Event Notification Report for June 20, 2024

AGREEMENT STATE REPORT - LOST SOURCE

The following was received from the Texas Department of State Health Services (the Department) via email:

"On June 11, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a 40 millicurie americium-241/beryllium (Am-241/Be) source from a Troxler 3430 moisture/density gauge could not be located. The gauge did not pass the standardization test, and was later sent to the service provider. On June 10, 2024, the service provider informed the RSO that the gauge was inspected, the cap that held the Am-241/Be source in place was no longer screwed in, and the source was missing. Radiation surveys were conducted at the facility but were unable to locate the Am-241/Be source. RSO contacted the service provider and requested a facility survey. The RSO will be interviewing their technicians and reviewing use records for the gauge in an attempt to locate where the source could have fallen out of the gauge. An exposure risk to an individual was not reported. Additional information will be provided as it is received in accordance with SA-300."

TX Incident Number: 10109

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 - STUCK SOURCE

The following information was provided by the California Department of Public Health (the Department) via email:

"At 1034 PDT on June 6, 2024, the Department received an email from the Mistras Group, notifying the Department of an event at the MRC Martinez Refinery. At 1407 PDT on June 3, 2024, the radiation safety officer (RSO) received a call from a radiography crew at MRC Martinez Refinery regarding a 61 curie Ir-192 source (serial number 475 I) that would not retract back into the industrial nuclear IR-100 radiographic exposure device (serial number 4059). The RSO arrived on the site at 1444 PDT to find that the extension tube female end crimp had dislodged from the tubing and was laying on the deck of the structure that the crew was working on. At 1555 PDT, the RSO was able to manipulate the cable into a position where they were able to retract the source back into the locked and shielded position without incident or overexposure. Five crew members were present during the time the source was in an unshielded position: the RSO, one radiographer trainer, and three assistants. The highest exposure recorded to their instadose [dosimeter] was 40 mR for the radiographer trainer. The RSO will submit a written report within 30 days following an investigation."

California 5010 report number: 060424

MEDICAL EVENT - LUTETIUM-177 MISADMINISTRATION

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

"A Lu-177 administration was performed on June 12, 2024. The administration team did not start the patient on amino acids prior to the administration. Upon discovery of the error, the acids were started and ran for 4 hours. This resulted in an unintended dose to the kidneys. The radiation safety officer (RSO) and staff were notified on June 12, 2024. They determined it was a medical event on Jun 12, 2024 at 1600 CDT. The event was reported to the Nuclear Regulatory Commission at 1620 CDT on June 12, 2024. The dose calculation, which is still being estimated by the health physicist, falls under 10 CFR 35.3045 Subpart M Item (a)(1)(i): `a dose to the skin or an organ or tissue other than the treatment site that exceeds 50 rem of the dose expected from the administration defined in the written directive'."

* * * RETRACTION ON 6/19/2024 AT 1123 EDT FROM AVERY MCKENNAN HOSPITAL TO IAN HOWARD * * *

The following information was provided by the licensee via email:

"Avera McKennan Hospital, would like to retract this medical event notification that was issued on Wednesday, June 12, 2024, under our radioactive material license number 40-16571-02. After further investigating into Subpart M Section 35.3045, report and notification of a medical event, our event only falls under one of the criteria under (iii) "A dose to the skin or an organ or tissue other than the treatment site that exceeds by: (A) 0.5 (50 rem) or more than expected dose to that site from the procedure if the administration had been given in accordance with the written directive prepared or revised before administration; and (B) 50 percent or more the expected dose to that site from the procedure if the administration had been given in accordance with the written directive prepared or revised before administration.

"Per the Lutathera package insert, the critical organ is the kidneys. The estimated absorbed dose per unit activity to the kidneys is, 0.654 Gy per GBq. The total activity given to patient was 196.6 mCi of lutitium-177. [Based on the activity] given to the [patient, the] estimated absorbed intended dose to the kidneys is 475 rem per unit activity if the amino acids were given. The delivered dose to the kidney was 698 rem (best case scenario calculation). This would fall under Subpart M section 35.3045 (iii) (A): `A dose to the organ exceeds by 0.5 Sv (50 rem).'

"However, according to the Lutetium package insert, `The co-administration of amino acids reduced the median radiation dose to the kidneys by 47 percent'. When we calculate 50 percent of our intended dose of 475 rem, we get 237 rem. The difference between the intended dose of 475 rem and the delivered dose of 698 rem is 223 rem which is under the under (iii) (B) 50 percent or more of the expected dose.

"For this to be a medical event, both criteria's under (iii) need to be met. The Avera McKennan Hospital Lutathera event, does not fall under (iii)(B)."

Notified R4DO (Josey) and NMSS Events (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 - DOSE MISADMINISTRATION

The following information was provided by the Oregon Department of Health Radiation Protection (the Department) via email:

"During a Y-90 Therasphere microsphere therapy treatment of the entire left lobe of the liver, the catheter was positioned incorrectly inside the hepatic artery, resulting in sections 2 and 3 of the left lobe being treated instead of sections 1 and 4. Prescribed dose was 100 Gy to the entire left lobe. The licensee discovered the event on 6/14/2024 and notified the Department on 6/14/2024 at 1226 PDT.

"The patient has not been notified yet, but the provider is meeting with the patient to do so this week and discuss. The licensee is unsure whether the referring physician has been notified at this time but is going to find out. There will likely be an effect on patient outcome and plan of care. The licensee is also determining the actual doses given to sections 2/3 and 1/4 but information provided indicates 96 mCi of the dose was given to sections 2/3. The Department is awaiting further information from the licensee."

Oregon Event Report ID Number: OR-24-0030

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.

MANUAL REACTOR TRIP

The following information was provided by the licensee by email:

"On 06/18/2024 at 0317 EDT with Unit 2 at 18 percent power, the reactor was manually tripped due to elevated secondary chemistry levels (sodium and chlorides).

"The trip was uncomplicated with all systems responding normally post trip. Operations stabilized the plant in Mode 3. Decay heat is being removed by auxiliary feedwater and atmospheric dump valves.

"St. Lucie Unit 1 was unaffected and remains at 100 percent power.

"This event is being reported pursuant 10CFR 50.72(b)(2)(iv)(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:
All rods fully inserted. An investigation is underway to determine the root cause of the elevated chemistry levels.

NONCOMPLIANCE WITH TECHNICAL SPECIFICATION

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

"During investigation related to licensee event report (LER) number 24-001, a noncompliance with technical specification 3.10.d was discovered. During the period from July 2022 to April 2024, three filters operating at greater than 99 percent efficiency were not in service. The limiting condition of this technical specification is associated with operation of an I-131 processing suite, rather than with operation of the reactor. The University of Missouri Research Reactor's iodine suite ventilation includes a series of seven filter trains, each of which were in service during this period at an efficiency greater than 98 percent. Filter banks '2' and '3' were operating at greater than 99 percent efficiency. Filter '3-3' was also credited as greater than 99 percent efficiency, however, the bypass between the two banks of filter '3-3' consisted of dampers rather than valves. Therefore the total efficiency, when bypass was taken into account, was less than 99 percent.

"Processing of iodine was generally performed weekly during the referenced period. Processing of iodine was suspended in May 2024 in association with LER 24-001, and remains suspended until compliance is achieved.

"Several detectors were monitoring the suite and downstream effluent from the suite during the referenced period, including the off-gas (stack) radiation monitor per technical specification 3.10.c. Additional monitors were in service, including a duct monitor, in-room [derived air concentration] monitors, and the remaining three I-131 processing hot cells radiation monitors. No in-service monitors indicated abnormal rises in iodine levels during the period in question."

INOPERABILITY OF DIVISION 3 DIESEL GENERATOR SUPPORTING HIGH PRESSURE CORE SPRAY

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

"At 1640 EDT on 06/18/2024, the division 3 diesel generator was declared inoperable. This condition could prevent the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). All other emergency core cooling systems were operable during this time.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

"The division 3 diesel generator was declared inoperable due to potential water intrusion into the electrical generator. Inspection of the generator is in progress."


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

This event resulted in Perry Unit 1 entering a 72 hour limiting condition for operation (LCO) in accordance with Technical Specification 3.8.1. condition 'B'.

OFFSITE NOTIFICATION

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

"At 1537 CDT on June 19, 2024, the shift manager was informed that a contract company to Xcel Energy would be notifying the Occupational Safety and Health Administration (OSHA) pursuant to the requirements of 29 CFR 1904.39. Notification to OSHA is required due to a contract employee who suffered a personal health condition while at an offsite facility for training and was declared deceased following emergency medical service departure to the medical facility."

The NRC Resident Inspector has been notified of this event.