Event Notification Report for September 15, 2021

EN Revision Imported Date: 9/15/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST AMPULES FROM A TRITIUM EXIT SIGN

The following is a synopsis of information received via E-mail:

This event was originally reported via phone to the New Mexico Radiation Control Bureau on August 6, 2021.

This incident involved a double sided (2 sign faces) tritium exit sign. Specific details of the sign are: Radioactive Material: Tritium (H-3), Quantity: 7.5 Ci per sign face, Chemical and Physical form: Gas, Manufacturer: Sign Tex Inc.

This sign was located outside of the hospital building. The sign was damaged, and was then cleaned up by facilities and placed in a trash receptacle. The staff member who cleaned up the sign was confident that none of the glass ampules were broken and that all pieces were collected. The incident was then reported to the Safety Officer and the sign was removed from the waste bin. The Safety Officer then reported the sign to the RSO [Radiation Safety Officer] for guidance on how to properly dispose of the sign. Upon evaluation of the sign it was discovered that a part of one of the sign faces was missing. This piece includes the ampules which make up the letter "T" and an arrow (3 tubes total) of the sign. In addition, the sign casing was reported as missing. The activity information noted above was received from the sign manufacturer based off of the part number listed on the Order Acknowledgement document. The order date was reported as August 23, 2017. As there is no observable original date for the H-3, no decay correction was made in order to be conservative. It is currently assumed that the casing and the missing piece were disposed of, and due to the radiological properties, the piece was not detected by any waste radiation monitors. All remaining pieces of the sign are intact and were observed to glow, confirming that the ampules are not leaking.





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: 9/15/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDER-DOSING EVENT WITH Y-90 THERASPHERES

The following information was received via E-mail:

"On 8/24/21, a Y-90 TheraSphere treatment was to deliver a planned 13.65 GBq to the patient's anterior right hepatic lobe. The written instructions were followed in the usual fashion and the dose was administered to the patient. The catheter and administration set tubing were placed into the waste container. The patient, personnel, and room were surveyed. No spill was detected. Upon post-calculation measurements, it was found that the patient only received approximately 77 percent of the expected dose of 200 Gray. While the received 154 Gray was medically appropriate given the patient's condition, tumor type and tumor location, this treatment still fell below that intended on the written directive. Further investigation found that this patient was rescheduled multiple times and the dose had decayed further than it was planned to, the patient really should have been treated the day before on a Monday instead of the Tuesday to get the full dose as planned or a new Treatment Window Illustrator to secure a more appropriate Y-90 dose should have been completed. Patient and referring provider were notified. There were no contaminations verified by survey meter measurements. The licensee is currently implementing an Excel spreadsheet program to review accuracy prior to patient scheduling and dose ordered. Reporting Criteria under 10 CFR 35.3045."

Kentucky Event Report ID No.: KY210002

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: 9/15/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 MICROSPHERES

The following information was received via E-mail:


"On September 7, 2021 at 1535 EDT, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on September 2, 2021 (procedure date). The Authorized User (AU) discovered the event on September 3, 2021. According to the written directive, the prescribed dose to liver segments 2 and 3 was 130 Gy and to liver segments, 4 and 8 was also 130 Gy. After the procedure, the licensee discovered that the dose intended to liver segments 2 and 3 went to liver segment 4. As a result, liver segment 4 received the unintended dose of 54 Gy and the intended dose of 130 Gy for a sum of 184 Gy, which is a difference of 41.5 percent. The licensee reported that the cause of the event was a result of incorrect location of the delivery catheter and the patient was notified on September 3, 2021.

"The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."

Virginia Event Report ID No.: VA210005

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: 9/15/2021

EN Revision Text: SPECIFIED SYSTEM ACTUATION

"At 0011 EDT, with Unit 2 in Mode 5 (Cold Shutdown), actuations of the 2B Diesel Generator (DG) and the 2B Motor Driven Auxiliary Feedwater (AFW) Pump occurred during Engineered Safety Features Actuation Periodic Testing while resetting the 2B DG Load Sequencer. The 2B DG was running unloaded following test actuation, and during realignment from the test, a blackout condition was experienced when the breaker opened supplying the 4160 Volt Essential Power System 2ETB from the Standby Auxiliary Power Transformer SATB. Sequencer actuation closed the emergency breaker to 2ETB and loaded the 2B Motor Driven AFW Pump onto the bus. Steam supply valves to the Turbine Driven AFW Pump were open from the previous test configuration.

"This event is being reported in accordance with 10CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the 2B DG and the 2B Motor Driven AFW Pump.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

EN Revision Imported Date: 9/15/2021

EN Revision Text: UNANALYZED CONDITION OF FIRE SAFE SHUTDOWN EQUIPMENT

"On September 13, 2021, at 1822 EDT, an apparent non-compliance with 10 CFR 50, Appendix R, section III.G.2 (separation of redundant fire safe shutdown equipment) was identified. Specifically, it was determined that some Emergency Diesel Generator (EDG) cables may be susceptible to a hot short/spurious operation to the close circuit. A spurious closure of the emergency bus normal supply breakers after the EDG is powering the bus could result in non-synchronous paralleling, EDG overloading, or EDG output breaker tripping due to faulted power cable from normal supply breaker. The spurious closure of the normal supply breakers is not currently addressed in the Appendix R Report or previous Multiple Spurious Operations (MSO) analysis.

"This condition is associated with the Appendix R safe-shutdown function of the Emergency Power System. The Emergency Power System is considered operable but not fully qualified for its safety-related design function.

"The following fire areas are impacted:
1) Fire Area 13, Unit 1 Normal Switchgear Room
2) Fire Area 46, Unit 1 Cable Tray Room
3) Fire Area 3, Unit 1 Emergency Switchgear and Relay Room
4) Fire Area 2, Unit 2 Cable Vault and Tunnel

"Until this condition is analyzed, Surry has implemented mitigating actions in the above fire areas.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). This is also reportable as a 60-day written report pursuant to 10 CFR 50.73(a)(2)(ii)(B). This event was entered into the licensee's Corrective Action Program as CR [condition report] 1180502.

"The NRC Resident Inspector has been notified of this event."

Mitigating actions include posting fire watches in the affected areas.