Event Notification Report for June 14, 2024

EN Revision Imported Date: 6/14/2024

EN Revision Text: TWO OF THREE ESSENTIAL CHILLED WATER TRAINS DECLARED INOPERABLE

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

"At 0210 CDT 5/24/24, essential chiller 'A' train and cascading equipment was declared inoperable for maintenance to correct a temperature control malfunction.

"At 0720 CDT 5/26/24, essential cooling water 'B' train and cascading equipment (including 'B' train essential chiller) was declared inoperable due to a through wall leak discovered on the essential cooling water return header temperature element thermal well.

"This condition resulted in an inoperable condition on two out of three safety trains for the accident mitigating function, including the train 'A' and train 'B' high head safety injection, low head safety injection, containment spray, electrical auxiliary building heating ventilation and air conditioning (HVAC), and essential chilled water. All 'C' train safety related equipment remains operable.

"This was determined to be reportable within 8 hours as required by 10CFR50.72(b)(3)(v)(D).

"NRC Resident Inspector has been notified."

* * * RETRACTION ON 6/13/24 AT 1552 EDT FROM RAY RULEY TO BILL NYTKO * * *

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

"This is a communication to retract the 8-hour notification Event Notification (EN) 57146 reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) on 05/26/2024. Based on a subsequent engineering review of the conditions that existed at the time of discovery, it was determined that:

"1) The maximum postulated leak rate, conservatively estimated, from the 'B' Train essential cooling water return piping thermowell in the mechanical auxiliary building sump room would have been less than the administrative allowable limit for leakage in this room during a design basis accident,
"2) No adjacent safety related components or functions would have been adversely affected, and
"3) the return line leakage represented a negligible impact regarding essential cooling water system inventory and the system ability to cool required components.

"Therefore, it was recommended that the 'B' Train essential cooling water system with the as-found leakage condition be considered operable. Therefore, this event notification is being retracted.

"The NRC Resident Inspector has been notified."

Notified R4DO (Taylor)

AGREEMENT STATE REPORT - BRACHYTHERAPY MISADMINISTRATION

The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:

"The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024. The licensee is reporting that the total source strength administered differed by 20 percent or more from the total source strength documented in the post-implantation portion of the written directive."

SC Event Number: 240003


* * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

"For the medical event, the licensee is reporting that the total source strength documented in the post-implantation portion of the written directive is 5.54 millicuries per seed, and 221.6 millicuries total (forty seeds implanted). At the conclusion of the initial procedure on May 16, 2024, the licensee is reporting that all seeds as documented in the post-implantation portion of the written directive were administered. As of May 30, 2024, all seeds had been removed from the patient due to medical complications."

Notified R1DO (Bickett), NMSS Events Notification (email).


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 BRACHYTHERAPY SEEDS

The following information was provided by the South Carolina Department of Health and Environmental Control via phone and email:

"The South Carolina Department of Health and Environmental Control was notified on June 5, 2024, at 1130 EDT via telephone that a medical event had occurred at Medical University Hospital Authority d/b/a Medical University of South Carolina (licensee). The licensee reported that a patient had undergone a manual brachytherapy procedure (Gammatile Implantation) resulting in the implantation of forty (40) Cs-131 seeds in the patient's brain on May 16, 2024. The licensee reported that the patient had been released and then returned on May 27, 2024, due to medical complications. Seven (7) of the forty (40) Cs-131 seeds were removed from the patient on May 27, 2024, and the remaining thirty three (33) seeds were removed from the patient on May 30, 2024.

"The licensee is reporting that on May 27, 2024, the seven (7) Cs-131 seeds that were removed from the patient are lost or missing. The other thirty three (33) seeds are accounted for."

SC Event Number: 240003

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

The exact source strength of the lost seeds was not provided, however, the licensee reported that the quantity was greater than 10 times but less than 1000 times the 10CFR20 Appendix C value for Cs-131.


* * * UPDATE ON 6/7/24 AT 0812 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following information was provided by the South Carolina Department of Health and Environmental Control via email:

"For the seven (7) Cs-131 seeds that were lost on May 27, 2024, the licensee is reporting the estimated activity at the time of removal and loss was approximately 2.5 millicuries per seed and approximately 17.5 millicuries total."

Notified R1DO (Bickett), NMSS Events Notification (email), ILTAB (email).


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

The following information was provided by the licensee via email:

"At 1331 EDT on 6/13/2024, it was determined that a non-active licensed operator supervisor tested positive in accordance with the fitness for duty testing program. The individual's authorization for site access has been denied. The NRC Resident Inspector has been notified."