Event Notification Report for April 26, 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

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

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

"The Department received notification from the licensee on April 16, 2021, that a sealed source leak test for a Cs-137 vial source showed that removable contamination was present. The source was wiped and tested repeatedly and showed contamination each time, with an activity level of 0.008 microCuries or greater. The specific source information is as follows:

"Manufacturer: Eckert & Ziegler
Isotope: Cs-137
Reference Date: 1 September 2011
Activity contained: 205.2 microCuries
Source No: 1523-2-4

"The Department has requested additional information and continues to investigate the event."

Arizona Incident No.: 21-003

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"[The licensee] contacted the Agency this afternoon to report a medical underdose of Y-90 that occurred today, April 19, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.

"[The] Radiation Safety Officer for the licensee contacted the Agency at 1515 CDT on April 19, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer received only 63 percent of the dose prescribed in the written directive. The Agency understands this to be one of three fractions delivered. Additional data is forthcoming.

"Reportedly, the underdosing was due to a leakage of Y-90 microspheres in the connection between the Therasphere tubing and the microcatheter. The leakage resulted in area and personnel contamination which was promptly and successfully addressed by on-site radiation safety staff. No skin doses are reported or anticipated.

"[The Agency] will dispatch staff to the site tomorrow for a reactionary inspection."

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.

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.

TECHNICAL SPECIFICATION VIOLATION

The following report was received by phone and email from the licensee:

"At 1705 EDT, [the licensee] called the HOO to report a violation of MIT Reactor (MITR) Technical Specification (TS) 7.1.3 (2) on Staffing requirement: 'Whenever the reactor is not secured, two persons shall be onsite, one of whom shall be a licensed senior reactor operator. An operator or senior operator shall be present in the control room.' Between 0900 EDT and 1010 EDT on [April 24, 2021], the MIT reactor was operated at 5.7 MW (95 percent of the licensed full power of 6 MW) with less than the minimum staffing requirement.

"At 0817 EDT, the incoming senior reactor operator (SRO), also the reactor supervisor, received a turnover from and relieved the outgoing SRO. The incoming SRO proceeded to the reactor control room, received a turnover from and relived the outgoing operator (RO). The outgoing RO left the site at 0900 EDT. The incoming RO, was originally scheduled to report to the reactor at 0800 EDT, arrived the reactor site and went directly to the control room at 1010 EDT. During the duration without the minimum staffing requirement, the reactor operated at steady state 5.7 MW with no abnormal conditions or alarms. The SRO remained in the control room, while an operator trainee qualified to respond to abnormal reactor conditions was also present in the control room. The incoming RO was available within ne mile to the reactor site, while the outgoing RO within 3.5 miles.

"The verbal report was made in accordance with MITR TS 7.7.2(1), Reportable Occurrence Reports, for which a verbal report is to be made to the NRC Headquarters Operations Center within 24 hours of a reportable occurrence. [The licensee] will submit a written report within ten working days of the occurrence."

SEISMIC MONITORING SYSTEM OUT OF SERVICE FOR PLANNED MAINTENANCE

"At 1200 EDT on April 25, 2021, planned maintenance activities on the Harris Nuclear Plant Seismic Monitoring System will be performed. The work includes performance of preventive maintenance and system upgrades. The work duration is approximately 10 days and compensatory measures will be in place for seismic monitoring.

"This is an eight-hour, non-emergency notification for a planned loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii). There is no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."