Event Notification Report for November 24, 2021

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: 11/24/2021

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."