Event Notification Report for April 16, 2024

MEDICAL EVENT - UNDERDOSE

The following information is an event summary via phone call from Vartanian Medical, PLLC:

On April 9, 2024, at 1240 EDT, a patient received only 73 percent of the intended dose of Y-90 TheraSpheres during a radioembolization. The prescribed dose was 3000 Gy and the dose received was approximately 2200 Gy. The physician described the cause of the event to be due to a smaller catheter needle used for treatment, which impeded the requisite flow.

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.

INVALID ACTUATION OF EMERGENCY DIESEL GENERATORS

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 invalid start 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 1A-A, 1B-B, and 2B-B EDGs started and functioned successfully.

"The start signal for the 1A-A, 1B-B, and 2B-B EDGs was generated from the common emergency start of the 2A-A EDG. The signal 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 [basis] 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.

"This event was originally reported under EN 56970 on February 16, 2024, at 0205 EST 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. This EN was retracted on February 21, 2024, at 1549 EST.

"This event is being reported in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid 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."