Event Notification Report for September 06, 2023

EN Revision Imported Date: 9/6/2023

EN Revision Text: Ge-68 SOURCE MISSING FOLLOWING MAINTENANCE

The following is a summary of information provided by the licensee via phone and email:

The licensee reported two missing Ge-68 sources with an activity of 0.312 mCi per source. The sources were stored on a PET CT mobile imaging unit used throughout the State of Michigan. The mobile unit went for repair to TDC Trailer in Rensselaer, IN. While the unit was at TDC Trailer, the unit needed a structural repair which required items in the camera room to be removed from their designated place. The trailer repairman unbolted the source holder from the floor and moved it to the hot lab and placed it in a radiopharmaceutical dose container. The licensee believes the sources were inadvertently picked up by PetNet Radiopharmacy as part of their routine pick up of empty radiopharmaceutical cases on August 16, 2023.

* * * UPDATE FROM KAY KASSEL TO DONALD NORWOOD AT 1025 EDT ON 9/5/2023 * * *

"There were two rod sources missing from PETCT 142. The medical physicist estimates that the dose resulting from these sources over their lifetime to be 31 mSv at 1 meter from the unshielded sources."

Notified R3DO Skokowski, 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

AGREEMENT STATE - MEDICAL UNDERDOSE

The following information was provided by the Wisconsin Radiation Protection (the Department) via email:

"On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident."

Wisconsin Event Report ID Number: WI230015

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 - RECOVERED LOOSE SOURCE FOR FLOW METER

The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:

Mineral Development Safety Officer notified the BRC the morning of 8/28/23, of a 50 mCi [Cs-137] source that had fallen out of a Endress Hauser flow density gamma meter due to vibration. The source was on the ground adjacent to the meter. The area was secured and excluded. Mineral Development has no radiological survey meters onsite and a BRC manager and inspector were sent to investigate and secure the source.

On 8/29/23, a BRC inspector returned to the site and verified that a local representative from Qal-Tek had returned the source to the shielded position within the gamma meter. The meter will remain out of service until its subsequent removal from the piping system.

The BRC verified that Endress Hauser sold the gauge to Mineral Development, but the sale was not reported to the BRC by any party.

Florida Incident Number: FL23-131

AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE

The following is a summary of information received via email from the Illinois Emergency Management Agency (IEMA):

IEMA was notified August 29, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise a radiopharmaceutical package was missing - presumably in transit. This package contained (3) shielded vials of In-111, accounting for 12.3 mCi at the time of shipment. The last known location was the [common carrier] Indianapolis transfer hub on August 24, 2023. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.

The radiopharmaceutical package was offered for shipment on August 24, 2023, for delivery to the customer the following day. The package was labeled Yellow-II (TI of 0.1), UN2915. At of the time of the report, the activity has since decayed to approximately 2.8 mCi. The licensee advised that on August 29, 2023, [common carrier] declared the package as lost with an unknown status.

Illinois Item Number: IL230022

See EN56682 and EN56697 for similar events.

* * * UPDATE ON 9/5/203 AT 1448 EDT FROM GARY FORSEE TO ERNEST WEST * * *

"This package was located at a landfill in Indiana on 9/5/2023"

Notified R3DO (Ruiz), NMSS Event Notifications 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

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The contract supervisor's access to the plant has been terminated.

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

A supplemental contract manager had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 8/30/2023, at 1700 CDT, by a representative from University of Kentucky Broadscope Medical, of an underdose of a patient during a lutetium 177 (Lu-177) treatment. The underdosing was due to a leakage in the administration line.

"The underdosing was considered more than 20 percent. There was no harm to the patient. A separate report will be submitted once all the facts are gathered."

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 - MEDICAL UNDERDOSE

The following is a summary of information that was provided by the New Mexico Environment Department via phone and email:

On August 31, 2023, at approximately 1530 MDT, X-ray Associates of New Mexico reported that an original prescribed dose of 2.11 Gbq of Yttrium 90 was attempted to be delivered, but the patient received a reported dose of 0.927 Gbq, which was only 43 percent of the prescribed dose. The cause for the undelivered amount is undetermined. The licensee has been instructed to provide a complete written report.

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.

PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS

The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.

On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.

Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077

Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

A supplemental contract supervisor had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.

CONTROLLED SUBSTANCE FOUND IN THE PROTECTED AREA

The following information was provided by the licensee via email:

"On 09/06/2023, at approximately 0830 [CDT], a bottle of vanilla extract, intended for use in cooking, with an alcohol content of greater than 0.5 percent by volume was found in the protected area. An immediate extent-of-condition search of other kitchen areas within the protected area identified four additional bottles of vanilla extract or imitation vanilla extract, for a total of five bottles identified. The alcohol content by volume (ABV) of these extracts ranged from an unlisted percentage (with ethyl alcohol as a listed ingredient) up to 41 percent ABV. The volume capacities of the bottles ranged from 2 to 8 fluid ounces, with varying volumes of remaining contents."