Event Notification Report for August 06, 2024

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was provided by the Colorado Department of Public Health and Environment via email:

"This event in Colorado was originally sent to the wrong NRC email address and it is now being provided to the NRC. This event is being tracked as NMED number 240183.

"A patient was administered a measured dose of 0.613 GBq Y-90 TheraSpheres on 5/13/2024, at 1524 MDT. The desired administration location in the liver received a dose of 0.582 Gbq. Post administration imaging analysis conducted on 5/15/2024, showed an uptake to the stomach wall of 1.5 Sievert."

Notification made per: 10 CFR 35.3045(a)(1)(iii)

Colorado event report ID No.: CO240013

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.

POSSIBLE OVEREXPOSURE DUE TO LOSS OF CONTROL

The following information was provided by the BWXT Nuclear Operations Group, Inc. (BWXT NOG-L) via email:

"At approximately 1025 EDT on Monday, July 29, 2024, a BWXT NOG-L recycle vendor notified the licensee that a shipment of scrap aluminum machining chips was identified as being potentially radioactive and/or contaminated. The shipment of material activated the recycle vendor's portal detectors. BWXT NOG-L responded to the vendor's facility and performed a preliminary assessment, exterior smears of the shipping container and inside the transport vehicle confirmed no contamination. The recycle vendor obtained a special permit, from the Commonwealth of Virginia, to return the container back to BWXT NOG-L for evaluation of uranium contamination. Upon return of the container, the contents were re-packaged into drums, values established through non-destructive assay (NDA), and stored within a radiation-controlled area.

"No one was exposed and the material did not pose a risk to the public or the environment during its transportation to and from the recycle vendor. BWXT NOG-L recognizes the potential exposure implications had this material processed through the recycler's facility and is reporting accordingly under 10 CFR 20.2202(b). BWXT NOG-L also recognizes the failure to properly ship radioactive material in accordance with 10 CFR 71.5.

"The resident inspector has been notified. "

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

As a corrected action the licensee has suspended shipments until an evaluation is completed.

EN Revision Imported Date: 8/6/2024

EN Revision Text: CONTROL ROOM ENVELOPE FAILED SURVEILLANCE

The following information was provided by the licensee via email:

"At 0146 CDT on June 7, 2024, River Bend Station (RBS) was operating at 100 percent power when a loss of control room envelope (CRE) was declared due to failing to meet Technical Specification (TS) 3.7.2, Surveillance Requirement (SR) 3.7.2.4, during surveillance testing. Mitigating actions were established which included the ability to issue potassium iodide to control room staff. With mitigating actions in place, the dose consequence to control room staff continued to be less than the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event.

"The CRE is considered a single train system at RBS, therefore, this event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function.

"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 failed surveillance (SR 3.7.2.4) was for unfiltered air in-leakage greater than 300 cubic feet per minute.

* * * RETRACTION ON 08/05/2024 AT 1456 EDT FROM DARREN FARTHING TO ROBERT THOMPSON * * *

"This event was initially reported under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function. The licensee determined in a subsequent engineering evaluation of the conditions that existed at the time, that there was no adverse impact on the control room emergency ventilation system or the control room envelope (CRE) boundary's ability to perform its safety function. The CRE would not have been challenged to meet the regulatory limit of 5 rem total effective dose equivalent for the duration of a design basis event. Consequently, this condition is not reportable as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC resident inspector has been notified."

Notified R4DO (Vossmar).