Event Notification Report for March 28, 2023

AGREEMENT STATE REPORT - DOSE ABOVE PRESCRIBED DOSE

The following information was provided by the Massachusetts Radiation Control Program (MA RCP) via email:

"On 3/29/2023 at 1353 EDT, the Radiation Safety Officer (RSO) at Tufts Medical Center reported a medical event, misadministration, to the MA Radiation Control Program.

"On 3/28/2023 at 2230 EDT, the licensee discovered that a patient was administered, on the same date shortly before the discovery, a therapeutic activity of 37.9 mCi of Y-90 microspheres to the right lobe of the liver instead of the intended total of 11 mCi in a two-step successive administration per written directive. The patient and the referring physician have been notified.

"It was reported by the RSO that the administering physician determined that there will be no adverse effect to the patient as a result of the event. The cause of the event has initially attributed to human error by the administering technologist. The error was the improper application of a dose calibrator correction factor for the administration of Y-90 microspheres. A correction factor of 10 was not applied as per procedure. As a result, the technologist drew an activity of 60.3 mCi into the vial instead of 6.03 mCi as per the written directive for the first dose in an intended two step successive administration up to 11 mCi. The actual stasis administration was 37.9 mCi, which is the portion actually delivered to the right lobe of the liver via the delivery apparatus resulting in overloading. No further administrations to the patient occurred.

"At 1538 EDT on 3/29/2023, the Tufts RSO was contacted to discuss the facility's immediate corrective action. MA RCP recommended that the technologist responsible for the event not be allowed to perform any further therapeutic or diagnostic procedures at this time due to their failure to follow procedures (written directive). The Tufts RSO agreed. It was also agreed that he would contact the administering physician and forward the request for the dose conversion from mCi to rads or Grays to the target tumor.
Tufts will provide any additional immediate corrective actions and the delivered dose estimate to the Radiation Control Program in a preliminary summary report on 3/30/2023."

MA Event 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.

AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received from the Texas Department of State Health Services [the Agency] via email:

"On March 29, 2023, the licensee reported to the Agency that on March 28, 2023, one of its technicians was performing routine shutter checks, and the shutter on one of their Vega SHF-2 gauges, containing a 50 millicurie cesium-137 source, was stuck in the open position. Open is the normal operating position for the gauge. The gauge is mounted 10-12 feet above the ground on the side of a tank with no direct access so there is no risk of exposure to individuals The licensee will contact a service company to make repairs. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No.: 10002

Texas NMED No.: TX230013

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following report was received from the Washington State Department of Health [WA State] via email:

"WA State received a licensee report of a stuck radiography source incident at 1606 [PDT] on March 28, 2023. The incident took place at the licensee's facility in Tacoma. The source guide tube was crimped, preventing the source drive cable from retracting into the device's shielded enclosure. A two milli-Roentgen per hour, radiation boundary was established, and the facility operations location/entrance was secured. No overexposures or spread of contamination occurred due to the event. Source retrieval/recovery actions have been completed. WA State was notified that the source was fully retracted into the shielded exposure device today, March 29, 2023, at 0430 [PDT]."

WA Incident No.: WA-23-006

FITNESS FOR DUTY REPORT

A non-licensed supervisor had a confirmed positive for a controlled substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.

PART 21 - DEFECT IDENTIFIED IN EMERGENCY DIESEL GENERATOR GOVERNOR

The following is a synopsis of information provided by the Engine Systems, Inc (ESI) via fax:

Component Description: Woodward Governor, Part No. 9903-722, Serial No. 18847017

Problem Description: An EGB-35P governor/actuator (governor) installed on a customer's emergency diesel generator failed soon after installation. Investigation revealed a piece of foreign material, a loose buffer plug, inside the governor that caused the failure. Since the governor is used to maintain fuel rack position of the diesel engine, failure of the governor would prevent the emergency diesel generator from performing its safety-related function during an event.

Affected Plants: Brunswick Nuclear Plant

Corrective Actions for Brunswick Nuclear Plant: No action required. The affected governor has been returned to ESI.

Corrective Actions for ESI: The governor will be refurbished under ESI's 10 CFR 50 Appendix B program and certified for continued use at Brunswick Nuclear Plant. To prevent reoccurrence, ESI will revise the dedication requirements to enhance existing foreign material inspection practices to include a visual inspection where the buffer plug was located within the governor. The revisions are expected to be complete within 30 days but in all cases prior to future shipments.