage. Surveys of the device and source holders were consistent with an undamaged device.

"On 2/24/2023, IEMA inspectors initiated a reactionary inspection to verify the presence of both sources, assess for removeable contamination, advise on proper return of the unit to the manufacturer, determine root cause of the incident and evaluate compliance with IEMA regulations. Updates from that inspection, as well as specifics on the device serial number and sources will be provided once available."

Illinois Item Number: IL230005

* * * UPDATE ON 4/18/23 AT 1326 EDT FROM IEMA TO SAM COLVARD* * *

"On 2/24/23, IEMA inspectors performed a reactionary inspection and verified the presence of both sources. An assessment for removeable contamination was performed with negative results. Inspectors advised on the proper return of the unit to the manufacturer and verified the package TI [Transport Index]. No items of non-compliance were identified as the licensee met license and regulatory requirements. The root cause was determined as ill-advised placement of the gauge on filter fabric (near the edge of a hill) which got pulled by a skid steer while backing at the bottom of the hill causing the gauge to tumble down the hill in the path of the backing skid steer.

"The licensee advised that corrective actions included advising gauge users regarding placement of gauges near any edge while at a field site and discussion on modification of field use procedures to place the gauge back in the transport container during lapses between testing.

"This matter may be considered closed pending satisfactory sealed source leak test results from the manufacturer upon return of the gauge to Troxler and the licensee's required written report per 340.1230(b)."

Notified R3DO (ORTH), and NMSS Events Notification (E-mail).

EN Revision Imported Date: 4/19/2023

EN Revision Text: AGREEMENT STATE REPORT - LOST PACKAGES

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

"The Agency [Illinois Emergency Management Agency] was notified the evening of 3/16/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of two radiopharmaceutical packages that were missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and both have been declared as lost. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. TN and TX program officials have been notified as well. Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC [Nuclear Regulatory Commission] with a required call to the NRC Headquarters Operations Officer (HOO). Details on the packages are as follows:

"Package 1:
[The package] shipped 3/8/23 to Doctor's Hospital at Renaissance in Edinburg, TX. [The package] contained (1) 10mL shielded vial of I-123. Package activity at the time of shipment was 14.3 mCi. [The package contains] 0.0002 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 2247 CDT on 3/8/23. GE Healthcare contacted the customer and confirmed that the package was not received.

"Package 2:
[The package] shipped 3/10/23 to Panhandle Nuclear in Amarillo, TX. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package contains] 0.585 mCi of activity as of 3/17/2022 at 1500 EDT. The last scan occurred 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received."

IL Event Number: IL230007

* * * UPDATE ON 04/18/23 AT 1220 EDT FROM GARY FORSEE TO JOHN RUSSELL * * *

"As of 4/17/2023 the packages remain lost. No additional information has been provided by the carrier. The packages have decayed to background and do not represent a public safety hazard. This report will be updated with any new information but is otherwise considered closed."

Notified R3DO (Orth), NMSS Events Notification, and ILTAB 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: 4/19/2023

EN Revision Text: AGREEMENT STATE REPORT - LOST PACKAGES

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

"Shortly after reporting the first two missing packages (see EN56418), the Agency was contacted on 3/17/23 by General Electric (GE) Healthcare in Arlington Heights, IL to advise of a third radiopharmaceutical package that went missing in transit. The last known location was the carrier hub in Memphis, TN. The carrier has advised efforts to locate the packages have ceased and the package was declared as lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. TN and AL program officials were notified. Details are provided below.

"Package Details:
[The package] shipped on 3/10/23 to Cardinal Health in Birmingham, AL. [The package] contained (1) 10mL shielded vial of In-111. Package activity at the time of shipment was 3.2 mCi. [The package] contains 0.563 mCi [as of 3/17/2023, 1647 EDT]. The last scan occurred at 0009 CDT on 3/11/23. GE Healthcare contacted the customer and confirmed that the package was not received.

"Additional details will be provided as they become available. This matter has a 30-day reporting requirement to the NRC with a required call to the NRC Headquarters Operations Officer."

IL Event Number: IL230008

* * * UPDATE ON 04/18/23 AT 1220 EDT FROM GARY FORSEE TO JOHN RUSSELL * * *

"As of 4/17/23 the packages remain lost. No additional information has been provided by the carrier. The packages have decayed to background and do not represent a public safety hazard. This report will be updated with any new information but is otherwise considered closed."

Notified R3DO (Orth), NMSS Events Notification, and ILTAB 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

MEDICAL EVENT - DOSE RECEIVED GREATER THAN PRESCRIBED

The following information is a synopsis of information provided by the licensee:

This event occurred at Community Health Network, North Hospital on 4/10/2023 and the error was discovered at approximately 12:00 p.m. [EDT].

This procedure involved a split dose, so the patient received two separate doses in two separate locations in the liver. Hospital personnel use a spreadsheet to help with calculations while drawing the dose and to determine the administered activity after the procedure. Hospital personnel had two spreadsheets due to the split dose. When the radiation safety officer (RSO) was completing the worksheets after the procedure, she noticed that the Grays (Gy) delivered on one of the doses was much higher than anticipated. When the RSO reviewed the worksheet, she realized that she had a typo in the prescribed activity in the worksheet and did not catch it prior to administration. Typically, the physician will fill out the written directive with giga-becquerel (GBq) and the RSO would enter millicuries (mCi) in parentheses, since the dose calibrator reads in mCi. Although the worksheet converts dose, this helps as a double check when completing the written directive. In this case, the RSO had not entered mCi, only GBq and did not catch that the second dose was much higher than the prescribed activity. If the RSO had entered the mCi on the written directive (WD) as per usual, she would have caught that this dose was higher than prescribed.

Initial corrective action will be to enter both GBq and mCi on the WD and give both versions of activity when doing the patient identification at the beginning of the procedure with the physician.

The physician was notified immediately and she was notifying the patient. At this time there is not expected to be any detrimental effects to the patient.

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

The prescribed first dose was 43.2 mCi of Y-90 SIR-Spheres, 63.2 mCi was delivered. The prescribed second dose was 18.9 mCi and 20.8 mCi was delivered.

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 - STUCK OPEN SHUTTER (REPAIRED)

The following information was provided by the Ohio Department of Health via email:

"On 3/3/23, the general licensee discovered a generally licensed device [used for package content measuring] with a failing source shutter, or the 'open-close' mechanism, was likely failing in the open position during scheduled internal routine inspection. The receiver portion of the device demonstrated radiation readings were present in the bridge opening when the shutter should have be closed and reading no presence.

"The manufacturer was contacted and the device was taken out of service per the manufacturer's advice regarding the regulations. On 3/21/23, the manufacturer arrived on site, repaired the shutter device, and conducted a survey of the device to ensure the shutter was closing properly after repairing. The survey after the repairs, showed that even with the shutter open, outside the direct beam, annual radiation levels would be less than 100 mrem per year.

Device Manufacturer: Heuft
Device Model: 45US
Device Serial Number: 9KG005979
Source Model: AMC.25
Source Serial Number: 2097LQ containing 40 mCi of Am-241 assayed 3/28/2000

"Note: Initial report made on 4/7/23, by manufacturer to Illinois Agreement State program which passed along to Ohio program. When contacted by Ohio on 4/11/23, the general licensee expressed they were unaware of the requirement to report. General licensee was instructed as to the requirements and they submitted report on 4/12/23."

Ohio Event Item Number: OH230006

SINGLE TRAIN OF LOW PRESSURE CORE SPRAY INOPERABLE

The following information was provided by the licensee via email:

"At 0246 CDT on April 17, 2023, it was discovered that the single train low pressure core spray system was inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). All other emergency core cooling systems remained operable during this time period.

"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:

LaSalle Unit 1 is in a 7 day limiting condition for operation.

RCS PRESSURE BOUNDARY DEGRADED

The following information was provided by the licensee via email:

"At 1112 EDT on 4/15/23, it was determined that the [reactor coolant system] RCS pressure boundary does not meet ASME Section XI, Table IWB-341 0-1, `Acceptable Standards,' due to through wall leak of the flux mapper seal table guide tube H-6. Corrective actions have been scheduled. `This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A).

"A follow-up review of the condition revealed that 10 CFR 50.72 notification was applicable within 8 hours of the time of discovery on 04/15/23.

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 4/20/2023

EN Revision Text: AGREEMENT STATE REPORT - INDIVIDUAL EXPOSED TO RADIOACTIVE MATERIALS

The following event was received by the New York State Department of Health [the Department] via email:

"On 8/15/22, the Radiation Safety Officer of NRD, LLC notified the Department that an individual may have been exposed to radioactive materials. At approximately 1145 EDT, the continuous air monitoring system located in the Rolling Room area of the Isotope Production Lab triggered an alarm. All associates immediately exited the lab per established protocol. Nasal smears were collected and accounted for all six lab personnel. With exception of one individual, all other personnel's nasal smear results were below the facility's 500 dpm [disintegrations per minute] threshold. One individual produced a nasal smear reading of 725 dpm in the left nostril and 781 dpm in the right nostril. This employee was instructed to blow their nose twice and a second nasal smear test was performed. The nasal smear readings were 27 dpm and 30 dpm respectively. Blank samples that were counted along with the nasal smears were 39 dpm and 7 dpm respectively.

"The effected individual was removed from working with radioactive material and has begun a 24-hour bioassay collection. A root cause investigation into the cause of the air alarm and the positive nasal smear is underway. The air monitor filter paper was replaced and the activity displayed on the continuous air monitor system returned to normal levels, indicating that the cause of the alarm was a very short duration event."

New York Event Number: NYDOH-22-4

NMED Number: 220369

* * * UPDATE ON 4/19/23 AT 1054 EDT FROM DANIEL SAMSON TO ADAM KOZIOL * * *

The following update was received by the New York State Department of Health (NYSDOH) via fax:

NYSDOH contacted Radiation Emergency Assistance Center/Training Site (REAC/TS) to independently review the nasal smear readings. The review revealed a likely overexposure to one worker who was advised to seek medical treatment. Further site investigation identified a defective machine utilized in producing smoke detectors with americium-241 foil. The worker with the overexposure had been using that machine and had to repeatedly open the fume hood to keep the machine operational.

"NYSDOH took administrative action to halt licensee production activities, require modification to radiation safety program, enhance oversight of the licensee through increased inspection frequency, provide specific conditions requiring immediate notification, requirement of an independent safety analysis and adoption of recommendations from these findings, and multiple follow-up site visits by inspection staff to verify progress and status of decontamination and corrective actions."

The investigation showed that several workers had elevated doses and one worker had exceeded occupational dose limits in 10 CFR 20.1201 for Committed Dose Equivalent (CDE) to bone surfaces (56 rem). It was found that the licensee had failed to calculate CDE and committed effective dose equivalent (CEDE) from collected bioassay data from 2019 to the date of the incident. NYSDOH requested the licensee utilize a consultant certified health physicist third-party evaluation of all collected bioassay data for all workers. The one worker with the overdose from this incident was found to have consistently exceeded the occupational dose limits for CDE to bone surfaces for calendar years 2019 (115 rem), 2020 (51 rem), and 2021 (51 rem). Additionally, one previous worker that left employment of the licensee in 2022 received 76 rem CDE to bone surfaces. NYSDOH is following up on the computational methods used by the consultant to clarify and potentially modify the internal doses calculated.

Additionally, significant Am-241 contamination was found on floors, tables, walls, light fixtures, and specific equipment. Further directed corrective actions include replacement of equipment, improvement to the air monitoring systems in the labs, implementation of a respiratory protection plan, enhancement of emergency response plans, restructuring of management and organizational structure of the company, hiring of additional radiation safety technicians, enhancement of training and personnel monitoring programs, and modification to proprietary work procedures to prevent recurrence. NYSDOH and licensee are discussing further investigation and corrective actions.

Notified R1DO (Arner), NMSS (Rivera-Capella), NMSS Events Notification

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was provided by the Utah Division of Waste Management and Radiation Control (DWMRC) via email:

"The University of Utah contacted the DWMRC to report that they had found that an Isotope Products Laboratories, Cs-137 Resin Vial Source, Source Number 988-97-3 with an assayed activity of 208.9 microcuries (assay date May 1, 2004), was leaking.

"A routine quarterly leak test was taken of the sealed source. When counted with a PerkinElmer 2480 Wizard2 radiation detector, the wipe showed an elevated reading. The wipe results showed 4531 cpm (background 32 cpm). The technologist who performed the wipe contacted the licensee's Radiological Health Department. The technologist was told to count the wipe in the well counter (Biodex AtomLab 500). The well counter on the Cs-137 channel showed there was 0.6 microcuries with a 0.3 microcuries background on the sample for a leak test result of 0.3 microcuries. Since there was no obvious leak in the resin vial, the licensee suspected it had been contaminated with short lived radioisotopes. The source was doubly bagged and isolated in storage until the next day when it was again verified to be above background. On April 11, 2023, it was retested. The leak test was performed with both an alcohol pad and a gauze pad. The results of these samples were counted with the PerkinElmer instrument, but not the well counter. The result of the wipes was 4248 cpm and 7303 cpm respectively (PerkinElmer 2480 Wizard2 radiation detector for both tests was 32 cpm). This showed it was not a short-lived isotope and the source was leaking.

"The individual stated that when he performed the wipe test on April 11, 2023, he heard the plastic vial crack and the crack opened while the wipe was being taken but returned to a 'closed position' when the wipe was completed. He immediately returned the wipe to the baggies and put it in storage. Since the wipes taken verified the original assessment was correct, the licensee stated that the source would be placed with their waste and disposed in their normal waste shipments to a licensed radioactive waste disposal site.

"After the initial finding on April 4, 2023, radiation surveys of the area and equipment were conducted to verify that no contamination was present. No contamination was found, and the area and equipment were released for use.

"The licensee stated that the vial appeared to be slightly yellowed around the crack and believes the plastic may have cracked due to radiation fatigue. The licensee had ordered two of these sources in 2004. The other source was in use at one of the licensee's other medical facilities but was removed from service and will be disposed of with the leaking source as a precaution."

Utah Event Report ID Number: UT 23-0004

UNACCOUNTED FOR TROXLER MOISTURE GAUGE

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

"While finishing the renewal of our license, I was not able to account for one device found in a 2016 inventory, the number of devices matched the number of devices listed on our 2016 license.
"Both the license and inventory from 2016 listed 10 devices, I could only account for 9 devices.
"On the 11th of April, documentation was found in our property management system that listed the device as transferred to an outside agency, agency is unknown.
"The last leak test preformed on this device was in 2013, so the condition of the shielding in 2016 is not known, when it was transferred.
"The missing device is a Troxler model 3411 device serial number is 13760.
"The device contains two sources americium-241 with 44 millicuries at 1.480 giga becquerels (SN 47-9073), and cesium-137 with 9 millicuries at 0.296 giga becquerels (SN 50-2578)"

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

OFFSITE NOTIFICATION FOR SEWAGE DISCHARGE

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

"At 1905 [EDT], a security force member discovered what appeared to be a sewage leak along the gravel roadway northwest of the gatehouse entrance. The affected area was approximately 12' X 15'. The water was slowly bubbling up from the ground about 20' along one of our access roads.
"Large absorbent spill containment barriers were placed at the scene to minimize the incident. Water usage was stopped within our facility, and sewer pumps isolated. The Maine State Department of Environmental Protection (DEP) was notified of the incident (DEP spill # 23-0004705). The area was inspected at approximately 2130 [EDT], and water discharge was no longer observed.
"Maine Yankee site management is currently in the process of contacting contractors to resolve the issue.
"The site is safe and secure. The concrete cask heat removal system is operable, and the temperature monitoring system is functional."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee notified Region 1 personnel.