Event Notification Report for May 31, 2024

EN Revision Imported Date: 5/31/2024

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was provided by the Illinois Emergency Management Agency (the Agency) via email:

"On April 30, 2024, the Agency was notified by Northwestern Memorial HealthCare's radiation safety officer of an yttrium-90 (Y-90) TheraSphere underdose. There were no adverse patient impacts reported, and the treatment is scheduled to be repeated the following week. The initial information indicated an underdose of Y-90 TheraSpheres of near 100 percent. Additional information is forthcoming, and Agency staff will be on-site to perform a reactive inspection on May 5, 2024. Updates will be made when available."

* * * UPDATE ON 05/30/2024 AT 1105 EDT FROM WHITNEY COX TO JOSUE RAMIREZ * * *

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"Based on the May 2, 2024, reactive investigation, agency inspectors determined that this case qualifies as a medical event under 335.1080(a)(1). The authorized user (AU) stated that no negative health effects were expected for the patient and that the patient will be retreated in the future. The patient and referring physician were notified of the event within 24 hours as required. Agency inspectors determined the potential root cause as the clumping of microspheres due to the overtightening of the tuohy luer lock. This matter may be considered closed pending further information."

Notified R3DO (Szwarc) and NMSS Events Notifications (Email).

IL Event Number: IL240009

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 EVENT

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

"On May 23, 2024, the Department received notification from the licensee about a medical event involving Y-90 TheraSpheres that occurred on May 22, 2024. A patient was prescribed a dose of 1.304 GBq but was delivered 0.931 GBq, a percent dose delivered of 71.4 percent. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

Arizona incident number: 24-007

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.

AUTOMATIC REACTOR TRIP

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

"On May 29, 2024, at 0624 EDT, Unit 1 automatically tripped from 100 percent power due to a negative rate trip. The unit has been stabilized in mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). The auxiliary feedwater pumps actuated as designed because of the reactor trip and is reportable per 10 CFR 50.72(b)(3)(iv)(A) for a valid engineered safety feature (ESF) actuation. Decay heat is being removed by the condenser steam dump system and Unit 1 is in a normal shutdown electrical lineup. Unit 2 was not affected by this event."

The NRC Resident has been notified.

MEDICAL TRANSPORT WITH CONTAMINATION

The following information was provided by the licensee via email:

"At approximately 0430 [EDT] on May 30, 2024, conversion operators were performing a deionized (DI) water flush on the conversion line 3 decanter following completion of the acid wash. The DI water valve required closing on the conversion line 3 decanter platform to complete the evolution. In the process of completing this step on the decanter platform, an operator inadvertently stepped on a catch pan containing a small quantity of nitric acid. When the operator stepped on the pan, it flipped over causing nitric acid to splash onto the operator's leg. The nitric acid is added either manually to a bucket or by connecting a hose to the decanter system to perform the acid wash step. The nitric acid supply line for acid wash additions is isolated by a spring-loaded valve, and a catch pan is located underneath this segment of nitric acid piping to collect residual liquid drips and protect the decanter platform floor from corrosion.

"The operator was wearing the required personal protective equipment for the DI water flushing evolution.

"The operator immediately reported the exposure to a nearby coworker and was instructed to rinse the exposed skin. The skin area was rinsed for approximately twenty minutes.

"The incident commander and medical first responders from the Columbia Fuel Fabrication Facility (CFFF) emergency brigade provided initial medical treatment. Health physics (HP) surveys detected contamination on the exposed area of the employee's skin. Direct survey results were 2700 dpm/100 cm squared alpha for the inner right thigh/knee area, 2000 dpm/100 cm squared for the inner right ankle and 800 dpm/100 cm squared alpha for the left hand. All smear survey results of the exposed skin area were below clean area limits (less than 200 dpm/100 cm squared). As a precaution to ensure comprehensive evaluation and treatment for nitric acid exposure to the skin, the operator was transported by ambulance to an offsite medical facility. Per procedure the employee's leg was wrapped in plastic, and the employee was accompanied by a CFFF HP technician for evaluation. Contamination surveys were performed in the ambulance and at the offsite medical facility and all results were below clean area limits indicating no spread of contamination during care for the employee. All potentially contaminated materials associated with the transport were collected and returned to the CFFF for disposal.

"All Conversion lines were inspected for extent of condition with pans or pales containing nitric acid. Containers with acid were emptied and valves in the vicinity of each decanter in conversion were inspected for leaks.

"The event did not exceed the performance requirements of 10 CFR 70.61 as analyzed in the integrated safety analysis.

"This event did not impact safety equipment.

"A causal analysis and corrective actions will be documented in the corrective action program.

NRC Regional staff was notified.

EN Revision Imported Date: 6/7/2024

EN Revision Text: FITNESS FOR DUTY (FFD) REPORT

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

"On May 30, 2024, at 1200 CDT, South Texas Project (STP) FFD management identified from industry operating experience (OE) a programmatic failure, degradation, or discovered a vulnerability of the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within a protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program. A review of the personnel in-processed and placed into the follow-up program by STP and external utilities since the implementation of the Illuminate software (07/31/2023) was completed. The issue affecting individuals placed into the follow-up program by external utilities was bound to in-processing of individuals [between] 02/22/2024 and 04/09/2024. One other individual processed in November of 2023, was also affected by this event. This event did not impact STP personnel that were either placed or had an existing record in the follow-up program. Compensatory measures were implemented and an extent of condition review was completed.

"This is a 24-hour reportable event per 10 CFR 26.719(b)(4)."

The NRC Resident Inspector has been notified.

AUTOMATIC REACTOR TRIP

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

"On May 30, 2024, at 1949 EDT, Unit 1 automatically tripped from 100 percent power due to an electrical fault on the 'B' unit auxiliary transformer. The unit has been stabilized in mode 3 at normal operating temperature and pressure. The reactor trip was uncomplicated and all control rods fully inserted into the core. This reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). Decay heat is being removed by the condenser steam dump system and Unit 1 is in a normal shutdown electrical lineup. There was no impact on the health and safety of the public or personnel."

The NRC Resident Inspector has been notified.