Event Notification Report for November 03, 2020

AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERS BY GREATER THAN 20 PERCENT



The following was received from the Georgia Radioactive Materials Program (the Program) via email:

"The Y-90 event [occurred] on October 23, 2020. The AU [(Authorized User)] notified the Assistant RSO [(Radiation Safety Officer)] on October 26 and then subsequently notified our Program on October 27, 2020. The reason for the delay notifying the Program was both the Radiation Safety Officer (RSO) and Assistant Radiation Safety Officer (ARSO) were furloughed on Friday [(October 23)] and they did not check their emails until Monday. They used Monday to gather information before contacting the State Program.

"The patient was administered with 1.58 GBq using a 10 mL syringe. The reason for the 10 mL syringe was a small gauge catheter was used. The line was subsequently flushed 3 times with saline solution to ensure the Y-90 was pushed through.

"After the procedure, the catheter was removed and surveyed along with the vial to determine residual activity. It was calculated that there was more residual [activity] than expected.

"Though it is has not been clearly determined the cause of the excess residual [activity], it is thought to be either not enough saline was used to push the Y-90 through or it got stuck in the catheter.

"The ARSO and the Authorized User will discuss the cause of the event, best way to prevent occurrence, and [perform] patient follow-up.

"The licensee will follow-up with a report within 15 days. In the interim, the licensee is required to submit a copy of the written directive, Y-90 procedure and checklist, and the rational why they used a small catheter gauge."

The actual dose delivered was 1.039 GBq (65.5 percent).

Georgia Incident No: 31

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.

AUTOMATIC REACTOR TRIP DUE TO CONTROL ELEMENT DRIVE MECHANISM CONTROL SYSTEM TIMER FAILURE

"On November 2, 2020, at 0419 CST, Waterford 3 experienced an automatic reactor trip due to a Control Element Drive Mechanism Control System timer failure while attempting to synchronize a second motor generator set. All control rods fully inserted.

"The plant is currently in Mode 3 and stable with normal feedwater feeding and maintaining both Steam Generators.

"The NRC Senior Resident Inspector has been notified."

The cause of the failure is still under investigation.