Event Notification Report for November 08, 2023

EN Revision Imported Date: 11/8/2023

EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by West Virginia University Hospital via telephone and email:

"It was determined on 8/21/2023, that during a Y-90 (yttrium-90) Thera Sphere treatment performed on 8/17/2023, the delivered dose differed from the prescribed dose by more than 20 percent. The prescribed activity was 101.5 mCi and the administered activity was 3.4 mCi.

"At the start of the infusion the authorized user (AU) was unable to deliver the microspheres due to a blood clot in the microcatheter. The AU then decided to abort the infusion and reschedule instead of chancing potential contamination that could occur by changing out the microcatheter.

"The AU had completed the pre-treatment safety checklist with no issues. The AU has made the notification to the referring physician."


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.

* * * RETRACTION ON NOVEMBER 7, 2023, AT 1207 EST FROM WEST VIRGINIA UNIVERSITY HOSPITAL TO KAREN COTTON * * *

It was determined that the dose of yttrium-90 Thera Spheres was not delivered according to the written directive due to an emergent patient condition. Therefore, the incident does not qualify as a reportable medical event.

The patient's blood formed a clot within the microcatheter which prevented the passage of Y-90 microspheres. At the onset of administration, the Authorized User (AU) encountered significant resistance in the microcatheter, and they could not flush forward. When troubleshooting the delivery set, the AU visually identified the blood clot within the microcatheter. After several unsuccessful attempts to clear the blood clot, and in consultation with representatives from Boston Scientific, the AU decided to terminate the procedure. On September 1st, the Y-90 prescribed activity, as stated on the written directive, was successfully administered to the patient's hepatic artery. There were no adverse effects to the patient because of the underdose incident. The details of this incident were discussed with NRC inspectors who were on site for a reactive inspection. During those discussions it was concluded that since the patient's blood clotted within the microcatheter, the inability to complete the administration was due to an emergent patient condition.

The blood clot within the microcatheter was confirmed by an analysis of the delivery set performed by Boston Scientific's Product Analysis Team.

Notified: R1DO (Elise), NMSS Events Notification (E-mail)

AGREEMENT STATE REPORT - BROKEN CABLE ON EXPOSURE DEVICE

The following information was provided by the Texas Department of State Health Services via email:

"On October 30, 2023, the licensee reported that on October 27, 2023, they had an industrial radiography source disconnect when the drive cable broke at the connector while the crew was working at a temporary job site. The exposure device was an INC IR-100 [containing a 92.1 curie Iridium-192 source]. The source was retrieved and secured in the exposure device by trained personnel. Self reading pocket dosimeters for the radiographers and retriever involved indicate there were no overexposures as a result of this event. Dosimetry badges are being sent for processing. The licensee is re-inspecting and re-servicing all of its crank and cable assemblies. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 10063
Texas NMED Number: TX230049

EN Revision Imported Date: 11/9/2023

EN Revision Text: AUXILIARY FEEDWATER SYSTEM INOPERABLE

The following information was provided by the licensee via email:

"On November 07, 2023 at 1200 EST, it was discovered that all pumps in the Auxiliary Feedwater system were inoperable due to the loss of control power to the 'B' train Emergency Feedwater (EFW) flow control valve which supplies the 'D' steam generator. The redundant 'A' train EFW control valve for the 'D' steam generator remains functional, as well as the capability of the Auxiliary Feedwater system to supply all steam generators.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(B).

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

"The 'A' and 'B' EFW Flow Control Valves are arranged in a series configuration for each Steam Generator. Failure of any of the 8 EFW Flow Control Valves to meet its Surveillance Requirements will render all EFW
Pumps inoperable per tech specs."

REACTOR TRIP DUE TO NON-SAFETY RELATED BUS UNDER VOLTAGE

The following information was provided by the licensee via email:

"At 1617 on 11/7/2023, Calvert Cliffs Unit 2 experienced an automatic trip from a Reactor Protection System (RPS) based on reactor trip bus under voltage (UV). At that time a loss of U-4000-22 caused a loss of 22, 23, and 24 4kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV condition. The loss of 22 and 23 4kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser.

"RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4-hour report.

"ESFAS actuation (2B DG start on UV) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8-hour report.

"ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8-hour report.

"Site Senior NRC resident inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Unit 1 was unaffected. Estimation of duration of shutdown is 24 hours.

AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES

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

"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.

"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."

Washington Incident Number: WA-23-029

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.

ALERT - SEISMIC EVENT FELT ONSITE

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

"An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility and felt inside the control room. A release of hazardous material has not occurred."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

On 11/08/2023 at 0337 MST, Urenco USA declared an Alert (EAL 5.1A) due to a seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 0559 EST (0359 MST). No radioactive release has occurred. A 5.2 magnitude earthquake occurred in western Texas with an epicenter 36.7 km west-southwest of Mentone, Texas. Plant personnel are conducting walkdowns of the site.

The State and local authorities have been notified.

Notified 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)

* * * UPDATE ON 11/8/2023 AT 1153 EST FROM JIM RICKMAN TO SAMUEL COLVARD * * *

TERMINATION OF SEISMIC EVENT ALERT

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

"The earthquake of 5.2 magnitude in western Texas was felt in the control room. No release of UF6 was detected. Building inspections have been completed with no damage identified. This event has been terminated at 0937 MST and has entered into the recovery process. The State and local authorities have been notified."

Notified 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), R2DO (Miller), NMSS (Brenneman), IRMOC (Grant), OPA (Burnell).


The following additional information was obtained in accordance with Headquarters Operations Officers Report Guidance:
US Geological Survey (USGS) updated the seismic event to 5.3 magnitude at 10:27 on 11/08/23.

MANUAL ACTUATION OF AUXILIARY FEEDWATER SYSTEM (AFW)

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

"At 0645 EST, on November 8, 2023, with Unit 2 in Mode 3 at zero percent power, a manual actuation of the auxiliary feedwater system (AFW) occurred during a planned plant cooldown. The reason for the AFW manual-start was a trip of the 22 steam generator feed pump due to a high casing level. The 23 AFW motor driven pump was manually started in accordance with implementation of AOP-3G, Malfunction of Main Feedwater System to restore steam generator levels.

"There was no impact to Unit 1. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the AFW system. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

No other systems were affected. No other compensatory or mitigation strategies implemented. Plant cooldown was the only significant evolution in progress. No impact to other technical specifications or limiting conditions for operation. All systems functioned as required. The electric plant is being supplied by offsite power with all diesel generators available. No significant increase in plant risk. There was nothing unusual or not understood.