Event Notification Report for November 19, 2021

EN Revision Imported Date: 11/19/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSAGE

The following was received from the Texas Department of State Health Services (the Agency):

"On November 10, 2021, the Agency received notification from [the Radiation Safety Officer] RSO of the licensee reporting that a yttrium-90 TheraSphere administration with an intended activity of 44.8 mCi (120 Gy) to be inserted resulted in only 18.7 mCi inserted into the patient with the remainder still in the delivery system. RSO reported the procedure was completed indicating there was no stoppage due to patient or otherwise intervention. This was 41.6 percent of the prescribed activity inserted into the patient and at present an unknown dose. The target was a tumor in the liver. A survey of the room was done with no contamination found."

Texas Incident: I-9895

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: 11/19/2021

EN Revision Text: MEDICAL EVENT - UNDERDOSAGE DUE TO HDR AFTERLOADER MALFUNCTION

The following information was received via E-mail:

"On November 12, 2021, the Department (Arizona Department of Health Services) was notified by the licensee that during an HDR treatment, an error message showed up after the first 15 channels were delivered. The error message was '8C:2 Dummy park switch or drive failure.' The Varian Medical System help desk was contacted for the error message without resolution. The field service engineer was called and suggested to power down the afterloader unit and reboot it, which did not resolve the problem. To avoid putting the patient under general anesthesia any longer, the Authorized User decided to stop the treatment and left the remaining four (4) channels untreated. The prescribed dose was 14 Gy and the estimated dose given was 10.2 Gy. The afterloader unit was a Varian Varisource iX, with an activity of 7.5 Ci of Iridium-192. The Department has requested additional information and continues to investigate the event."

Arizona Incident: 21-010

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: 11/19/2021

EN Revision Text: MANUAL REACTOR TRIP AND AUTOMATIC AUXILIARY FEEDWATER ACTUATION

"At 1313 hours on November 17, 2021, with Unit 2 in Mode 1 at 100 percent power, the reactor was manually tripped due to a loss of the 21B Main Feedwater Pump [due to low suction pressure]. The Auxiliary Feedwater System automatically started as designed in response to the full power reactor trip. Additionally, the Main Steam Isolation Valves were manually closed to prevent excessive reactor coolant system cooldown. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response. Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the atmosphere using the Atmospheric Dump Valves.
"Beaver Valley Power Station Unit 1 is unaffected and remains at 100 percent power in Mode 1.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, the automatic actuation of the Auxiliary Feedwater System is being reported as an eight-hour, non-emergency Specific System Actuation per 10 CFR 50.72(b)(3)(vi)(A).

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

EN Revision Imported Date: 11/19/2021

EN Revision Text: Non-Work Related On-Site Fatality

"At 2238 Eastern Standard Time (EST), on 11/17/2021, a Watts Bar Nuclear Plant contractor was transported offsite for treatment at an offsite medical facility. The offsite medical facility notified Watts Barr Nuclear Plant at 2310 EST that the individual had been declared deceased.

"The fatality was not work-related and the individual was inside of the Unit 1 Radiological Controlled Area. The individual was confirmed not to be contaminated.

"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).

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

The licensee will notify OSHA.