Event Notification Report for September 01, 2023

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department):

"On August 24, 2023, the licensee informed the Department of an under-dose incident involving cesium-131 (Cs-131). It is reportable per 10 CFR 35.3045(a)(1).

"On August 23, 2023 a patient received prostate seed therapy with Cs-131. The therapy plan detailed the need for 24 needles with 98 Cs-131 seeds total (1.8U/seed). A total of 107 Cs-131 seeds were received by the facility, based on the pre-plan volume. Devices used in the operation included: Ultrasound - BK Medical, BK 3000, serial number: 2003107; Planning System - Varian, Variseed 9.0, serial number: B29WL33; Stepper and applicator - CIVCO, Classic Stepper, serial number: 02107; MICK Medical, Mick TP applicator.

"Seed assay was performed with the activity per seed within acceptable regulatory limits. However, after the medical procedure, more than 37 seeds were found unused. According to the plan, the unused number was supposed to be 9. Thus, a total of 70 seeds were implanted. The physician and patient have been informed. The patient received 201.9 mCi (70 seeds) of the 282.6 mCi (98 seeds) prescribed.

"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report ID No.: PA230023.

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 - LOST LESS THAN CAT 3 SOURCE

The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):

"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.

"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.

"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."

Illinois Item Number: IL230021

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

NOTICE OF MISSED 24-HOUR NOTIFICATION PER 10 CFR 26.719(b)(1)

The following information was provided by the licensee via email:

"On 07/05/2023, at 0130 hours, a security officer found a 1 ounce bottle of vanilla extract in the protected area. Alcohol was identified as an ingredient on the ingredients label. It was determined the alcohol by volume (ABV) for vanilla extract is 35 percent ABV, above the 0.5 percent ABV considered low alcohol content. Vanilla extract is not listed as a prohibited item within Comanche Peak procedures.

"The initial reporting assessment of not reportable has been questioned during an in-process security access inspection and reassessed as a reportable condition. Emergency Notification System notification should have been made by 0130 CDT on 07/06/2023. This report restores compliance."

The NRC Resident will be notified.

AGREEMENT STATE - MEDICAL UNDERDOSE

The following information was provided by the Wisconsin Radiation Protection (the Department) via email:

"On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident."

Wisconsin Event Report ID Number: WI230015

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 - RECOVERED LOOSE SOURCE FOR FLOW METER

The following is a summary of information provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:

Mineral Development Safety Officer notified the BRC the morning of 8/28/23, of a 50 mCi [Cs-137] source that had fallen out of a Endress Hauser flow density gamma meter due to vibration. The source was on the ground adjacent to the meter. The area was secured and excluded. Mineral Development has no radiological survey meters onsite and a BRC manager and inspector were sent to investigate and secure the source.

On 8/29/23, a BRC inspector returned to the site and verified that a local representative from Qal-Tek had returned the source to the shielded position within the gamma meter. The meter will remain out of service until its subsequent removal from the piping system.

The BRC verified that Endress Hauser sold the gauge to Mineral Development, but the sale was not reported to the BRC by any party.

Florida Incident Number: FL23-131

CONTROLLED SUBSTANCE FOUND IN THE PROTECTED AREA

The following information was provided by the licensee via email:

"On 9/1/23 at 0900 hours, site personnel identified a 1 ounce bottle of vanilla extract in the protected area. Alcohol was identified as an ingredient on the ingredients label. It was determined that the alcohol by volume (ABV) for vanilla extract was 35 percent, above the 0.5 percent ABV considered low alcohol content."

AUTOMATIC REACTOR SCRAM DUE TO FEEDWATER TRANSIENT

The following information was provided by the licensee via email:

"On 9/2/2023 at 0632 EDT, a feedwater transient occurred resulting in an reactor protection system (RPS) automatic reactor scram on low level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 recirculation sample system isolation, Group 3 traveling in-core probe (TIP) isolation valve isolation, Group 6 and 7 reactor water cleanup isolation, and Group 9 containment purge isolations. All control rods inserted as expected. High pressure core spray and reactor core isolation cooling initiated and injected as expected. ECCS systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable and in Mode 3.

"These 4 hour and 8 hour non-emergency reports are being made in accordance with 10 CFR 50.72(b)(2) (iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident was informed. There was no impact on Unit 1."

ALERT DECLARED DUE TO UF6 RELEASE

The following information was provided by the licensee via email:

"On 09/02/2023, Honeywell declared a 'Plant Emergency' at 0815 CDT and upgraded to an 'Alert' at 0835 CDT in accordance with the Honeywell Emergency Response Plan due to a uranium hexafluoride leak on the kinney pump system."

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

* * * UPDATE ON 9/2/2023 AT 2241 EDT FROM HONEYWELL INTERNATIONAL TO IAN B. HOWARD * * *

"The 'All Clear' was declared at 2115 CDT on 09/02/2023. There were no injuries related to this incident. This statement constitutes the NRC notification related to the incident. Honeywell is currently investigating the cause of the event."

Notified R2DO (Miller), NMSS/DFM Division Director (Helton), NMSS Events Notification (email), IRMOC (Grant), DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email).