Event Notification Report for July 09, 2021

EN Revision Imported Date: 7/9/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDER DOSE

The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email:

"On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy.

"During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event.

"RHB will be following up on the medical event."

CA 5010 Number: 070121

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: 7/9/2021

EN Revision Text: REPORT OF LOST MATERIAL

The following is a summary of a phone call with the licensee:

During a recent NRC inspection, the Radiation Safety Officer (RSO) and the NRC inspector determined that 2 Exit Signs (H-3; 0.352 Bq each) were missing and could not be located. The RSO has been searching since the inspection and has yet to locate the signs. The RSO noted that the exit signs were ordered in 2009 but was unable to find any removal work orders and is unaware of any effort to dispose of the signs. The RSO is unsure how long the signs have been missing. The licensee notified the NRC Region III Office.

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: 7/9/2021

EN Revision Text: SAMPLE DISCOVERED MISSING

The following was received from the licensee via email:

"A metallurgy laboratory (Met Lab) sample was determined to be missing from its prescribed location in the Physical Test Lab on June 30, 2021 at approximately 1330 EDT. A search for the item was immediately initiated per requirements. As of 1300 EDT on July 2, 2021, the item has not been located and as a result, formal notification of a missing item is being made to the NRC per Chapter 3 of BWXT NOG-L's Fundamental Nuclear Material Control Plan (FNMCP). 10 CFR 74.51 requirements do not apply since the item does not contain Strategic Special Nuclear Material (SSNM). The search for the item has been concluded and an investigation into the disposition has been initiated. The missing item was categorized as low enriched uranium and contained 0.03 grams of U-235.

"The Resident Inspector will be notified."

EN Revision Imported Date: 7/9/2021

EN Revision Text: INVALID ACTUATION OF CONTAINMENT ISOLATION SIGNAL

"This 60-Day telephone notification is being made per the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid actuation of containment isolation signal affecting more than one system. On May 13, 2021, during the restoration of the Unit 2 Refuel Floor High Radiation Isolation Logic an invalid isolation signal was received. The condition requiring an isolation signal was verified not to be present prior to restoring the logic; however, it was not recognized that a previous isolation signal was latched in and had not been reset. When the isolation logic was restored, the Primary Containment Isolation System (PCIS) isolated on the invalid signal. The systems successfully completed the isolation per the plant design and plant configuration.

"The following systems actuated due to the Unit 2 PCIS Group 6C Isolation:
- Isolation of Containment Hydrogen and Oxygen Sampling Valves,
- Start of the 2A Reactor Enclosure Recirculation System,
- Trip of the Units 1 and 2 Refuel Floor HVAC,
- Start of the A and B Trains of Standby Gas Treatment Systems."

The NRC Resident Inspector was notified.