Event Notification Report for July 19, 2021

EN Revision Imported Date: 7/19/2021

EN Revision Text: AGREEMENT STATE REPORT - SHUTTER STUCK OPEN

The following was received from the Alabama Department of Public Health (the agency) via email:

"An agency representative received a call about 1400 CDT from the RSO (Radiation Safety Officer) of International Paper Company, license no. 222, in Pine Hill, Alabama. The RSO stated that a fixed gauge was discovered with its shutter stuck open about 1000 CDT on 7/9/2021. The RSO stated that the gauge is located on functioning process equipment; there are no health and safety issues. The RSO stated that the gauge will have shielding added, be removed, and placed in storage on the plant site, on Monday, 7/12/2021.

"The gauge is an Ohmart SH-L1-0 s/n M6846 with a cesium-137 source, 80 mCi on 8/1992."

Alabama Event 21-22

EN Revision Imported Date: 7/19/2021

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Georgia Radioactive Material Program (the department) via email:

"The Safety Leader of Georgia-Pacific LLC sent an email on 6/18/21 stating they discovered a stuck shutter [on a Kay-Ray model 7064P instrument, (5000 mCi of Cs-137) while conducting pre-operational tests] at the end of an outage on 6/17/21. They contacted a contractor who was able to restore it properly.

"The department spoke with the Safety Leader and the RSO [(Radiation Safety Officer)] on June 28, 2021 concerning the stuck shutter that was reported on June 18, 2021. The shutter was unable to close due to a broken pin in the handle. This occurred 0600 EDT on June 17, 2021. No personnel were exposed during this occurrence. BBP [Sales, LLC] was contacted to fix the broken shutter. A BBP [certified technician] arrived around 1400 EDT that same day and was able to replace the broken pin and close the shutter. This job was completed about 1700 EDT. The BPP [certified technician] used his Geiger counter to check the area and a leak test was performed which showed no leakage."

Georgia Incident number: 42


* * * UPDATE ON 07/14/21 AT 0925 EDT FROM SHEREE BUTLER TO OSSY FONT * * *

The following update was received from the department via email:

"An inspection was completed by the department on 7/8/21. They observed the gauge in the closed position and were able to take readings with the Rad Eye survey meter of the area. Readings were 700 cpms. The department is requesting to close the report."

Notified R1DO (Cahill) and NMSS Events Notification via email.

EN Revision Imported Date: 7/19/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following was received from the state of California via e-mail:

"On Monday, July 12, 2021, [Radiation Health Branch] (RHB) Licensing Unit forwarded a July 9, 2021 email from [Radiation Safety Officer] (RSO) [redacted] (Permanente Medical Group, RML # 0269) stating that a patient received only half of the intended dosage for a Y-90 procedure of the liver.

"RHB contacted the RSO [redacted] for additional information on July 12, 2021. The RSO [redacted] emailed a statement from the Authorized User (AU), Interventional Radiologist, [redacted], stating that a Therasphere procedure was performed on Friday, July 9, 2021 that called for a prescribed dosage of 2.876 GBq of Y-90 Theraspheres. Prior to administration of the Y-90, the catheter was flushed with saline. AU reported that a slight resistance was felt, but all of the flush went through the catheter. He attributed the resistance to the sharp turns of the catheter in the branch vessel. The administration of 2.876 GBq Y-90 Therasphere was started. Upon administration of the Y-90 Theraspheres, the resistance became appreciated. Administration of the Y-90 Theraspheres was stopped and the catheter was withdrawn. Subsequent Geiger counter examination of the removed catheter indicated greater than normal activity remained.

"AU later confirmed that of the 2.876 GBq prescribed dosage, only 47.6 percent was delivered. 1.34 GBq Y-90 went to the liver and 0.027 GBq went to the lung. The resulting dose was 162.8 Gy to the liver and 1.37 Gy to the lungs.

"A written report will be provided to RHB within two weeks.

"CA Incident No.: 070921"

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: 7/19/2021

EN Revision Text: OFFSITE NOTIFICATION DUE TO EXCEEDING NPDES LIMIT

"While preparing for the June 2021 Discharge Monitoring Report (DMR), Environmental was entering data per the lab results that were sent from Pace Analytical for the June DMRs. On June 1, 2021, a National Pollutant Discharge Eliminating System (NPDES) sample was collected at outfall 001A to test for copper, there is a NPDES permit condition to monitor for copper on a quarterly basis. The lab report was returned to Fermi Environmental on June 15, 2021. The results came back at 41.2 micrograms/liter. Fermi's NPDES permit maximum limit is 40 micrograms/liter for outfall 001A. Due to the June 1, 2021 sample exceeding the permit limit, a second sample was collected on June 21, 2021 as a verification sample and the copper results came back July 13, 2021. Those results came back at 5.9 micrograms/liter which is within the permit limit. Environmental was aware of the June 1, 2021 copper exceedance limit but failed to recognize the reporting requirement at the time of the discovery because it was thought that the exceedance would be reported through the DMR submittal. The June DMRs are due on July 20, 2021.

"At approximately 1740 EDT on July 15, 2021, a Fermi environmental engineer was preparing and reviewing the Discharge Monitoring Report and identified that a recent sample result for outfall 001A was outside of the NPDES permit limit for Copper. The Copper sample result was 41.2 micrograms/liter with a limit of 40 micrograms/liter. Subsequent discussions with Environmental personnel determined that this issue should be reported to the state of Michigan Department of Environment, Great Lakes and Energy (EGLE). A discussion is planned with EGLE on July 16, 2021. This notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) based on the planned notification to EGLE."

The licensee notified the NRC Resident Inspector.