Event Notification Report for September 08, 2023

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 8/30/2023, at 1700 CDT, by a representative from University of Kentucky Broadscope Medical, of an underdose of a patient during a lutetium 177 (Lu-177) treatment. The underdosing was due to a leakage in the administration line.

"The underdosing was considered more than 20 percent. There was no harm to the patient. A separate report will be submitted once all the facts are gathered."

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 - MEDICAL UNDERDOSE

The following is a summary of information that was provided by the New Mexico Environment Department via phone and email:

On August 31, 2023, at approximately 1530 MDT, X-ray Associates of New Mexico reported that an original prescribed dose of 2.11 Gbq of Yttrium 90 was attempted to be delivered, but the patient received a reported dose of 0.927 Gbq, which was only 43 percent of the prescribed dose. The cause for the undelivered amount is undetermined. The licensee has been instructed to provide a complete written report.

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.

UNACCOUNTED FOR IODINE-125 SEEDS

The following is a summary of information that was provided by the licensee via phone and follow-up email:

On 8/4/2023 at 1000 CDT, at SSM St. Clare Hospital in Fenton, MO, an oncologist implanted an I-125 prostate seed. After completion of the implant, a radiation oncology physicist went to the hot lab to return the backup seeds that had not been used. The first four unused needles had a single seed, which was expected. The next two had two seeds, which was expected. The last needle, was expected to have three seeds. However, when the physicist pushed the "stylette," the bone wax came out, followed by just one seed. The physicist surveyed the package, but there were no seeds in it. The final needle was still sealed in its sterile package, thus the physicist believed the seed could not have fallen out anywhere but into the sealed package itself. The physicist surveyed the hot packaging with a Geiger-Mller counter and found no radioactivity. The physicist surveyed the entire hot lab, and found no activity. An investigation is ongoing with the vendor. Unaccounted for activity was 0.504 mCi of I-125 on the date of the event.

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

AGREEMENT STATE REPORT - Y-90 UNDERDOSE

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

"On September 1, 2023, the department received a notification from the licensee's radiation safety officer about a Y-90 Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred the morning of September 1, 2023. The written directive stated that the activity administered should be 1.24 GBq. The estimated activity administered to the patient was 0.715 GBq, 57.7 percent of the prescribed activity. During the administration, it was identified that the spheres required increased pressure to deliver, and that the spillover vial collected a high volume of material. Post-procedure surveys confirmed that a large portion of the material had not been administered to the patient. 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."

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 - LOSS OF STATIC ELIMINATION DEVICE

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

"On September 1, 2023, the Department was notified by a general licensee that a generally licensed NRD, LLC device containing 10 microcuries (original activity on June 8, 2022) of polonium-210 was lost. This is greater than 10 times the Appendix C value of 0.1 microcuries. The device was to be disposed of after the general licensee switched to another non-radioactive material method of eliminating static. However, the device was believed to have been thrown away in municipal waste before this could happen and was last seen on May 12, 2023. The device is not expected to provide significant dose to anyone.

"The licensee does not believe this device would pose a safety or health risk to the public. Further information will be provided per SA-300."

Texas NMED: TX 230038

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

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was provided by the Arizona Department of Health Services (the Department) via email:

"The Department was notified by the licensee that on September 1, 2023, a patient was prescribed 1,800 centigray in 3 fractions using a 2.5 cm diameter vaginal cylinder. After the start of the first fraction of the treatment, the patient notified the Authorized User and Authorized Medical Physicist that she thought the cylinder was in the `wrong place.' The treatment was stopped at 111 seconds into the treatment and the licensee discovered that the cylinder was placed into the rectum instead of the vagina. The treatment utilized a Varian GammaMedplus iX with an approximate 5.2 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event."

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.

PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS

The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.

On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.

Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077

Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna

FITNESS-FOR-DUTY VIOLATION

The following information was provided by the licensee via email:

A supplemental contract supervisor had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.

CONTROLLED SUBSTANCE FOUND IN THE PROTECTED AREA

The following information was provided by the licensee via email:

"On 09/06/2023, at approximately 0830 [CDT], a bottle of vanilla extract, intended for use in cooking, with an alcohol content of greater than 0.5 percent by volume was found in the protected area. An immediate extent-of-condition search of other kitchen areas within the protected area identified four additional bottles of vanilla extract or imitation vanilla extract, for a total of five bottles identified. The alcohol content by volume (ABV) of these extracts ranged from an unlisted percentage (with ethyl alcohol as a listed ingredient) up to 41 percent ABV. The volume capacities of the bottles ranged from 2 to 8 fluid ounces, with varying volumes of remaining contents."

CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA

The following information was provided by the licensee via email:

"On September 6 at 15:00 CDT, Grand Gulf Nuclear Station personnel identified a bottle of vanilla extract in a kitchen area located within the Protected Area. Ingredients were listed as 'pure vanilla extract in water and alcohol. The percentage by volume of alcohol was not specified. It was subsequently determined that the alcohol by volume was likely 35 percent.

"The NRC Resident Inspector has been notified."