Event Notification Report for February 12, 2024

MEDICAL EVENT - OVERDOSE

The following is a summary of information provided by the licensee via phone:

A patient received a Y-90 Therasphere injection to the liver. The procedure was successfully completed with no abnormalities noted. After the procedure, an imaging study was conducted on the patient's liver, and it was determined that the Theraspheres had concentrated in a single segment of the liver (segment 4) when they had been expected to distribute throughout the entire liver. The calculated dose to the single segment would have exceeded the prescribed dose (633 Gy vice 91 Gy) due to the higher concentration of Y-90. The physician and patient were notified. No adverse effect is expected to the patient or the target organ.

* * * RETRACTION ON 2/8/24 AT 1547 EDT FROM VRINDA NARAYANA TO BILL GOTT * * *

After further review, the correct target was irradiated, the correct activity was injected and all procedures were followed. The average dose to the target matched the written directive. Thus, the event was not reportable, and the licensee is retracting the event.

Notified R3DO (Ziolkowski), NMSS Events (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 SOURCE

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email:

The licensee's Assistant Director of Radiation Safety contacted the Department on February 1, 2024, at 1700 EST, to report a missing source. He stated he was notified that morning that a germanium-68 Phantom, for use with a PET/MRI (positron emission tomography/magnetic resonance imaging) machine was reported missing. It has a reference activity of 55 MBq / 1.5mCi. During a follow up call from the Department, the Assistant Director stated the source was delivered and accounted for Monday, January 29, 2024, then reported missing February 1, 2024. The source was in a restricted area and locked in the hot lab. The Assistant Director stated they have created a police report and are awaiting surveillance footage. The licensee believes it may have been thrown away accidentally, therefore they are also searching their dumpsters.

Georgia Incident Number: 77

* * * UPDATE ON 02/06/24 AT 1428 EST FROM STACY ALLMAN TO NATALIE STARFISH * * *

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email:

The Assistant Director of Radiation Safety contacted the Department on 02/02/24 to provide an update on the steps being taken to find the lost source. They had informed the police department and opened an investigation. Security was also assisting in the investigation. The radiopharmacy that supports Emory University, called on 02/05/24 and reported their driver accidentally removed the source. The source was returned on 02/05/24 and the Assistant Director of Radiation Safety completed the check in and the leak test on the source.

Notified R1DO (Lilliendahl), NMSS Events Notification, and ILTAB 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 - LOST/MISSING SOURCE

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

"The Agency was notified 2/2/24, by G.E. Healthcare in Arlington Heights, IL, (RML IL-01109-01) to advise two radiopharmaceutical packages were missing at the Memphis, TN, [common carrier] hub. The first package contained two shielded vials of iodine-123 (I-123), accounting for 66.8 mCi at the time of shipment. The second package contained 1.0 mCi of indium-111 (In-111); but was located in the [common carrier] facility damaged with the contents missing. [Common carrier] staff advise they are actively searching the facility.

"The first radiopharmaceutical package containing two vials of I-123 (and believed to be intact) was shipped 1/29/24 from Arlington Heights, IL, to Nuclear Diagnostic in Budd Lake, NJ. It was last reported at the [common carrier] hub in Memphis, TN, on 1/29/24. The second package believed to be damaged and within the [common carrier] facility was shipped 1/13/24 from Arlington Heights, IL, to RLS USA in Pittston, PA. Missing is a vial of In-111 Oxyquinoline Solution within a 6-mm thick lead-shielded container. The current activity is estimated to be 19.0 microcuries. If unshielded, this vial would present an exposure rate of approximately 1 millirem per hour at three inches. GE Healthcare has been provided photos and a description of the container and inner product. [Common carrier] staff are currently surveying with radiation detection equipment."

Illinois Item Number: IL24004

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 - FIRE DAMAGED MATERIAL

The following is a summary of information received from the Tennessee Division of Radiological Health via email:

A fire on a truck involving a super sack containing low level waste consisting mostly of personal protective equipment and other small items occurred on Interstate 40 in Nashville. The licensee believes there may have been batteries in the sack that could have caused the fire. With the fire out there were no airborne or exposure hazards associated with the material involved. The exposure rates at the trailer were approximately 15 microR/hr. The licensee has dispatched health physicists and a truck with overpack materials to re-pack the load for transport back to their facility in Oak Ridge. No personnel exposures were reported.

Tennessee Event Report Identification Number: TN-24-015
National Response Center Incident Report Number: 1390886

FITNESS FOR DUTY PROGRAMATIC ISSUE

The following information was provided by the licensee via email:

"A programmatic vulnerability, failure, or degradation was discovered within the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within the protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program.

"Public and plant safety have not been affected."

The NRC Resident Inspector was notified.

FITNESS FOR DUTY VIOLATION

The following information was provided by the licensee via email:

A supervisor had a confirmed positive for alcohol during a random fitness for duty test. The supervisor's access to the plant has been terminated.

UNANALYZED CONDITION - INADEQUATE FUSES FOR FUEL POOL COOLING

The following information was provided by the licensee via email:

"On 2/9/24 at 1322 EST, it was determined that the unit was in an unanalyzed condition. A review of DC feeder circuit protection schemes identified a circuit for the fuel pool cooling system is uncoordinated due to inadequate fuse sizing. This results in a concern that postulated fire damage in one area could cause a short circuit without adequate protection, leading to the unavailability of equipment credited for in 10 CFR 50 Appendix R, Fire Safe Shutdown. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"The postulated event affects the following fire zones: fire areas 6S and 6N (within the Unit 2 reactor building). Compensatory actions for affected fire areas have been implemented. An extent of condition review is being performed.

"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:

Fire watches have been established in the affected areas. These will be maintained until the protection scheme is revised.

PART 21 - INTERIM REPORT FOR OIL FILLED CAPACITORS

The following is a synopsis of information that was provided by AMETEK Solidstate Controls Inc. via email:

This component (07-020139-10) is a 13 micro-Farad AC oil filled capacitor. During operation in an inverter, oil may be visible on, around, or dripping from the capacitor or its mounting bracket or tray. If allowed sufficient time, enough oil will leak from the capacitor that it will short internally and fail. Time required for the failure could be greater than the recommended 10-year preventative maintenance cycle for this part.

AMETEK Solidstate Controls has not been able to determine a definitive cause of the failure, but is working to do so.

These capacitors are generally part of a larger capacitor bank. The failure would result in a reduction of output voltage that is directly proportional to the number of capacitors in the bank that fail. Any single capacitor failure would be less than a 3 volt decrease in output voltage.

Users of these capacitors should visually inspect any equipment containing the capacitor part number stated above for evidence of an oil leak. A review of the output voltage for the parent equipment for any consistent decrease in voltage of 0-3V may serve as an indication of capacitor failure. The user should notify AMETEK Solidstate Controls if any oil is observed during inspection.

Corrective actions should be established by May 2024.

Affected plants are not listed.

PRIMARY CONTAINMENT DEGRADED

The following information was provided by the licensee via email:

"At 1011 EST on 02/11/2024, during a refueling outage at 0 percent power, while performing local leakage rate testing (LLRT) of the feedwater check valves [part of the containment boundary], it was determined that the Unit 1 primary containment leakage rate did not meet 10 CFR 50 Appendix J requirements specified in Technical Specification 5.5.12. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified. "