Event Notification Report for December 15, 2020

EN Revision Imported Date: 12/8/2020

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE

The following was received from the Virginia Radioactive Materials Program via email:

"On December 3, 2020, at 1540 EST, the Virginia Radioactive Materials Program (VRMP) received a report from the licensee via telephone that a medical event occurred on December 3, 2020, as a result of a therapy procedure using SIR-Spheres Yttrium-90 resin microspheres. The prescribed dosage to the tumor was 27.9 milliCuries. The actual delivered dosage to the tumor was 20.03 milliCuries, which resulted a difference of 28.3 percent (under-dosage). The preliminary report indicated that this difference was determined based on the measurement of the remaining residual activity in the delivery system.

"Referring physician was notified and an Authorized User was requested to contact the patient concerning the event. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."

Event Report ID No.: VA20006

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.

* * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *

The following retraction was received from the Commonwealth of Virginia via email:

"On 12/7/2020, VRMP received a report from the licensee re-investigation the event by two independent teams on 12/4/2020 for verification. Both teams found an error on the first measurement of the remaining residual radioactivity in the delivery system. Based on the teams' new measurements, the dosage left over after the procedure was now calculated to be 1.4 milliCuries of Yttrium-90 versus the original value of 8 milliCuries. Those measurements were corrected for the radioactive decay to the time of the procedure. The new value is within the allowed dose deviation of a normal procedure (new estimate 5 percent deviation of prescription). Thus, VRMP requests the NRC Operation Center retract this event report."

Notified R1DO (Bower) and NMSS Event Notification via email.

This material event contains a "Category 3" level of radioactive material.

AGREEMENT STATE REPORT - LOST HIGH DOSE RATE SOURCE WHILE IN TRANSIT

The following was received from the state of Louisiana via email:

"On December 04, 2020, Alpha-Omega Services RSO contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was lost in transit with the commercial carrier.

"The source was being shipped to Stanford University Medical Center, 820 Quarry Road, Palo Alto, CA 94304.

"The source serial number is 02-01-2922-001-111120-11438-41.

"The activity of the Ir-192 source was 11.44 Ci (423.22 GBq) on November 13, 2020 when it was shipped. The source was last tracked in the commercial carrier Memphis, TN Hub on November 14, 2020 at 06:07 am CST."

Louisiana Incident Number: LA20200011

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

This material event contains a "Less than Cat 3" level of radioactive material.

AGREEMENT STATE REPORT - LOST IODINE-125 SEEDS

The following was received from the state of Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee that seven approximately 0.4 milliCurie Iodine-125 seeds used for breast localization were discovered missing [during inventory on 12/1/2020]. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 20-024.

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

DISCOVERY OF AFTER-THE-FACT UNUSUAL EVENT - INADVERTENT RELEASE OF ARGON-41 GAS

At 0336 EST, operators declared an Unusual Event due to elevated radioactivity levels observed at the facility's ventilation stack. The elevated levels were due to a release of Argon-41 gas caused by a failure of the facility's fan system. This failure caused the Argon gas to be released to the ventilation stack into the atmosphere. The reactor was operating at 19.5 MW at the time of the incident and was shutdown when the ventilation stack set point was reached. Facility personnel secured the offsite gas release and verified no fission product release occurred. The Unusual Event was terminated at 0422 EST.

OFFSITE NOTIFICATION DUE TO TRITIUM LEAKAGE TO THE GROUND

"At 2214 EST on 12/12/20, Surry Power Station personnel identified leakage from the Unit 2 Refueling Water Storage Tank (RWST) Cooling System to the ground. Leakage was estimated to be greater than 100 gallons and tritium concentration determined to be 4.5E07 picocuries per liter (pCi/L), requiring report in accordance with the industry voluntary groundwater protection program.

"As such, at 1450 EST on 12/14/2020, the Surry County Administrator, NRC Resident, Virginia Department of Health, Virginia Department of Emergency Management, and Virginia Department of Environmental Quality were notified of this release to the environment.

"Due to the offsite agency notifications, this 4-hour, non-emergency report is being made in accordance with 10 CFR 50.72(b)(2)(xi).

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

CHARGING PUMP AND BORATION FLOWPATHS SIMULTANEOUSLY INOPERABLE

"At 1240 EST on 12/14/20, it was determined that all Unit 4 Charging Pumps and Boration Flowpaths were simultaneously inoperable.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v).

"The NRC Resident Inspector has been notified."