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Event Notification Report for September 16, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
09/13/2024 - 09/16/2024

EVENT NUMBERS
57308 57309 57310 57311 57312 57321
Agreement State
Event Number: 57308
Rep Org: Florida Bureau of Radiation Control
Licensee: Advent Health Altamonte
Region: 1
City: Altamonte Springs   State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Josue Ramirez
Notification Date: 09/06/2024
Notification Time: 13:06 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/06/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ferdas, Marc (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS)
Event Text
AGREEMENT STATE REPORT - DOSE TO UNINTENDED ORGAN

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"BRC received notification from the Advent Health Altamonte radiation safety officer of a possible medical event. A patient received a Y-90 TheraSphere treatment, intended for the liver, which migrated to the stomach. The prescribed dose was 250 Gy, and the dose assessment is still being conducted. The facility states a majority of the prescribed dose was received by the stomach. Migration was identified by the patient's physician, and the patient was notified this morning."

Florida incident number: FL-24-082

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
Event Number: 57309
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Virtua Our Lady of Lourdes Hospital
Region: 1
City: Camden   State: NJ
County:
License #: 329968
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Josue Ramirez
Notification Date: 09/06/2024
Notification Time: 14:48 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/06/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ferdas, Marc (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - Y-90 UNDERDOSE

The following information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email:

"The licensee was scheduled to administer a Y-90 SIR-Sphere therapy to a patient. There was a tubing failure, and the administration was suspended. It is estimated that only 59 percent of the prescribed activity was administered. The patient has been re-scheduled. The licensee will follow-up with a full written report.

"The intended Y-90 SIR-Sphere therapy activity was 13.5 mCi, and the administered activity was 7.99 mCi. The target organ was the liver.

"The licensee is investigating. The root cause(s) and contributing factors will be addressed in a full report.

"Follow-up actions are to be determined."

NJ Event Report ID number: To be determined.

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.


Non-Agreement State
Event Number: 57310
Rep Org: Washington University
Licensee: Washington University
Region: 3
City: St Louis   State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: Briana Davis
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/06/2024
Notification Time: 15:01 [ET]
Event Date: 09/05/2024
Event Time: 09:40 [CDT]
Last Update Date: 09/06/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Hills, David (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
THERASPHERE FRACTIONATED DOSE MISADMINISTRATION

The following is a summary of information provided by the licensee via phone:

A TheraSphere treatment comprised of three fractions was planned to be administered to the patient's liver. The first fraction was planned to be 1.1 GBq Y-90, the second fraction 1.1 GBq Y-90, and the third fraction 1.46 GBq Y-90.

When the treatment was administered, the third fraction (actual activity 1.48 GBq Y-90) was administered first, in place of the intended first fraction. The second fraction was administered as planned. The error was discovered when the vial containing the third fraction was found to have already been used. The treatment plan was then revised to use the remaining first fraction vial (actual activity 1.02 GBq).

All fractions were administered to the patient's liver as planned and the total dose was in accordance with the treatment plan.

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
Event Number: 57311
Rep Org: Texas Dept of State Health Services
Licensee: Acend Performance Materials Texas
Region: 4
City: Alvin   State: TX
County:
License #: L 06630
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Josue Ramirez
Notification Date: 09/06/2024
Notification Time: 15:44 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/06/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MALFUNCTIONING SHUTTER

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

"On September 6, 2024, the Department was notified that the shutter on a Texas Nuclear model 5204 gauge was found stuck in the open position during routine testing. The gauge contains a 4,000 mCi (original activity) Cs-137 source. Open is the normal position for the shutter. The licensee reported there is no risk of additional exposure to members of the general public or radiation workers at the facility due to the failure.
"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10126
Texas NMED Number: TX240027


Agreement State
Event Number: 57312
Rep Org: Kentucky Dept of Radiation Control
Licensee: Coal mining facility
Region: 1
City: Helton   State: KY
County:
License #: TBD
Agreement: Y
Docket:
NRC Notified By: Matthew McKinley
HQ OPS Officer: Josue Ramirez
Notification Date: 09/06/2024
Notification Time: 18:49 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [CDT]
Last Update Date: 09/06/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ferdas, Marc (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
AGREEMENT STATE REPORT - MISSING GAUGES

The following is a summary of information provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via phone:

In the conduct of their regulatory duties, RHB established a program to collect and store nuclear gauges from closed or abandoned mining sites. This initiative is aimed at preventing improper disposal of nuclear gauges during reclamation operations.

On September 6, 2024, RHB inspected one such coal mining facility located in Helton, KY, in an attempt to recover six fixed Cs-137 level gauges with an aggregate activity of approximately 700 mCi. The storage facility for the gauges was found open and the gauges were missing. The last recorded inventory of the gauges occurred in 2021. Local law enforcement and state emergency operations were notified. It is believed that the gauges were improperly discarded either by the previous owner or by the reclamation company.

RHB will continue to investigate this event and provide updates in accordance with SA-300. No risk to the public is anticipated from this event.

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


Power Reactor
Event Number: 57321
Facility: Byron
Region: 3     State: IL
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Richard Bowman
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 09/13/2024
Notification Time: 13:54 [ET]
Event Date: 09/13/2024
Event Time: 08:23 [CDT]
Last Update Date: 09/13/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Ziolkowski, Michael (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
Event Text
DEGRADED REACTOR VESSEL CLOSURE HEAD PENETRATION
The following information was provided by the licensee via phone and email:

"On 9/13/2024 at 0823 CDT, during the Byron Unit 1 refueling outage, it was determined that a previous overlay repair on penetration number 31 of the reactor vessel closure head was degraded because the results of a planned liquid penetrant test did not meet applicable acceptance criteria. Any required repairs will be completed in accordance with the ASME code of record prior to returning the vessel head to service. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

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