Event Notification Report for November 17, 2023

EN Revision Imported Date: 11/16/2023

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES

The following information was received from the Washington State Department of Health via email:

"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.

"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."

Washington Incident Number: WA-23-029

* * * UPDATE ON 11/15/23 AT 1855 EST FROM BORIS TSENOV TO ERIC SIMPSON * * *

The following information was received from the Washington State Department of Health via email:
"Attached is the final report for the reported medical event # WA-23-029.
"We are also reviewing the event closely and are available to provide further information if needed."

Notified R4DO (Vossmar) and NMSS Events via email.

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 - LOST RADIOACTIVE MATERIAL

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On November 9, 2023, the Department was notified by the licensee that a shipment of 960 millicuries of iridium - 192 Zero Wash had not arrived at its Alice, Texas, location. The licensee stated the shipment was scheduled to arrive in Alice, Texas on October 31, 2023. The licensee stated that the carrier used often misses the arrival date by as much as a week, so they did not start looking for the shipment until November 7, 2023. The licensee contacted the shipping company and the last know location of the shipment is Abilene, Texas. The shipper is searching that location for the material. The licensee stated the material was shipped inside a 55 gallon drum. It is currently believed that it is not likely that any individual would exceed any exposure limits. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number 10065

Texas NMED Number: TX230051

* * * UPDATE ON 11/9/23 AT 1529 EST FROM ART TUCKER TO KERBY SCALES * * *

The following update was provided by the Texas Department of State Health Services via email:

"On November 9, 2023, the licensee reported they had located the missing shipment of 960 millicuries of iridium - 192 Zero Wash. The licensee had placed two orders for the materials for two separate locations and the shipping company had inadvertently delivered both shipments to the same location."

Notified R4DO (Warnick), and NMSS Event Notifications, ILTAB, and CSNS Mexico 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 REPORT - PATIENT RECEIVED 45 PERCENT UNDERDOSE

The following was received from the South Carolina Department of Health and Environmental Control (Department) via phone and email:

"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 0930 EST on 11/10/23 that a medical event had been discovered by the licensee on 11/09/23 at approximately 1700 EST. The Medical University of South Carolina (MUSC) reported an underdose to a patient's liver during a Y-90 microsphere procedure by 45 percent of the prescribed 500 Gray (Gy) dose. MUSC estimates that the patient received 276 Gy of the intended 500 Gy dose. The licensee reported that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

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.

AUTOMATIC REACTOR TRIP

The following information was provided by the licensee via email:

"At 0227 EST on 11/16/23, Calvert Cliffs Unit 2 experienced an automatic trip from the reactor protection system (RPS) based on reactor trip bus undervoltage (UV). At that time, a loss of U-4000-22 (13 kV to 4 kV transformer) caused a loss of 22, 23, and 24 4 kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV. The loss of 22 and 23 4 kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4 kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser.

"RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4 hour report
"ESFAS (engineering safety features actuation system) actuation (2B DG start on UV) is reportable under 10 CFR 50.72(b)(3)(iv)(A) - 8 hour report
"AFW operation is reportable under 10 CFR 50.73(a)(2)(iv)(A) - 60 day report

"The NRC Senior Resident Inspector has been notified."

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

All rods fully inserted. There was no impact on Unit 1 operations. Unit 2 is stable in mode 3.

* * * UPDATE ON AT 0940 EST FROM KERRY HUMMER TO ADAM KOZIOL * * *

"ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8 hour report"

Notified R1DO (Defrancisco).

FAILED FITNESS FOR DUTY TEST

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

"At 0906 Eastern Standard Time (EST) on November 16, 2023, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness for Duty (FFD) testing program. The individual's authorization for site access has been removed.

"The NRC Resident Inspector has been notified."

ESSENTIAL CHILLER TRAINS INOPERABLE

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

"11/05/23, 2200 CST: Essential Chiller 'B' train and associated cascading equipment were declared INOPERABLE for planned maintenance. Unit 2 entered the Configuration Risk Management Program as required by Technical Specifications on 11/12/23 at 2200.

"11/16/23, 1541: Essential Chiller 'C' train and associated cascading equipment were declared INOPERABLE due to an unexpected material condition causing the Essential Chiller to trip. The most limiting [Limiting Condition of Operability] LCO is 3.7.7, Action c.

"This condition resulted in the INOPERABILITY of two of the three safety trains required for the accident mitigating function including: High Head Safety Injection, Low Head Safety Injection, Containment Spray, Electrical Auxiliary Building HVAC, Control Room Envelope HVAC, Essential Chilled Water.

"This is an 8 hour reportable condition per 10CFR50.72(b)(3)(v)(D) because it could affect the ability to mitigate the consequences of an accident.

"A risk analysis was performed for the equipment INOPERABILITY and mitigating actions have been taken per site procedures. All 'A' train equipment remains operable."

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

The 'B' train Emergency Diesel Generator was also inoperable due to planned maintenance and continues to be inoperable. It was considered in the Configuration Risk Management Program and it was determined this condition could be maintained. LCO 3.7.7, Action c requires reactor shutdown within 72 hours.