Event Notification Report for January 19, 2021

PROCESS GAUGE SHUTTER STUCK OPEN

The following is a synopsis of the phone call and email from Dow Chemical, Midland:

While conducting a troubleshooting evaluation on the process gauge, personnel became aware that the shutter for the gauge was stuck in the open (normal operating) position. The unit is located approximately fifteen feet above the operating level. Personnel exposure is precluded by the location. The vendor has been contacted to determine a resolution plan and will be on-site next week.

Gauge Info:
Manufacturer: Vega Americas
Source Holder Model: SH-F2B
Isotope and quantity: Cesium-137, 750 mCi
Source serial number 9006CP
Source holder serial number 46168107

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT UNDERGOING RADIATION TREATMENT

The following information was received from the Radiologic Health Branch, California Department of Public Health via email:

"On Friday, January 8, 2021, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a potential medical event involving Y-90 had occurred that day. A liver cancer patient was administered four vials of Y-90 BTG Nordion Inc. TheraSpheres to the patient's liver segments 4, 5, 6 and 7.

"Segment 4 was prescribed 120 Gy ( 0.86 GBq) and the delivered dose was 110.6 Gy (92.17%). Segment 5 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 113.4 Gy (94.5%). Segment 6 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 111.7 Gy (93.08%). Segment 7 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 50.2 Gy (41.83%), which is less than 20 % of the prescribed amount. Overall, the average of the four administrations to the patient's liver was 80.4%.

"On January 10, 2021, the Radiologic Health Branch, sent an email to UCLA's Radiation Safety Officer requesting that UCLA's Environmental Health and Safety medical team perform an investigation to try to determine the root cause of the delivery failure for segment 7. They were asked to interview the authorized user and all other personnel attending the procedure and also to provide copies of the authorized user's written directives. The patient was notified of the under-dosage and potential continuation of their cancer treatment. "

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.

OFFSITE NOTIFICATION DUE TO LEAK FROM UNDERGROUND SEWAGE STORAGE TANK

"On January 18, 2021 at 1600 hours (EDT), Holtec Decommissioning International (HDI) made an off-site notification to the Environmental Protection Agency's Enforcement and Compliance Assurance Division in accordance with Section B of the station's National Pollutant Discharge Elimination System (NPDES) Permit No. 0003557. The event was associated with an underground sewage water system holding tank. The specific details of the occurrence are as follows:

"On January 13, 2021 at 1000 hours [EDT] site personnel identified what appeared to be water bubbling up from an unidentified cover within the security protected area of the site. The water emanating from the cap had no visible color or solid material and no odor. The water estimated at 25 gallons per hour or less was flowing to a site storm drain connected to permitted outfall number 007. Initial indication was that the water was potable water as part of the station's fire protection system. Further investigation determined that a back-up in an underground sewage holding tank inlet was the source of the leakage. By 1400 hours [EDT] when bathrooms including toilets on site were shutdown and removed from service, efforts were underway to pump the tank and remove the blockage, and the bubbling from the cover had stopped."

The licensee has notified the Massachusetts Environmental Protection Agency, the Massachusetts Emergency Management Agency and the NRC Resident Inspector.