Event Notification Report for March 27, 2024

AGREEMENT STATE REPORT - DOSE TO UNPLANNED SITE

The following was received from the Iowa Health and Human Services (HHS) via email:

"On 3/19/2024, MercyOne Des Moines Medical Center reported an equipment failure involving a Best Vascular Inc. A1000 series intravascular brachytherapy device, and a 2.16 Gbq (58.4 mCi) strontium-90 source that occurred on 3/18/2024.

"The initial attempt to send the source train failed to reach the dwell position and stopped short of the treatment area by about 30 millimeters. After the authorized user's (AU) attempts to try and increase pressure to send the sources further to the treatment area failed, the licensee decided to return the source to the device. There was a small delay in the source returning, because there was a slight bend in the catheter, and it seemed that was impeding the water pressure to push the source back. The licensee straightened the catheter a little bit, and when they did the source train returned to the device. At that point, the licensee disconnected and reconnected the catheter to try again and the source train again stopped in the same exact place. The licensee returned the source immediately.

"In total the source was in the incorrect position for approximately 30 seconds. The source was at the same position about 30 millimeters proximal to the treatment area.

"The AU picked up the radiopaque marker set to put back in and see if they could see how far it would go in on fluoroscopic imaging. When the AU picked up the radiopaque marker set, he noticed that there was a very strong kink (almost 90-degree bend) in the radiopaque marker set. Instead of putting the source radiopaque marker set back in, the licensee decided to pull the entire catheter and place a new beta-cath catheter in the patient. While testing the new radiopaque marker set (pulled them out, push them back in) the AU realized that when he did it on the other radiopaque marker set, he had felt a click at some point.

"The licensee's hypothesis is that, when the AU felt the click, the radiopaque marker set bent and there is a potential that when it bent, there was damage to the catheter itself, and it would not allow the source train to go past that position where the kink happened. With the new catheter in place, the AU connected the device and sent the source train out to the treatment position without issue. The licensee continued to treat for the prescribed treatment time.

"Preliminary information: It is estimated that the source train sat for approximately 30 seconds in the wrong location. The dose delivered to that area about 30 millimeter proximal to the treatment site is 0.0632 Gy/s times 30 s equals1.896 Gy, which is greater than the limits described in 10 CFR 35.3045(a)(1)(iii) reports and notification of a medical event.

"Iowa HHS will do a reactive inspection on 3/20/2024 and will update this event as more details are confirmed."

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 - MINOR TRANSPORTATION EVENT

The following was received from the Washington State Department of Health (the department) via email:

"A hospital [Baptist Hospital of Miami, Miami, FL.] shipped unused brachytherapy seeds and GammaTiles back to the manufacturer, who is GT Medical Technologies. The manufacturer surveyed the returned package and measured about 14.6 mR/hour on the outside of the package instead of the typical reading of about 1.5 mR/hour.

"The manufacturer opened the package and found that the hospital did not follow the written instructions on how to pack return shipments. The top piece of foam packaging was not included in the package.

"The manufacturer found that, during transportation, two glass vials containing [cesium-131] reference brachytherapy seeds had escaped from their shielded storage container. The glass vials did not break and the seeds were still inside them. It was the unshielded seeds that caused the elevated reading on the outside of the package.

"The manufacturer notified the hospital, the [common] carrier, and the regulator [(the department)].

"The department expects to obtain additional information tomorrow about this event, and will provide an updated event report."

Washington Event Number: WA-24-008

VALID SPECIFIED SYSTEM ACTUATIONS OF UNIT 2 TRAIN B EMERGENCY DIESEL GENERATOR AND TRAIN B AUXILIARY FEEDWATER

The following information was provided by the licensee via email:

"At 1634 MST on March 24, 2024, an engineered safety features (ESF) service transformer deenergized resulting in a loss of power to the Unit 2 Train B 4.16 kV Class 1E Bus. The Unit 2 Train B emergency diesel generator (EDG) automatically started and energized the Unit 2 Train B 4.16 kV Class 1E Bus.

"As a result of the loss of power on the Unit 2 Train B 4.16 kV Class 1E Bus and subsequent load sequencing after the Unit 2 Train B EDG started, the Unit 2 Train B auxiliary feedwater (AFW) pump automatically started as designed. The Train B AFW pump was not needed for steam generator level control and no auxiliary feedwater valves repositioned. The Train B AFW Pump did not supply feedwater to the steam generators.

"All systems operated as designed. Per the emergency plan, no classification was required due to the event. Units 1, 2, and 3 remain in Mode 1 at 100 percent power. The 4.16 kV Class 1E Buses in Units 1 and 3 were not affected by the deenergization of the ESF service transformer.

"The cause of the ESF service transformer being deenergized is under investigation.

"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 emergency AC electrical power systems and auxiliary feedwater system.

"The NRC Resident Inspectors have been informed."

EN Revision Imported Date: 3/27/2024

EN Revision Text: FITNESS FOR DUTY

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

"At 1027 CDT on 3/25/24, it was determined that a contract supervisor tested positive in accordance with the fitness for duty testing program. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified."

ACTUATION OF REACTOR PROTECTION SYSTEM

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

"On March 26, 2024 at 1115 CDT, Grand Gulf Nuclear Station experienced an actuation of the reactor protection system (RPS) due to high reactor coolant system pressure. The plant was in Mode 4 at zero percent power and performing scram time testing. All rods were fully inserted at the time of the RPS actuation, and all required equipment responded as designed.

"This actuation is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"The cause of the event is under investigation.

"The NRC resident inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The unit has been in a refueling outage since the beginning of March. There were no compensatory measures taken in response to this actuation.