Event Notification Report for January 07, 2021

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT UNDERGOING RADIATION TREATMENT

The following information was received from the Texas Department of State Health Services (the Agency) via email:

"On December 30, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred at their facility. A patient was to receive a single fraction of 700 centigray from a high dose rate remote afterloader unit (HDR) but received a dose of 525 centigray. The patient was notified of the error and the RSO stated they were in the process of notifying the physician. The RSO stated that there would be no adverse effects to the patient from the error. The RSO was unsure of the manufacturer and model of the HDR unit and the activity of the iridium source that was used. Additional information was requested by the Agency. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 9819

WHOLE BODY DOSIMETRY INDICATES EXPOSURE OF OVER 11 REM

On December 29, 2020, Yale University received notification from their dosimetry vendor that one of their employee's badge indicated a whole body dose of 11,843 mRem for the October 2020 wear period. The employee works in the radiopharmaceutical area of the University.

When the employee was interviewed, they admitted that they could not locate their whole body badge when swapping out the October badges for the November badges. The employee found their badge on November 17, 2020 in the fume hood where they believed it fell off their lab coat when cleaning the fume hood for maintenance.

The employee's ring badges for the October wear period was 73 mR (left) and 63 mR (right). November ring badge readings were about the same with November whole body dose of zero. During the October/November timeframe, there were no abnormal surveys or area radiation monitor alarms. No other employee badge read abnormally high.

Yale intends to perform an extensive investigation after the holidays, they believe the October badge was dosed while misplaced in the fume hood for the two-week period is was missing.

The licensee will update this event, if required, once the investigation is complete.

UNUSUAL EVENT DECLARED DUE TO RISE IN DRYWELL UNIDENTIFIED REACTOR COOLANT SYSTEM LEAKAGE

"An Unusual Event was declared at Grand Gulf Nuclear Station at 0124 [CST] on 01/07/2021 due to Unidentified Drywell Leakage exceeding 10 GPM for 15 minutes. Unidentified leakage has reduced to less than 0.44 GPM as of 0213 CST on 01/07/2021."

The cause of the increase leakage rate is under investigation.

The licensee notified the NRC Resident Inspector.

Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).