Event Notification Report for September 16, 2021

EN Revision Imported Date: 9/16/2021

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: 9/16/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN THEN RECOVERED PORTABLE GAUGE

The following information was received via E-mail:

"On 9/7/2021 the New Jersey Department of Environmental Protection was notified that a licensee Authorized User's (AU) car was stolen in Jersey City with a portable gauge inside. The gauge and vehicle were both recovered on 9/8/2021 and are currently in the licensee's possession. An update will be provided once additional information from the licensee is obtained."

* * * UPDATE FROM SARAH SANDERLIN TO DONALD NORWOOD AT 1621 EDT ON 9/9/2021 * * *

The following information was received via E-mail:

"On 9/7/2021 New Jersey Department of Environmental Protection (NJDEP) received notification from a licensee that an AU's car was stolen while containing radioactive material. NJDEP was informed by the licensee that the AU's personal vehicle was stolen from his residence in Jersey City on the night of 9/6/2021. The AU reported the missing vehicle to the police (report to be sent to NJDEP staff when received). By 1459 EDT on 9/8/2021 the AU found their vehicle on the street and notified the police who then released the vehicle back to them. The gauge was still secured in the vehicle with no signs of being tampered with."

Troxler portable gauge, Model 3430, S/N 20606 containing 9 mCi of Cs-137 and 44mCi of Am/Be-241.

Notified R1DO (Dentel) and NMSS Events Notification group.

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: 9/16/2021

EN Revision Text: AGREEMENT STATE REPORT - MINOR VEHICLE ACCIDENT WHILE TRANSPORTING A MEDICAL SOURCE

The following information was received via E-mail:

"The licensee Radiation Safety Officer (RSO) called the Florida Bureau of Radiation Control today, 9/9/21, to report a minor vehicle accident which occurred on Sunday afternoon, 9/5/21, around 1700 EDT, involving one of their Nuclear medicine drivers. The RSO indicated one of their pharmacists received a call on Sunday for a stat nuclear medicine delivery to Gulf Coast Hospital. The pharmacist's wife drove him in her personal vehicle to deliver the nuclear medicine but was involved in a minor vehicle accident on the way to deliver the meds. The RSO indicated the package was entirely intact with no breakage or leakage occurring. The pharmacy manager arrived on the scene to continue with the delivery while the pharmacist and his wife went to the hospital for evaluation. The Florida Bureau of Radiation Control is waiting for the police report and video surveillance from the pharmacy to complete the incident report."

Florida Incident Number: FL21-114

EN Revision Imported Date: 9/16/2021

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.

OFFSITE NOTIFICATION DUE TO EMPLOYEE FATALITY

"At 0658 CDT on 09/15/2021 a non work-related death occurred of a site employee. The individual was outside of the Radiological Controlled Area. This is a four-hour notification, non-emergency for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified."

PART 21 - LOOSE CONNECTION ON EGP/ETR SERIES RELAYS
The following is a summary of information received from TE Connectivity via fax:
During Management of Change review on 7/23/21, TE Connectivity discovered test load was unconnected to HI-POT tester for EGP/ETR series relays. TE's investigation found a connection remained loose after scheduled calibration testing on 12/30/2020.
This report serves to document TE's evaluation and the corrective action taken on this issue:
1. A search of TE's database finds no occurrence of Dielectric Withstand Voltage (DWV) test failure at TE facility or similar failure with our customers in the field.
2. Many nuclear customers perform thorough inspections and testing prior to installing relays.
3. No customer history of EGP/ETR complaints of DWV failures found.
4. A series of corrective actions are now in place to guarantee full DWV testing to specification including: a mistake proof HI-POT test fixture developed and installed, and Hi-Pot test setup verification included as part of testing routine.

There have been no reported field failures for the identified impacted produce. However, out of an abundance of caution TE will notify customers of the issue and the option to return any relays potentially related to this issue for retesting and recertification.

Point of Contact:
Lucinda Hodge
Quality Manager
TE Connectivity, Aerospace Defense and Marine Division
1396 Charlotte Highway
Fairview, NC 28730