Event Notification Report for July 19, 2024

EN Revision Imported Date: 7/19/2024

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"On July 3, 2024, the licensee informed the Department of a medical event involving a treatment with SirSpheres [Y-90 resin microspheres].

"A patient was about to undergo a treatment with SirSpheres when the physician noticed a globule on the vial septum. They cleared the globule and began the treatment. At the beginning of treatment, the tube became occluded immediately, resulting in the patient receiving only 0.2% of the prescribed dose. The procedure was stopped. The physician and patient have been informed. No harm to the patient is expected from this event."

PA Event Report ID: PA240014

* * * UPDATE ON 7/15/2024 AT 1050 EDT FROM JOHN CHIPPO TO SAMUEL COLVARD * * *

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"On July 11, 2024, the Authorized User (AU) for the event was interviewed and provided the following additional information:

"The treatment used Y-90 SirSpheres administered through the `SIROS' apparatus. The treatment location was the right lobe of the liver. When the vial was placed into the apparatus the `C' and `D' lines were not in the right location and no spheres were at the bottom of the dose vial where they usually are. The AU saw the spheres clumped at the top of the dose vial, so they agitated the vial to try to suspend the spheres. The vial was then connected to the `SIROS' unit. The AU started the procedure by trying to push a 20 mL syringe of saline solution through the `D-Line' which connects to the dose vial. After many attempts the AU could not get any solution through the `D-line' which he thought may be occluded. The AU then checked the patient's catheter line with contrast and tried to slightly move the catheter. The AU then connected a 3 mL syringe to the `D-line' to create more pressure to try to push the solution to the dose vial, but the line remained occluded. The treatment was then terminated. The patient was retreated on July 10th, 2024, successfully.

"The Department will perform a reactive inspection."

Notified R1DO (Schroeder), 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.

* * * RETRACTION ON 7/18/2024 AT 1407 EDT FROM PA DEP BEREAU OF RADIATION PROTECTION TO JORDAN WINGATE* * *

The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email:

"After the licensee's physicists performed all calculations and consultation with the NRC, it was determined that no dose was delivered and since no material was administered the dose threshold would not be met and there would not be a radiation protection concern to the patient. Therefore, this is not considered a medical event and PA wishes to formally retract the submission."

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

AGREEMENT STATE - LOST TROXLER GAUGE

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

On July 10, 2024, a truck carrying a portable gauge was involved in a car accident. The driver was transported to the hospital. The location and the extent of damage to the gauge and truck are currently unknown. The portable gauge is a Troxler 3440, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be.

The Department has requested additional information and continues to investigate the event.

Arizona Incident: 24-008

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 - DAMAGED GAUGE

The following is a summary of information provided by the Washington State Department of Health (DOH) via email:

A portable gauge (PG) was ran over by a roller around 0930 PDT. The main body was crushed and the gauge source rod broke off but appeared to be intact.

The PG user used a shovel to pick up the source and placed it in the transport box. The PG user stayed with the PG until the radiation safety officer (RSO) arrived. The RSO confirmed [an] intact source rod and gathered the remaining damaged PG parts into the transport box. It was then transported to the licensee storage location.

The RSO and local fire department did not have a survey meter for radiation and contamination surveys.

Three DOH representatives were sent for radiation and contamination survey data collection. The highest on-contact radiation level on the PG container was 1.7 mR/hr. No indication of contamination outside of the PG container was detected. A direct frisk of the RSO and PG user's hands found no indication of contamination.

DOH will take survey data including wipes and verify they are negative. Once verified, the RSO will contact the manufacturer or a waste broker for PG disposal. A leak test will be performed prior to transport. The damaged PG will remain secured in the transport box until disposal.

Washington state event number: WA-24-016

AUTOMATIC REACTOR TRIP

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

"At 1524 [EDT] on 07/18/2024, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a turbine trip. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"Unit 1 implemented AOP-7K (abnormal operating procedure), overcooling event, due to a grid transient. Operations responded and stabilized Unit 1 in Mode 1 at 100 percent power.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"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:

All rods fully inserted. There were no other specified system actuations.