Event Notification Report for April 23, 2021

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE EVENT

The following report was received by the Maine Radiation Control Program via email:

"[The doctor] prescribed a patient 3.60 GBq Y-90 resin microspheres (Sirtex SIR-Spheres) for treatment of hepatocellular carcinoma (HCC). Due to the patient's anatomy, [the doctor] administered the dosage through two separate arteries using Surefire catheters. The two administrations were 0.90 GBq and 2.70 GBq.

"The first dosage was administered successfully, with an estimated 0.87 GBq (97 percent) of the planned 0.90 GBq being deposited within the patient's liver. The second dosage was not administered successfully, with an estimated 1.59 GBq (58.7 percent) of the planned 2.70 GBq being deposited within the patient's liver. This occurred because the catheter became occluded during the administration of Y-90 microspheres.

"Overall, the patient did not receive the full prescribed dose, with an estimated 2.46 GBq (68.3 percent) of the prescribed 3.60 GBq being deposited within the patient's liver. The event occurred on April 2, 2021 around 1200 EDT."

Maine Event Number: ME 21-001

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: MEDICAL EVENT - UNDERDOSAGE

The following is a summary of a call from the Department of Veteran Affairs:

During a Y-90 SIR-Spheres radioembolization of the liver, the patient was delivered 6.2 milliCurries of the prescribed 8.1 milliCurrie dose, for an underdosage of 23 percent.

The patient is aware of the underdosage. The cause of the underdosage is currently under investigation.

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 - LOST TRITUM EXIT SIGN

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

"On April 16, 2021, at 1605 EDT, the Virginia Radioactive Materials Program received a report from the licensee that a 6.2 Curie [tritium] exit sign (Shield Source Inc., S/N: 11-36361) was lost. The licensee was performing an inventory of [tritium] exit signs on April 15, 2021. The licensee's report indicated that the exit sign was not found at the location where it was last inventoried in 2020 by the Radiation Safety Department. The licensee contacted their Facilities Management Department, asked them about construction being performed at the location, and if the whereabouts of the sign was known. On April 16, 2021 after another search and email correspondence with Facilities Management, the licensee determined that the [tritium] exit sign was lost and was likely discarded with construction trash.

"The licensee submitted a corrective action plan in their report stipulating that Facilities Management will provide a point of contact with whom the Radiation Safety Program will work with regarding [tritium] exit signs to: (1) ensure they are not removed without proper notification, and (2) to notify the Radiation Safety Program of the installation of any new [tritium] exit signs placed within the University of Virginia."

Virginia Report ID No.: VA210002

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

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.

INADVERTANT ACTIVATION OF EMERGENCY SIRENS
At 0925 Mountain Standard Time (MST) on April 22, 2021, Palo Verde Nuclear Generating Station staff received reports that Emergency Notification sirens were activated. Current information indicates that the inadvertent activation of the sirens was caused by an offsite agency during performance of a planned silent test that occurred at approximately 0916 MST. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
All sirens remain functional, and the NRC Resident Inspectors have been notified of the issue.
Additional notifications will be made as needed.

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

"At 1450 CDT on April 22, 2021, with Unit 1 in Mode 1 at 48 percent reactor power, the reactor automatically tripped due to a turbine trip. The trip was not complex with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Auxiliary feedwater pumps were manually started using operations procedures. Main steam isolation valves were closed to prevent excessive cooldown. Decay heat is being removed by the steam generators through the main steam system via atmospheric relief valves. Unit 2 is not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"There was no impact on the health and safety of the public or plant personnel."

The Resident Inspector has been notified.