Event Notification Report for July 20, 2021

EN Revision Imported Date: 7/20/2021

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: 7/20/2021

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: 7/20/2021

EN Revision Text: REACTOR OPERATED AT GREATER THAN 100 PERCENT TECHNICAL SPECIFICATION POWER LIMIT

"On February 28, 2021, [at approximately 1500 EST], following recalibration of the reactor power in accordance with PUR-1 Technical Specifications, the reactor operator operated the reactor at 8.5 kW (85% of nominal power) and noticed that the rate of temperature change of the coolant was greater than expected. Noting that this presents the possibility of the power being in excess of expectations, PUR-1 was shut down and has remained shut down to date. PUR-1 staff immediately notified the Committee on Reactor Operations (CORO) and developed a plan to perform an in-depth investigation.

"Since then, multiple independent assessments on the reactor power have been performed, which include: Hand calculations, Monte Carlo N-Particle code (MCNP) simulations, analysis on activity measurements of irradiated materials, a thermal-hydraulic analysis using a Computational Fluid Dynamic (CFD) model of PUR-1, and a more physical assessment using resistance heaters as heat sources to determine the coolant temperature change rate as a function of power and pool temperature, which has just been completed.

"These five independent evaluation methods performed to determine the core power during the experiment on February 28, 2021, suggest that the reactor may have been operated for about 4 hours at a power in the range between 118.3 percent to 129.2 percent of our 12 kW maximum allowable power (per TS 2.2). While the reactor was not operated outside the bounds of the Safety Analysis Report (SAR), this represents a potential need for reporting under TS 6.7.b.1.c.vi, 'An observed inadequacy in the implementation of procedural controls...'.

"Staff are currently evaluating several potential corrective actions including adjustment of the current power calibration constant, which relates the activity of the gold foil to the core power, by the most conservative factor suggested by these five analyses. There was no impact to the safety of the public or PUR-1 staff and the Safety Limit was not exceeded at any point. A formal report will be subsequently issued."

EN Revision Imported Date: 7/20/2021

EN Revision Text: ONSITE MEDICAL EMERGENCY

On July 19, 2021 at 1316 EDT, an individual experienced a non-work related medical emergency. The onsite fire brigade and emergency medical technicians administered first aid, but the individual was unresponsive. The individual was transported to the local hospital. At 1458 EDT, the local hospital notified the station that the individual was deceased. The individual was outside of the radiological controlled area and was not contaminated.