Event Notification Report for May 21, 2021

EN Revision Imported Date: 5/21/2021

EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE

The following report was received via email from the VA National Health Physics Program (NHPP):

"VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, which holds Permit Number 37-01230-03 under the VA master materials license, reported discovery of a medical event to NHPP at approximately 0730 EDT, May 10, 2021.

"An iodine-131 sodium iodide thyroid ablation therapy administration was performed on Friday, May 7, 2021. The prescribed dose was 60 milliCuries but only 31.2 milliCuries were delivered.

"The patient and the referring physician have been notified.

"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.

"NHPP notified [their] NRC Region III Project Manager, Bryan Parker."

* * * RETRACTION ON 5/20/21 AT 1835 EST FROM EDWIN M. LEIDHOLDT, JR. TO BETHANY CECERE * * *

The following retraction was received via email from the VA National Health Physics Program (NHPP):

"A patient at VA Pittsburgh Healthcare System was administered a therapeutic dosage of iodine-131 sodium iodide on May 7, 2021. On May 10, 2021, the facility reported to NHPP that a medical event had occurred. We reported that to NRC Operations Center on May 10, 2021, pursuant to 10 CFR 35.3045. The basis for the medical event was that the facility believed that only a little more than half of the prescribed dosage of 60 milliCuries had been administered to the patient.

"Since that time, measurements were made of the material not administered to the patient. These measurements indicate that about 82% of the prescribed activity was administered and therefore a medical event did not occur. Therefore, we wish to retract the report of the medical event.

"We have notified Bryan Parker of NRC Region III, NRC project manager for the VA's Master Material License, of our plan to withdraw the event declaration."

Notified R3DO (Cameron) and NMSS Events (by email).

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: 5/21/2021

EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE AND WRONG TREATMENT SITE

The following was received from the California Department of Public Health via email:

"On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event."

California Item Number: 051221

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: 5/21/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOGRAPHY SOURCE

The following was received from the Florida Department of Health (Bureau of Radiation Control) via email:

"At around 2020 [EDT] this evening, [the licensee] reported a lost radiography source from the Nuc-Med department.

"It was confirmed as missing from the lead pig this morning by a PET-CT tech after performing a [quality control] QC check on the camera. The PET-CT tech believes that they put it in their pocket yesterday afternoon after they were finished using it, instead of putting it back in the pig. [The] licensee reports to have used four detectors in the work area, and in the PET-CT's car and residence, but the source is still missing."

Source: Na-22
Activity: 100 uCi on 01 June 2018, 45uCi today
Manufacturer: Eckert & Ziegler
Serial Number: Q5-225

Florida Event Number: FL21-063

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: 5/21/2021

EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO HIGH PRESSURIZER PRESSURE

"At 0315 MST on May 19, 2021, Unit 2 reactor automatically tripped during testing of the Plant Protection System. The Reactor Protection System actuated to trip the reactor on High Pressurizer Pressure, although no plant protection setpoints were exceeded. Main Steam Isolation Signal (MSIS), Safety Injection Actuation Signal (SIAS), and Containment Isolation Actuation Signal (CIAS) were received. No injection of water into the Reactor Coolant System occurred. Auxiliary Feedwater Actuation Signals (AFAS) 1 and 2 actuated on low Steam Generator water level post trip as designed. This event is being reported as a reactor protection system and a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).

"Following the reactor trip, all [Control Element Assemblies] CEAs inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. Unit 2 is stable and in Mode 3. Steam Generator heat removal is via the class 1 E powered motor driven auxiliary feedwater pump and Atmospheric Dump Valves.

"The NRC Senior Resident Inspector has been informed."

* * * UPDATE ON 5/19/21 AT 1351 EDT FROM JASON HILL TO BRIAN P. SMITH * * *

"The Unit 2 reactor tripped because of actual High Pressurizer Pressure that occurred as a result of a Main Steam Isolation Signal actuation.

"At 0337 MST, both trains of Low Pressure and High Pressure Safety Injection (LPSI and HPSI) were made inoperable when the injection valves were overridden and closed in accordance with station procedures. At 0346 MST, in accordance with station procedures, both trains of Containment Spray, LPSI, and HPSI pumps were overridden and stopped, rendering Containment Spray inoperable as well. This represents a condition that would have prevented the fulfillment of a safety function required to mitigate the consequences of an accident per 10 CFR 50.72(b)(3)(v)(D). Additionally, at the time of the Safety Injection Actuation Signal (0315 MST), both trains of Emergency Diesel Generators actuated as required and both 4160 VAC busses remained energized from off-site power.

"The NRC Senior Resident Inspector has been informed."

Notified R4DO (Young)

SURVEILLANCE NOT PERFORMED IN REQUIRED TIMEFRAME

"The [Missouri University of Science and Technology Reactor] MSTR is required by Technical Specification 4.6.2(1) to perform an experimental verification of calculated airborne effluent release values every five years and when a change in licensed power occurs. An experimental verification was performed on October 24, 2019. However, in a follow-up assessment of the verification report and data, the results and analysis were determined to be non-credible. As the most recent experimental verification was completed on October 27, 2014, the MSTR does not meet the requirement of TS 4.6.2(1).

"This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day (reported as EN-55266). Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days. An experimental verification of gaseous effluent release will be performed as soon as practical following restoring the MSTR to an operable status, which is expected to occur no later than July 31, 2021."

The licensee will notify the NRC PM (W. Kennedy).