Event Notification Report for January 26, 2023

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the Arizona Department of Health Services (the Department) via email:

"The Department identified a possible medical event involving Y-90 Sir-Spheres during a routine inspection. A patient was prescribed an activity of 0.05 GBq (1.45 mCi) but was delivered 0.02 GBq (0.53 mCi), a percent dose delivered of 36.55 percent. The procedure date was 9/30/2022. The Department has requested additional information and continues to investigate the event."

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 - UNABLE TO RETRACT SOURCE INTO FULLY RETRACTED POSITION

The following report was received via email from the Texas Department of State Services [the Agency]:

"On January 18, 2023, the Agency was notified by the licensee that one of its radiography crews [working in Midland, TX] was unable to retract a 99.0 curie iridium - 192 [Ir-192] source into the fully retracted and locked position in a QSA 880D exposure device. The licensee stated they were able to retract the source into the exposure device, but it would not lock in the fully retracted position. An individual on the license approved to recover sources went to the site to retract the source. The licensee contacted the manufacturer who was able to provide instructions to the field team on how to return the source to the locked position. The licensee reported no overexposure occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No: I-9981
Texas NMED No.: TX230002

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

The following is a summary of information provided by the Oregon Health Authority, Radiation Protection Services via email and phone:

The licensee reported a damaged Troxler 3430 portable moisture density gauge. The gauge's cover was found to be cracked in multiple places, including the electronic pad. The source is in the shielded position and readings around the gauge indicate that the shielding is intact. It is unclear how the gauge became damaged but was found near a vibrating plate compactor.

The gauge will be shipped to the manufacturer for repair once a leak test has been performed.

Dose readings at 3 feet from source: 0.12-0.16 mR/hr
Gauge source: 8 mCi Cs-137, 40 mCi Am-241:Be
Oregon Emergency Response System Incident Number: 2023-0140

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following is a summary of information provided by the Washington State Department of Health (DOH), Radioactive Materials Section via email:

The licensee reported that a Y-90 TheraSphere liver treatment was completed in accordance with manufacturer requirements and nothing out of the ordinary was observed. However, during a subsequent step to flush the system with saline, the technician, who is not an authorized user or radioactive material user, noticed bubbles coming up above the vial. Wipe samples of the procedure equipment were counted and showed radioactivity. A second flush of the system was initiated but the same bubbles were observed and therefore the flush was stopped, and the catheter was retracted from the patient. Additional flushes were not attempted. An evaluation showed that the patient received only 33 percent of the intended dose. The activity contained in the wipes and cleaning materials accounted for the balance of the intended dose (66 percent) and was disposed of as waste. DOH has requested additional information regarding potential occupational exposures. The licensee will submit a detailed report.

Washington Incident Number: WA-23-003.

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.

EN Revision Imported Date: 1/25/2023

EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE

The following information was provided by the licensee via email:

"At 0121 CST on 01/24/2023, it was discovered that the Unit 1 High Pressure Coolant Injection System (HPCI) was inoperable; therefore, the condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"1-FCV-073-0006B, HPCI Steam Line Condensate Outboard Drain Valve, failed closed during normal plant configuration. This valve is normally open. The HPCI steam line is not being drained with the valve in the current position.

"The Unit 1 Nuclear Unit Senior Operator entered Unit 1 Technical Specifications LCO 3.5.1 Condition C with required actions C.1 to immediately verify by administrative means that the Reactor Core Isolation Cooling (RCIC) system is operable and C.2 to restore HPCI to operable status in 14 days. RCIC has been verified operable by administrative means.

"There was no impact to the safety of the public or plant personnel. The NRC Resident Inspector has been notified."

PART 21 - MEDIUM VOLTAGE CIRCUIT BREAKERS

The following information is a synopsis of information provided by the licensee via fax and phone:

On May 23, 2022, Framatome informed Tennessee Valley Authority (TVA) of a deviation of breakers purchased under contract. On January 23, 2023, TVA determined that a defect of the basic component could create a substantial safety hazard.

Framatome Inc. identified a deviation in the Siemens medium voltage vacuum circuit breaker where a failure to electrically charge or electrically close could occur. Framatome Inc. identified this as a departure from the technical requirements included in the procurement document. It is noted that the ability to electrically trip the circuit breaker would not be affected by the condition. TVA was notified by Framatome under 10 CFR 21.21(b) to evaluate the application of the breaker for a substantial safety hazard.

The TVA evaluation identified these breakers as intended for use in safety related Class 1E applications where a loss of the closure function would impact mitigation of design basis accidents and transients. During the Framatome dedication testing/inspection of Siemens medium voltage vacuum breakers, a hi-pot test failure on one circuit breaker was encountered. Troubleshooting and inspection found damage to charging motor wiring. It was determined that the cause of the damage was due to the manner in which control wiring was routed and connected to the internal bracket in close proximity to a bracket edge. This edge caused damage to wiring after significant number of cycles were applied to the breaker prior to dedication testing.

TVA received nine medium voltage vacuum circuit breakers at an offsite warehouse facility. While located at that facility, TVA, with assistance from Framatome, examined the affected breakers for the wire routing condition. The wiring harnesses of certain breakers were corrected. Framatome is to examine medium voltage vacuum circuit breakers that may be purchased under this contract for the wiring condition and correct as necessary before delivery.

The NRC Senior Resident Inspector has been notified.

This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i).