Event Notification Report for April 22, 2021

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the Washington State Department of Health:

"University of Washington broad scope license C001 reported a medical event. The event involves y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."

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.

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVES WRONG DOSE

The following was received via e-mail from the State of Texas:

"On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive [potassium iodine, (KI)] KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was.

"Additional information will be provided as it is received in accordance with SA-300.

"Texas Incident #: 9840"

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.

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE - BROKEN RADIOGRAPHY CAMERA
The following was received via e-mail from the Texas Department of State Health Services:

"On April 14, 2021, the licensee reported to the agency [Texas Department of State Health Services] that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300.

"Equipment information:
QSA Delta 880 exposure device SN: D8849
96.7 curie iridium-192 source SN: 30413M

"Texas Incident no.: 9841"

FITNESS-FOR-DUTY REPORT - EMPLOYEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL

A non-licensed, employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

REACTOR COOLANT SYSTEM (RCS) PRESSURE BOUNDARY DEGRADED

"During the performance of reactor vessel closure head (RVCH) examinations, at 2230 EDT on April 20, 2021, it was determined that the Unit 2 RVCH penetration nozzle number 74 did not meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME code case N-729-6 . All other RVCH penetration examinations have been completed per 10CFR50.55a(g)(6)(ii)(D) and ASME code case N-729-6 with no other relevant indications identified. The condition of the Unit 2 reactor vessel head penetration nozzle number 74 will be resolved prior to re-installation of the Unit 2 RVCH. This event is being reported as an eight-hour, non-emergency notification per 10CFR50.72(b)(3)(ii)(A).

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

OFFSITE NOTIFICATION TO THE COMMONWEALTH OF MASSACHUSETTS

On April 21, 2021, at 0752 hours (EDT), an offsite notification was made to the Commonwealth of Massachusetts Department of Environmental Protection (MADEP) in accordance with Regulation 310 CMR 40.0000: Massachusetts Contingency Plan (MCP). The notification documents non-radiological contaminants found above reportable concentrations in select samples collected during site characterization efforts. The reported reportable concentrations were slightly above reporting limits in a soil sample for Per and Polyfluoroalkyl Substances (PFAS), two groundwater sampling locations for PFAS, and isolated instances of metals in groundwater including Arsenic, Vanadium, Lead, Antimony, Beryllium, Cadmium, Chromium, Nickel, and Thallium. This report is being submitted in accordance with 10CFR50.72(b)(2)(xi) based on notification being made to another government agency. Concentrations above reporting limits have been entered into the site's corrective action program. As per MCP, the site will proceed with requirements to implement the phased MCP process. This condition does not represent a threat to station personnel or to members of the general public.