Event Notification Report for June 15, 2022

AGREEMENT STATE REPORT - SUSPICIOUS ACTIVITY RELATED TO IRRADIATOR MOVE

The following was received from the Pennsylvania Department (DEP) Bureau of Radiation Protection via email:

"On June 5, 2022, the DEP was present for the removal of an irradiator at Children's Hospital of Philadelphia, a location on University of Pennsylvania license (PA-0131). A crew member of the rigging subcontractor was seen livestreaming the operation. Campus police were immediately notified, the filming was stopped, and the crew member was removed from the site. The DEP is investigating and will update this event as soon as more information is provided."

Event Report Identification Number: PA220020

AGREEMENT STATE REPORT - UNDERDOSE TO TREATMENT SITE

The following information was received from the Washington State Department of Health via email:

"On 06/08/2022, Inland Northwest (INW) Multicare's radiation safety officer (RSO) reported a medical event had occurred. A Y-90 therasphere procedure was done on the previous day (06/07/2022), the procedure went according to plan, however after the procedure was completed the after injection surveys and quality assurance was done, it revealed that a portion of the microspheres did not come out of the tubing as designed. After calculation it was determined that the patient only received 26 percent of the target dose. The licensee immediately notified the manufacturer to see what happened. The manufacturer told them this is a known issue and has happened before. INW is writing up a full report and will submit it when completed."

WA incident no.: WA-19-004

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: 6/14/2022

EN Revision Text: PARTIAL LOSS OF POWER TO RPS DURING MAINTENANCE

The following information was provided by the licensee via email:

"During thermography of a reactor protection system (RPS) distribution panel, a circuit breaker (RPS-CB-7B) was inadvertently opened. This resulted in a partial loss of power to RPS Division B, which caused containment isolations to occur in multiple systems (Reactor Water Clean Up, Equipment Drains Radioactive, Floor Drains Radioactive, Reactor Recirculation, and Traversing lncore Probe). Specifically, RWCU-V-1, FDR-V-3, EDR-V-19, RRC-V-19, and TIP-V-15 all closed. All actuations occurred as designed upon the partial loss of RPS power.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(iv)(A) due to an unplanned valid actuation of a system pursuant to 10 CFR 50.72(b)(3)(iv)(B)(2). Additionally, this is being reported pursuant to 10 CFR 50.72 (b)(3)(xiii) for a major loss of emergency assessment capability due to the inability to assess primary containment identified and unidentified leakage rates.

"Emergency assessment capability was restored at 1008 PDT upon system restoration."

The NRC resident was notified by the licensee.

FITNESS-FOR-DUTY REPORT

The following information was provided by the licensee via email:

"A licensed operator supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant is on hold in accordance with the licensee's fitness-for-duty policy.

"The NRC Senior Resident Inspector has been notified."