Event Notification Report for December 28, 2016

LOSS OF SAFETY FUNCTION DUE TO TWO INOPERABLE STANDBY LIQUID CONTROL SUBSYSTEMS

"On December 28, 2016 at 2119 EST, the Standby Liquid Control system (SLC) subsystem A was declared inoperable in accordance with the surveillance instruction for performance of a routine surveillance test. At 2229 EST, control room operators received an out-of-service alarm for the explosive-actuated injection valve for SLC subsystem B and declared subsystem B inoperable, thereby rendering both subsystems inoperable. With both subsystems inoperable, the SLC system was unable to fulfill its safety function. At 2335, the surveillance was completed and subsystem A was restored to operable status, which restored the ability for the system to fulfill its safety function.

"Troubleshooting determined that the cause for subsystem B inoperability was an intermittent electrical connection for the explosive-actuated injection valve. Repairs were conducted and the subsystem was restored to operable status on December 29, 2016 at 1708 EST.

"This issue was entered into the Corrective Action Program and during post reportability review, it was determined that this was a reportable event under 10 CFR 50.72(b)(3)(v)(A) for an event or condition that could have prevented the fulfillment of a safety function of a system that is needed to shut down the reactor and maintain it in a safe shutdown condition and under 10 CFR 50.72(b)(3)(v)(D) for a system that was unavailable for accident mitigation.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following report was received via email:

"On December 28, 2016, the Hazardous Materials [Manager] at NBC Universal i.e. Universal Studios in Universal City, California called Los Angeles County Radiation Management on the telephone to report the loss of two Tritium exit signs. As of December 28, 2016, the Los Angeles County does not have information regarding the make, model, or serial numbers of the missing exit signs, or the quantity of H-3 (Tritium) in them."

CA 5010 Number: 122816

* * * UPDATE FROM GEZA MIKO TO JOHN SHOEMAKER AT 1552 EST ON 1/25/2017 * * *

The following report update was received via email:

"On January 10, 2017, [the licensee's] Manager of Hazardous Materials at NBC Universal (i.e. Universal Studios in Universal City, California) reported to Los Angeles County Radiation Management by email that they have found the two Tritium exit signs that our agency reported to [the NRC] on December 28, 2016 (California 5010 # 122816). As of January 25, 2016, Los Angeles County does not have information regarding the make, model, or serial numbers of the missing exit signs, or the quantity of H-3 (Tritium) in them. [The State of California Los Angeles County Radiation Management] has requested this information from [the licensee], again, today. When [the Licensee] provides this information, it will be included in the California 5010 close-out.

"The NMED number for this event is 170010."

Notified the R4DO (Rollins) and NMSS_Events_Notification 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

EN Revision Imported Date: 3/22/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following information was provided by the Illinois Emergency Management Agency (Agency) via email:

"At 1400 CST on February 21, 2022, The Carle Foundation notified the Agency to advise of an unreported medical event that occurred on December 28, 2016. No adverse patient impact reported. This will be reported to the NRC this morning.

"Following a comprehensive review of Y-90 Therasphere procedures performed over the last several years, The Carle Foundation d/b/a The Carle Foundation Hospital identified an additional medical event in addition to the one identified during a recent Agency inspection on 2/16/22, that was not reported as required. On 12/28/2016, a written directive to deliver 0.51 GBq Y-90 Theraspheres to the Superior Branch of Segment 3 (liver) was prepared; however, only 0.16 GBq (31.4%) was delivered. The licensee was under the impression that this was not a reportable medical event since they revised the treatment plan and written directive after the procedure. Although still under investigation, the root cause appears to be the use of a smaller microcatheter than recommended. No further treatment to the patient is planned. The authorized user advised that the dose delivered to the critical mass of the segment treated was medically satisfactory for this case."

Illinois Report # IL220006

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.