Event Notification Report for April 01, 2024

LOST TRITIUM AIMING POST LIGHTS

The following information was provided by the licensee:

At around 1700 CDT on March 21, 2024, the Detroit Army Arsenal's radiation safety officer (RSO) noticed a picture of two Army M58 Aiming Post Lights, which typically contain 5 Ci of tritium each, on a Reddit sub-group. The post indicated that the devices were a "going away gift" from the Army, and that the individual was no longer in the Army. The sealed sources appeared to be intact, but the RSO could not see the serial numbers.

The RSO plans on reporting this to his chain of command and to the Army Criminal Investigative Service.

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 - Y-90 MICROSPHERE MISADMINISTRATION

The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:

"The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected.

"The discovery was made during a quarterly review of their written directive on March 20, 2024.

"The Agency is awaiting further information from the licensee."

Arkansas Event #: AR-2024-2

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 - Y-90 THERAPY MISADMINISTRATION

The following information was received from the California Department of Public Health, Radiological Health Branch (RHB) via email:

"On 3/24/24, the alternate radiation safety officer phoned the RHB to report a medical event associated with a yttrium-90 (Y-90) therapy. A patient receiving Y-90 therapy was underdosed by more than 20 percent from the planned dose.

"RHB will investigate."

California Report Number: 032424

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 - FOUND SOURCE

The following information was received from the Washington State Department of Health, Office of Radiation Protection (the Department) via email:

"Action Towing LLC transported a car to the Schnitzer Steel Industries scrap metal facility, and it triggered the scrap yard's radiation detectors. The scrap yard staff measured about 35 micro roentgen/hour on the outside of the car. Officials at Schnitzer Steel Industries contacted the Department which resulted in an evaluation of the concern and issuance of a DOT special permit so that the radioactive car could be returned to Action Towing LLC for proper handling.

"The Action Towing office manager was informed that the staff had seen some sort of radiation equipment in the car, so the Department requested pictures of the equipment. The pictures showed an old military Geiger-Mueller (GM) survey meter and other items. The Department went to Action Towing to investigate the radioactivity. In addition to the old military GM survey meter, which was not radioactive, the Department found two glass tubes containing radioactive material, which measured about 2 milliroentgen/hour on contact. One of the tubes was labeled as radium-226. The Department took the radioactive tubes for disposal, then surveyed the car and found no elevated radioactivity remaining in the car, and therefore released the car for unrestricted use."

WA State Item Number: WA240001

AUTOMATIC ACTUATION OF REACTOR PROTECTION SYSTEM

The following information was provided by the licensee via email:

"At 2046 [CDT] on 3/27/24 with the unit 2 in Mode 5 at 0% power, an actuation of the Reactor Protection System occurred during testing of the scram discharge volume. The cause of the Reactor Protection System actuation was leakage of water into the scram discharge volume causing a high level condition while drains were isolated for testing. The Reactor Protection System automatically actuated as designed when the high scram discharge volume signal was received. All rods were previously fully inserted and the Control Rod Drive system was shutdown. No rod movement occurred due to the actuation.

"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 Reactor Protection System.

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