Event Notification Report for February 22, 2024

MEDICAL EVENT - DOSE MISADMINISTRATION

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

At 1110 EST on February 14, 2024, a patient was administered the wrong radiopharmaceutical. The prescribed dose was 25 mCi Tc-99m pyrophosphate, and the administered dose was 25 mCi Tc-99m sestamibi. The patient and referring physician were informed. There were no adverse effects to the patient. The total effective dose equivalent for this study was estimated to be 1,200 mrem.

* * * RETRACTION ON 2/15/24 AT 1240 EDT FROM GLADYS KAGAOAN TO ADAM KOZIOL * * *

After further review, the dose to the patient was below reporting threshold. The radiopharmaceutical was a diagnostic tracer and non-therapeutic.

Notified R1DO (Bickett), NMSS (Rivera-Capella), and 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 - SHUTTER STUCK OPEN

The following is a summary of information provided by the New Mexico Radiation Control Bureau via email:

On February 14, 2024, a routine inspection discovered that a densitometer (Berthold LB8010, serial number 10377, 20 mCi of cesium-137) was missing the handle that actuates the shutter. The shutter was in the open position. The radiation safety officer packed the defective densitometer in lead pending disposal. There were no excessive exposures due to this event.

AGREEMENT STATE REPORT - STOLEN PORTABLE GAUGE

The following was received from the Colorado Department of Public Health and Environment (the Department) via email:

"On February 14, 2024, the radiation safety officer of CTL/Thompson, Inc. reported a stolen InstroTek model 3500 series portable moisture/density gauge (Serial Number 4764). The gauge user reported they loaded the gauge at their Pueblo office and stopped at their residence to retrieve their wallet. Upon returning to their truck, both chains that secured the gauge and transportation case were cut and the gauge and transportation case were stolen. The gauge contained a 10 mCi cesium-137 source (Serial Number BG1770) and a 40 mCi americium-241: beryllium source (K147/22).The licensee was instructed to file a police report. The Department is waiting for additional details regarding the event."

CO Event Number: CO240003

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 SOURCE

The following information was provided by the New York State Department of Health (the Department) via fax:

"The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at [the Plainview facility], RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause.

"Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements."

New York State Event Report Number: NY-24-01



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

EN Revision Imported Date: 2/22/2024

EN Revision Text: ACTUATION OF EMERGENCY DIESEL GENERATOR SYSTEM

The following information was provided by the licensee via email:

"At 2224 EST on February 15, 2024, with both units 1 and 2 in mode 1 at 100 percent power, an actuation of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The reason for the emergency diesel generator system auto-start was clearance removal sequencing errors. The emergency diesel generator system automatically started as designed when the common emergency start signal was received.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the emergency diesel generator system.

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

* * * RETRACTION ON 2/21/2024 AT 1549 EST FROM TYSON JONES TO KAREN COTTON * * *

The following information was provided by the licensee via email:

"In accordance with NUREG-1022, Section 2.8 and Section 4.2.3, Watts Barr is retracting the previous report EN 56970 pursuant to 10 CFR 50.72(b)(3)(iv)(A). The start signal for the 1A-A, 1B-B, and 2B-B emergency diesel generators (EDG)s was from activation of the common emergency start of the 2A-A EDG. The actuation was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design safety function.

"The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system. Since the starts were not initiated via an automatic signal from a LOOP, SI, or traditional operator action, the signal is not a valid actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A). Therefore, EN 56970 is being retracted.

"The NRC Resident Inspector has been notified of this retraction."

Notified R2DO (Miller)

FITNESS FOR DUTY

The following is a synopsis of information that was provided by the licensee via email and phone call:

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