Event Notification Report for June 28, 2023

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"On June 19, 2023, at approximately 1300 CDT, the licensee contacted the Arkansas Department of Health to report a medical event from Jefferson Regional Medical Center, Pine Bluff, Arkansas. The Radiation Safety Officer, Imaging Services Compliance Specialist, called to report a mishap with their first procedures with Y-90. It appears that their patient was to have received 19.8 Gray. However, due to equipment or patient issues the patient received only 6% (i.e. 2.6 Gray). The original injection was to have been 68.5 mCi.

"The report from the licensee is as follows: This is a termination of the Y-90 therapy due to stasis of the administration. 'Based on dosimeter readings of the Y-90 vial, and Geiger-Mueller meter measurements of the equipment, the microspheres were blocked in a tubing connector and did not fully reach the patient and/or organ. There was no spillage or contamination of microspheres from the Y-90 dose. The tubing and catheter were placed in appropriate shielding for long term decay in storage. Below and attached are the calculations we received from the lead Nuclear Medicine technologist and Therasphere representative.'

"Written Directive: 68.6 mCi

"Administration: 64.9 mCi at 1030 [CDT]

"Start: 1138 [CDT]

"Stasis Termination: 1209 [CDT]

"Dose to patient: 3.6 mCi"

AR event number: ARK-2023-004

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 - RADIOACTIVE MATERIAL RECOVERED AT A SCRAPYARD

The following information was received from the Illinois Emergency Management Agency (Agency) via email:

"Agency staff responded to a radiation monitor trip at a scrap metal recycling facility (SIMS Metal Management in Chicago) on 6/20/23 and identified an activated component from a high energy therapy device. The component is estimated to contain less than 1 microcurie of Co-60 and had an exposure rate of 100 microrem/hour on contact. The device originated from Varian Medical Systems and was decommissioned and transported by Legacy Transportation Services. Legacy is an Illinois radioactive materials licensee (IL-02445-01) that receives decommissioned Varian (and other low/high energy) devices and sorts the equipment for recoverable materials versus scrap. Radioactive components are to be identified and returned to Varian. This piece reportedly circumvented their radiation screening process. The licensee was contacted by the Agency and their staff promptly recovered the piece today (6/21/23). An assessment of contamination was performed and none identified. This incident did not result in members of the public receiving exposures in excess of (Illinois) Part 340 limits. Pending appropriate enforcement action and the licensee's written report; this matter is considered closed. Root cause and the adequacy of corrective action will be assessed in the licensee's response."

Illinois Item Number: IL230016

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

OFFSITE NOTIFICATION

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

"At 0831 on June 27, 2023, Sequoyah Nuclear Plant reported an oil discharge into the plant intake located on the Tennessee River to the [Department of Transportation] National Response Center (report number 1371356). The source of oil was from a broken hydraulic hose from equipment in use on the intake. This oil spill is minor and did not exceed any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

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

AUTOMATIC REACTOR TRIP

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

"At 1626 EDT, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a main turbine trip. The [reactor] trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed using the auxiliary feedwater and steam dump systems. Unit 1 is not affected.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). The expected actuation of the auxiliary feedwater system (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72 (b)(3)(iv)(A).

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

"All control rods are fully inserted. The cause of the turbine trip is being investigated."