Event Notification Report for December 25, 2020

AGREEMENT STATE REPORT- UNDER DOSAGE

The following was received from the state of Arizona via email:

"The Department (Arizona Department of Health Services) received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed a dose of 120 Gy but was delivered 47.6 Gy, a percent dose delivered of 32.5%. The Department has requested additional information and continues to investigate the event.

"The Licensee is: Arizona License Number- 10-044, Banner University Medical Center - Tucson, 1625 N. Campbell Ave, Tucson, Arizona 85719

"Additional information will be provided as it is received in accordance with SA-300.

Arizona Incident: 20-025

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 - SOURCE ROOM DOOR INTERLOCKS FAILED TO FUNCTION

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

"The South Carolina Department of Health and Environmental Control was notified on 12/16/20 that a piece of equipment was disabled or failed to function as designed when the equipment is required by regulation or license condition to prevent exposures to radiation and radioactive materials exceeding regulatory limits, or to mitigate the consequences of an accident. The licensee reported that the electrical interlocks at the remote afterloader room entrance failed to function from 12/14/20 until 12/17/20. The source in the remote afterloader unit is a Varian Medical Systems, Inc. Model GammaMed 232, Ir-192 source, with a reported activity of 8.5 Curies. The remote afterloader unit is a Varian Medical Systems, Inc. Model GammaMedplus iX. As of 12/17/20, the licensee is reporting that the electrical interlocks at the remote afterloader room entrance is now operable and functioning as designed. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control."

No overexposures were reported as a result of the failed interlocks.

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was obtained from California Department of Public Health Radiologic Health Branch Brea (RHB Brea) via email:

"On December 18, 2020, at approximately 1100 PST, [the] RSO [(Radiation Safety Officer)] of Sequoia Consultants, Inc., Radioactive Materials License #7597-30, contacted RHB Brea to report the theft of a moisture/density gauge: CPN, MC-3 Elite, serial #30582 (Cs-137 0.370 GBq, Am-241, 1.85 GBq). The gauge had been in a mobile storage unit at a temporary job site at approximate mile marker 20.07, Northbound State Route 99 (Golden State Highway) in Atwater, CA 95301. The storage unit had been broken into and the radioactive gauge was missing. The Authorized User who discovered the missing radioactive gauge at approximately 0830 on December 18, 2020 notified the RSO and then notified the Atwater Police Department, who directed him to contact the California Highway Patrol. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. The RSO will contact local newspapers in an attempt to retrieve the stolen radioactive gauge, as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered."

California 5010 number: 121820

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

AUTOMATIC TURBINE AND REACTOR TRIP

"At 1235 CST on December 24, 2020, Callaway Plant was in Mode 1 at approximately 90 percent power when a turbine trip/reactor trip, from a vital main generator trip signal, occurred. All safety systems responded as expected with exception of an indication issue with the 'B' Feedwater Isolation Valve, which was confirmed closed, and one intermediate range nuclear instrumentation channel which failed off-scale low following the trip. A valid Feedwater Isolation Signal and Auxiliary Feedwater Actuation Signal were also received as a result of the plant trip. The plant is being maintained stable in Mode 3.

"All control rods fully inserted from the reactor trip signal, and decay heat is being removed via the Auxiliary Feedwater and Steam Dump Systems.

"The NRC Senior Resident Inspector was notified."