Event Notification Report for May 30, 2023

AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)

The following information was received from the Pennsylvania Department of Radiation Protection via email:

"On March 28, 2023, a patient was treated with a permanent Cs-131 implant with a prescribed dose of 60 Gy. On April 11, 2023, the patient presented with a serious medical condition which necessitated the immediate removal of the implant. The seeds were all accounted for and placed into storage for decay to background. The actual dose delivered is calculated to be 37 Gy. The referring physician and the patient have been informed."

Event Report Identification Number: PA230015

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 - LEAKING SOURCE

The information below was provided by the Georgia Department of Natural Resources via email:

"During a routine sealed source inventory check, Cardiac Consultants of Central Georgia, LLC, license GA 1629-1 discovered that one of their Cs-137 vials (S/N 1615-4-2) appeared to display signs of moisture within. This source's current activity is 0.15078 mCi. A wipe test was then performed. Results of the wipe test confirmed that this source was leaking. The area surrounding the source was surveyed and wipe tested as well. No sign of contamination was discovered. The leaking source has been contained and is secured in the licensee's hot lab in an appropriate shielded container. The licensee waits for a hazardous waste disposal quote before properly disposing. This incident occurred on May 11, 2023, and the licensee reported to the State on May 15, 2023. The State is waiting for the licensee to provide a copy of leak test results for the source of concern and confirmation of source disposal."
GA Incident Number: 65

AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)

The following was received from the Colorado Department of Public Health and Environment via email:

"On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation."

Colorado Event Report Number: CO230012

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 - PACKAGE EXCEEDED RADIATION LIMITS

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"A telephone call received by the Agency from the [Radiation Safety Officer] RSO of Invicro, LLC, at 1054 EDT on 5/19/2023. A package was received on 5/19/2023 at approximately 1000 EDT at the licensee's site that exceeded the dose rate limit of 200 mrem/hr on the external surface of the package. The radionuclide was fluorine-18 (F-18) in liquid form enclosed in a glass vial. The assayed dose was 499 mCi at 0930 at PETNET Solutions, Inc. in Woburn, MA, the distributor of the F-18.

"The package was labeled Yellow II and the maximum surface dose rate should therefore not exceed 50 mrem/hour for a Yellow II labeled package. The package upon shipment was measured by the shipper to have a surface dose rate of 7 mrem/hour and a transport index (TI) of 0.4.

"The licensee reported that 5 wipe samples were taken on the external surface of the package with no resultant removable contamination observed. It was reported that the glass vial contained approximately 350 mCi of F-18 at the time the package was opened. The external dose rates on all external surfaces continued to exceed 200 mR/hr, even with the vial removed from the package.

"Surveys of areas where the package was opened, and where the vial was transported, are undergoing. The vial is currently stored in a hot cell. The external package is being stored in a shielded location. Personnel are being surveyed for contamination. At this time there is no indication of external contamination of the shipping package.

"The Agency, Invicro LLC, and PETNET Solutions, Inc. are in communication working the details of the scenario and potential personnel exposer.

"The Massachusetts Radiation Control Program considers this to be an open reportable event."

AGREEMENT STATE REPORT - SHUTTER MISSING

The following information was provided by the Texas Department of State Health Services (the Agency) via phone and email:

"On May 23, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine shutter checks, the shutter for a Thermo Fisher model 5190 gauge was missing. The shutter is a block of lead that slides across the radiation beam. The RSO stated they believe the lead block (shutter) must have vibrated off the slide. The gauge has been removed and placed in storage and will be disposed of. The gauge contains a 200 millicurie (original activity) [Cs-137] source. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10022

Texas NMED No.: TX230025

UNANALYZED CONDITION OF EMERGENCY DIESEL GENERATOR

The following information was provided by the licensee via phone and email:

"At 1345 EDT on May 25, 2023, it was determined that a fire barrier for area 737-A1B was not installed, and would render the 2A Emergency Diesel Generator (EDG) not operable in the event of a fire on the Unit 2 side of elevation 737 in the Auxiliary Building. The 2A EDG is the credited power source for fire safe shutdown for a fire located in this area. Without the credited source of power, this places WBN U2 [Watts Bar Nuclear Unit 2] in an unanalyzed condition. A fire watch has been established in the area until the issue is resolved. Therefore, this event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."

PART 21 INTERIM EVALUATION - MECHANICAL DRAFT COOLING TOWER FAN BRAKES DESIGN FLAW

The following is a summary of the information provided by the licensee via email:

"As previously reported under Fermi LER 2023-001-00, submitted on May 22, 2023, at 1145 EDT on March 23, 2023, it was determined that all mechanical draft cooling tower (MDCT) fan brakes would not perform their design function during a tornado due to the speed switch not functioning over its published voltage and frequency ranges. The MDCT fan brakes are required to prevent fan overspeed from a design basis tornado. On May 25, 2023, Fermi completed its 10 CFR Part 21 discovery process and determined the need to perform a 10 CFR Part 21 evaluation. The vendor (Engine Systems Inc. (ESI)) was contacted and the purchaser (Fermi) assumed responsibility for performing the Part 21 evaluation for the supplied mechanism. This Part 21 evaluation is being tracked by Fermi CARD 23-20075.

"It has been determined the direct cause of the event was due to the Dynalco speed switch model SST-2400A-1, supplied by ESI, not functioning over its published voltage and frequency ranges. Corrective actions were taken to develop a design change to correct MDCT fan speed control system returning the MDCT fans, ultimate heat sink, and the service water subsystems to service on March 24, 2023. The root cause evaluation is ongoing, and written follow-up will be provided in 30 days by providing a supplement to the original LER by June 24, 2023.

"No new commitments are being made in this submittal."

NOTIFICATION OF UNUSUAL EVENT DUE TO MULTIPLE FIRE ALARMS IN CONTAINMENT NOT VERIFIED WITHIN 15 MINUTES

The following information was provided by the licensee via email:

"Notification of Unusual Event, HU4.1 declared based on multiple fire alarms in the containment building not verified within 15 minutes.

"Turbine trip causing reactor trip due to fault on 2GT transformer.

"At 1845 CDT, verification of no fire in the containment building."

Notified DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center (email), HHS Operations Center (email), EPA Emergency Operations Center (email), USDA Operations Center (email), FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).

* * * UPDATE AT 0148 EDT ON 5/28/23 FROM CHRIS BAARTMAN TO BILL GOTT * * *

The following information was provided by the licensee via email:

"This update is being made to report the actuation of the auxiliary feedwater system following the reactor trip at 1819 CDT. This event is being reported as a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(3)(iv)(A).

"This update is also being made for the termination of the notification of unusual event at 2304 CDT on 5/27/2023. The basis for the termination was that there was no indication of a fire.

"Upon lockout of 2GT transformer, main to reserve power transfer did not occur on 3 of 4 non-safeguards buses. Subsequently, operator action successfully restored power to all non-safeguards buses at 1925 CDT.

"There was no impact to the health and safety of the public or plant personnel.

"The NRC resident inspector has been notified of the update."

Notified R3DO (Benjam¡n), NRR EO (Walker), IRMOC (Grant), DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center (email), HHS Operations Center (email), EPA Emergency Operations Center (email), USDA Operations Center (email), FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).