Event Notification Report for November 23, 2021

EN Revision Imported Date: 11/23/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - LOST OR STOLEN MOISTURE DENSITY GAUGE

The following is a synopsis of information received via telephone:

Upon arriving at a jobsite in West Indianapolis, the technician went to remove a Troxler gauge for use. Upon opening the toolbox in the bed of the truck, the technician found that the Troxler gauge was missing from its case. The toolbox is bolted to the bed of the truck, however the locks for the toolbox and case were found not to be locked.

At the present time, the licensee is not sure whether the Troxler gauge was stolen or possibly left at the last jobsite where it was used this past Saturday. The licensee is dispatching individuals to the last jobsite to search for the Troxler gauge. The licensee has also reported this event to the Indianapolis Police Department.

The Troxler gauge is a Model 3430 moisture density gauge, serial number 23266. The Troxler gauge contains 0.3 GBq of Cs-137 and 1.48 GBq of Am-241.

The licensee will provide updated information when available.

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: 11/23/2021

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

The following information was received via E-mail:

"One exit sign, model SLX60 was reported as lost when the State requested registration for 17 exit signs shipped to Pindustry for installation."

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: 11/23/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE DURING Y-90 ADMINISTRATION

The following information was received via E-mail:

"On Saturday, November 13, 2021 at 1420 PST, a CDPH-Radiologic Health Branch inspector was notified by E-mail that a medical event had occurred on November 12, 2021, at UCLA during a Y-90 liver cancer treatment. The signed written directive was included in the notification.

"The prescribed dose for 'Segment Left' was 70 Gy (6 GBq) and the dose delivered was 68.8 Gy (or 98.29 percent of the prescribed dose). The prescribed dose for 'Segment Right' was 120 Gy (3 GBq) and the dose delivered was 78.3 Gy (or 65.25 percent of the prescribed dose).

"The authorized user administered two vials of BTG Nordion Inc. TheraSphere Y-90 glass microspheres beginning approximately 1200 PST. Vial number 101 went to the right lobe and vial number 30 went to the left lobe of the liver.

"Radiation surveys of the waste containers occurred at 1516 PST and 1519 PST respectively, and the radiation level from vial number 30 was higher than expected. UCLA's medical physicist was consulted at 1630 PST November 12, 2021, who determined that a medical event had occurred.

"UCLA will be investigating the cause of the underdose and make a 15-day written report."

California 5010 Number: 111221

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: 11/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LEAKING CALIBRATION SOURCE

The following was received from the Ohio Department of Health Bureau of Radiation Protection via email:

"The licensee reported a sealed Cs-137 source (IPL Model SRV-137-200U) used to calibrate instruments was leaking. The leak test was taken on November 7, 2021 and the results were reported to the licensee on November 14, 2021. The leak test results were 338 Bq (0.009 microCi). Surveys of the lead pig and source storage area showed no contamination. The source will be returned to the manufacturer for disposal."

Ohio Item Number: OH210009

EN Revision Imported Date: 11/24/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health (CDPH) via email:

"On Monday, November 15, 2021, Twining, Inc. reported the theft of a CPN MC-1DR #MD0080857 containing sealed sources of Cs-137 (10 mCi) and Am-241 (50 mCi). The theft occurred after 1700 (PST) on Saturday November 13, 2021 at a temporary job storage site (Clipper's Stadium in Inglewood, CA). There was a locked perimeter fence and a guard onsite. The CPN nuclear gauge was locked in its transport case, locked inside a job box, which was chained to a larger Conex box on site. Other equipment was also stolen from the jobsite. A police report is being filed. Additional information has been requested by CDPH."
California event number: 111521

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: 11/23/2021

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

At 1046 EST on November 21, 2021, with Calvert Cliffs Nuclear Power Plant Unit 2 in Mode 1 at 100 percent power, the reactor was manually tripped due to lowering levels in both steam generators following a loss of the 21 and 22 steam generator feed pumps. An Auxiliary Feedwater System actuation occurred to restore steam generator water levels. The trip was not complicated, with all systems responding normally. Decay heat is being removed by the Auxiliary Feedwater System. Calvert Cliffs Nuclear Power Plant Unit 1 is unaffected and remains in Mode 1 at 100 percent power.

Due to the Reactor Protection System (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification. RPS actuation, 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 notification, 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 Inspector has been notified.

EN Revision Imported Date: 11/24/2021

EN Revision Text: MEDICAL EVENT - DOSE ABOVE THE PRESCRIBED DOSE

The following was received from the licensee via email:

"The VA National Health Physics Program is reporting a medical event as defined in 10 CFR 35.3045.

"The medical event occurred at the VA San Diego Healthcare System, San Diego, California. The Department of Veterans Affairs holds NRC license number 03-23853-01VA.

"The medical event occurred on July 13, 2021, and was discovered on November 16, 2021. The medical event involved the administration of approximately 152 millicuries of Iodine-131 sodium iodide to a patient. The patient received close to the activity intended by the authorized user physician. However, there was an error on the written directive form - the activity prescribed by the authorized user physician was mistakenly listed as 2 millicuries. Because the patient received the intended treatment, this medical event is not expected to cause any harm to the patient. The VA National Health Physics program has notified the NRC Project Manager, Bryan Parker of NRC Region III, for the VA Master Materials license."

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: 11/24/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - UNDER DOSE
The following is a synopsis of a report from the licensee:

On November 16, 2021 at approximately 1100 (EST) while delivering a Y-90 Thermosphere treatment to the liver, the vial septum failed under pressure. This resulted in not all the dose being delivered to the patient. The prescribed dose was 35.1 millicuries. The delivered dose was 14.4 millicuries. All the delivered dose was to the correct organ. No deleterious effects to the patient are expected.

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: 11/24/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL OVERDOSAGE

The following was received from the Wisconsin Radiation Protection Section (the State):

"On November 17, 2021, the licensee reported to the State a medical event involving Y-90 SIR-Spheres that was discovered that same day and occurred on November 16, 2021. Two administrations were prescribed to different segments of the left lobe of the liver, one of 0.4 GBq and one of 1.6 GBq. A calculation error occurred while converting these doses from GBq to milli-Ci which resulted in administered doses of 0.51 GBq and 2.3 GBq respectively; both of which are 27 percent above prescription. The State will continue to follow-up on the event."

No deleterious effects to the patient are expected. All dose was delivered to the intended organ.

Wisconsin Event Report ID Number: WI210008

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: 11/24/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDER DOSE

The following is a synopsis of a report received from the State of Washington, Office of Radiation Protection via email.
On Monday, November 15, 2021 a patient undergoing cancer treatment at University of Washington Medical Center, received an under dose of Y-90 TheraSpheres. The details of the intended dose to the liver (target organ) are yet to be provided. They will be forwarded when obtained.

Washington report number: TBD

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.

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID EMERGENCY DIESEL GENERATOR ACTUATION

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid specific system actuation.
At 0907 [EDT] on September 30, 2021, with Unit 1 in Mode 1, at 100 percent power, an actuation of the 1-1 emergency diesel generator (EDG) occurred during loss of voltage relay functional testing. The 1-1 EDG auto-start was due to human error during performance of the test procedure when the bus 1AE undervoltage signal was improperly defeated and a simulated undervoltage signal was applied. No actual undervoltage condition was present during this event. The 1-1 EDG automatically started as designed when the bus undervoltage signal was received. This was a complete actuation of an EDG to start and come to rated speed, and all affected systems functioned as expected in response to the actuation. Following the actuation, the relays were restored and the 1-1 EDG was shut down in accordance with plant procedures.

"This event is considered an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A).

"The actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. Therefore, in accordance with 10 CFR 50.73(a)(1), this telephone notification is provided within 60 days after discovery of the event instead of submitting a written Licensee Event Report.

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