Event Notification Report for December 16, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
12/15/2022 - 12/16/2022

EVENT NUMBERS
56265 56268 56274
Agreement State
Event Number: 56265
Rep Org: NJ Dept of Environmental Protection
Licensee: Astera Cancer Care
Region: 1
City: Monroe   State: NJ
County:
License #: 833985
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Thomas Herrity
Notification Date: 12/08/2022
Notification Time: 17:40 [ET]
Event Date: 12/08/2022
Event Time: 00:00 [EST]
Last Update Date: 12/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS DAY)
Event Text
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION

The following report was received from the New Jersey Department of Environmental Protection (NJDEP), via email:

"The licensee had scheduled two patients who were each to receive 200 mCi of Lu-177. One patient was to receive 200 mCi of Lu-177 Lutathera, while the other was to receive 200 mCi of Lu-177 PSMA. The PSMA patient was mistakenly administered the Lutathera, while the Lutathera patient was mistakenly administered the PSMA.

"Licensee is working with Radiation Safety Officer on steps needed to prevent recurrence.

"NJDEP Actions: Will conduct on-site visit if warranted."

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
Event Number: 56268
Rep Org: Maryland Dept of the Environment
Licensee: University of Maryland College Park
Region: 1
City: College Park   State: MD
County:
License #: MD-33-004-03
Agreement: Y
Docket:
NRC Notified By: Paul Kovach
HQ OPS Officer: Kerby Scales
Notification Date: 12/09/2022
Notification Time: 15:53 [ET]
Event Date: 12/08/2022
Event Time: 10:02 [EST]
Last Update Date: 12/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Brice (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - FAILED CABLE/DRIVE MECHANISM

The following event was received from the state of Maryland via email:

"On December 8, 2022 a UMD [University of Maryland] campus-wide power outage occurred and the panoramic irradiator source rack failed to automatically return to the fully shielded position. Operators responded and while remaining outside of the shielded vault, they manually lowered the sources to the fully shielded position. Shielding remained intact. Radiation levels in the irradiator area are at normal levels and the sources are secured in a safe and legal manner. The irradiator will not be operated until an investigation has been conducted and determined that the irradiator can be operated as normal. There was no risk for exposure to staff or members of the public. Operators are unloading the source rack and investigating to ensure that the sources will automatically return to the fully shielded position when power is lost."


Power Reactor
Event Number: 56274
Facility: Watts Bar
Region: 2     State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Brian McIlnay
HQ OPS Officer: Bill Gott
Notification Date: 12/15/2022
Notification Time: 12:52 [ET]
Event Date: 11/24/2022
Event Time: 16:21 [EST]
Last Update Date: 12/15/2022
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ACTUATION OF CONTAINMENT VENTILATION ISOLATION VALVES

The following information was provided by the licensee via email:

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid Containment Ventilation Isolation (CVI) actuation at Watts Bar Nuclear Plant (WBN) Unit 1.

"On November 24, 2022, at 1621 Eastern Standard Time (EST), the Train B CVI actuated due to an invalid high radiation signal from 1-RM-90-131, Containment Purge Air Exhaust Monitor. Upon investigation, the high radiation signal was caused by a failed power supply. Corrective action included replacing the power supply, 1-RM-90-131 ratemeter, and restoring the system to service.

"Prior to and following the invalid high radiation alarm, all radiation monitors except 1-RM-90-131 were stable at their normal values; therefore, the CVI was invalid. Control room operators performed appropriate checks and confirmed that all required automatic actuations occurred as designed. This event has been entered into the corrective action program as Condition Report 1819098.

"The NRC Resident Inspector was notified."