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Event Notification Report for October 09, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/08/2024 - 10/09/2024

EVENT NUMBERS
57356 57357 57358 57359 57366 57369
Agreement State
Event Number: 57356
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Bard Brachytherapy, Inc.
Region: 3
City: Carol Stream   State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Robert A. Thompson
Notification Date: 10/01/2024
Notification Time: 13:19 [ET]
Event Date: 09/26/2024
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Havertape, Joshua (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LEAKING SEALED SOURCES

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"On September 26, 2024, the radiation safety officer at Bard Brachytherapy, Inc. (the licensee) notified the Agency of a contamination event within a restricted area presumably resulting from the receipt of leaking Pd-103 brachytherapy seed or seeds. Seventy-one (71) Pd-103 seeds (solid/sealed sources, Theragenics Corp. Model 200 TheraSeed), each with an approximate activity of 1.6 mCi, were received on September 26, 2024, from Theragenics Corporation for loading into a Mick applicator. No contamination was noted on the incoming package and the [transportation information] on the package label was verified. As a result, no exposures to the carrier or members of the public are anticipated. However, upon working with the Pd-103 seeds within the restricted area, personnel surveys evidenced contamination on PPE. At the time of notification, the process of assessing the extent of contamination and decontaminating had begun. Personnel surveys had been performed and indicated contamination on clothing/shoes, with no skin contamination reported.

"Agency staff performed a reactive inspection on September 27, 2024. Inspectors verified that contamination was limited to the restricted area (loading room) and that no contamination to the skin was identified. The licensee is working to quantify the contamination and assess any potential skin dose to workers. At this time, Agency staff do not anticipate any occupational exposures in excess of regulatory limits as a result of this incident. No public exposures resulted from this incident and all contamination was limited to restricted areas. All 71 seeds had been placed in secured storage and radiation safety staff had successfully cleaned contaminated areas (floor, bench top, equipment, chairs) and had placed contaminated clothing (shoes, lab coats, gloves, a shirt, a pair of jeans) for decay-in-storage. Regarding reportability, the licensee committed [to Illinois] to performing leak tests of the sources once assembled. Therefore, [Illinois-specific] reporting requirements apply. There may not be an equivalent NRC requirement. There was no limit on contamination within the restricted area exceeded by the licensee. It is unlikely the potential for uptake of more than one annual limit on intake (greater than 3 seeds) would have been feasible within 24 hours. Therefore, unless there is a reportable occupational exposure, this matter may not be NRC reportable. Regardless, the incident will be shared with Georgia program staff as well. This report will be updated with the information obtained from the licensee's written report."

Illinois item number: IL240022


Agreement State
Event Number: 57357
Rep Org: California Radiation Control Prgm
Licensee: Mistras Group
Region: 4
City: Laguna Beach   State: CA
County:
License #: 8120-15
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Brian P. Smith
Notification Date: 10/01/2024
Notification Time: 16:04 [ET]
Event Date: 08/30/2024
Event Time: 08:45 [PDT]
Last Update Date: 10/01/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA FAILURE

The following report was received via email from the California Radiologic Health Branch (RHB),

"The Mistras Group's radiography crew was working at a temporary job site (inside a tank) on Friday, August 30, 2024. During the first exposure for the day at 0845 [PDT], the radiographer extended the source assembly and then felt the crank mechanism spin freely, causing the inability to retract the source assembly into the shielded position (a critical component failure). Emergency procedures were implemented; both radiographers extended their controlled radiation area boundary and monitored the area while the radiation safety officer (RSO) was notified at 0852. Source recovery personnel from Mistras Group's Torrance Lab arrived at 1040 to evaluate the situation. A recovery plan was discussed and implemented by the recovery radiographer. He entered the tank, opened the crank assembly, and determined the drive cable was not inside the housing. He opened the exposure side of the crank assembly and saw the end of the drive cable. He was able to retract the source assembly drive cable until the source assembly latched and locked inside the exposure device. This was accomplished at 1105. The RSO made a telephone notification to RHB at 1801 to report the event, but it went to voice mail, so he left his name and phone number. However, the voice mail was not forwarded and the RSO did not follow-up the next week to determine if his voice mail was received. A 30-day written notification of the event, per 10 CFR 34.101 was sent to RHB and received on September 28, 2024. Radiation exposures did not exceed 5 mrem for any involved personnel."

California Report Number: 093024


Non-Agreement State
Event Number: 57358
Rep Org: Mistras Group
Licensee: Mistras Group
Region: 4
City: Great Falls   State: MT
County:
License #: 12-16559-02
Agreement: N
Docket:
NRC Notified By: Matt Kim
HQ OPS Officer: Robert A. Thompson
Notification Date: 10/01/2024
Notification Time: 16:40 [ET]
Event Date: 10/01/2024
Event Time: 11:30 [MDT]
Last Update Date: 10/02/2024
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
RADIOGRAPHY CAMERA FAILURE

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

A Mistras two-person radiography crew was working at a customer site with a 61 Ci Ir-192 source from an elevated platform. The crew went to retract the source, but it did not move after several attempts. The crew then realized the source was disconnected from the drive cable.

The crew expanded the radiography boundaries to limit exposure to 2 mR/hr. The crew notified site personnel and is monitoring the posted boundaries until the source is secured. Additional Mistras personnel are en-route to retrieve the source.

No personnel exposures due to the malfunction have occurred.

* * * UPDATE ON 10/02/24 AT 0900 EDT FROM MATT KIM TO ERIC SIMPSON * * *

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

On October 2, 2024, at 0120 EDT, a repair crew arrived onsite to perform repairs to the radiography camera. The crew successfully repaired the device and retracted the source into the shielded position at approximately 0320 EDT.

No personnel overexposures occurred due to the radiography camera failure.

Notified the R4DO (Gepford) and NMSS Events Notifications via email.


Non-Agreement State
Event Number: 57359
Rep Org: IU Health Arnett
Licensee: Indiana University Health Arnett
Region: 3
City: Lafayette   State: IN
County:
License #: 13-32535-02
Agreement: N
Docket:
NRC Notified By: Amanda White
HQ OPS Officer: Eric Simpson
Notification Date: 10/02/2024
Notification Time: 14:17 [ET]
Event Date: 10/02/2024
Event Time: 12:30 [EDT]
Last Update Date: 10/04/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Havertape, Joshua (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
MEDICAL EVENT - Y-90 UNDERDOSE

The following information was provided by the licensee via phone:

A SIR-Spheres treatment to the liver of a patient was planned for 17.3 millicuries (mCi) of yttrium-90 (Y-90). During the dose application to the patient, leakage was noted by a nuclear medical technician. The attending physician tightened the connection between the syringe and catheter such that leakage was no longer observed. After the procedure was completed, a nuclear medicine worksheet was completed. The numbers on the worksheet showed that only 8.67 out of 17.3 mCi had been applied to the liver. This represents an underdose of approximately 50 percent. No other organs were impacted because of the underdose event.

* * * UPDATE ON 10/04/2024 AT 1014 EDT FROM AMANDA WHITE TO NATALIE STARFISH * * *

The following information was provided by the licensee via email:

"When the physician started the injection of Y-90 SIR-Spheres from the delivery system, it was noted that there was leakage coming from the connection tubing that attached to the patient's catheter from the radial access point. The injection process was quickly stopped, and the physician tightened the connection to prevent any further leakage. No further leakage was noted after the connection was tightened.

"After a Y-90 SIR-Spheres administration, the calculated patient dose delivered to the patient was determined to be less than 50 percent of the written directive prescribed dose. The prescribed dose was 17.3 mCi and the calculated patient dose delivered was 8.67 mCi. The intended dose to liver was 30 Gy and the intended dose to the tumor was 120 Gy. The estimated dose to the liver is 15 Gy.

"There were no effects to the patient with the exception that the patient was under-dosed.

"After discussion with the treating physician, they will now be using a new microcatheter and will do a test flush prior to delivering the dose to ensure no leakage.

"The patient and their significant other were notified by the referring physician. The referring physician also discussed with the patient that they might treat them again depending on how well they tolerated their last treatment."

Notified the R3DO (Havertape) and NMSS Events Notifications via 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.


Power Reactor
Event Number: 57366
Facility: Turkey Point
Region: 2     State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Ryan Frank
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/07/2024
Notification Time: 18:13 [ET]
Event Date: 10/07/2024
Event Time: 17:46 [EDT]
Last Update Date: 10/07/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Suber, Gregory (R2DO)
Grant, Jeffery (IR)
Felts, Russel (NRR)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
4 N Y 100 Power Operation 100 Power Operation
Event Text
OFFSITE NOTIFICATION

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

"On October 7, 2024 at 1444 EDT, a contract worker at Turkey Point was transported off-site for treatment at an off-site medical facility.

"On October 7, 2024 at 1746 EST, a courtesy notification was made to OSHA for an individual who was transported to an offsite medical facility for treatment of a personal medical condition. Upon arrival at that facility, medical personnel declared the individual was deceased.

"This event is being reported pursuant to accordance 10 CFR 50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."


Power Reactor
Event Number: 57369
Facility: Arkansas Nuclear
Region: 4     State: AR
Unit: [2] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: Keith Duke
HQ OPS Officer: Brian P. Smith
Notification Date: 10/08/2024
Notification Time: 18:12 [ET]
Event Date: 10/08/2024
Event Time: 14:31 [CDT]
Last Update Date: 10/08/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Gaddy, Vincent (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Defueled
Event Text
DEGRADED CONDITION

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

"At 1431 CDT, on October 8, 2024, Arkansas Nuclear One, Unit 2 (ANO-2) completed the analysis related to an indication revealed on head penetration '71' during reactor vessel closure head inspections. It was determined that the indication is not acceptable under the American Society of Mechanical Engineers (ASME) code requirements. The indication displays characteristics of abnormal degradation of a barrier that requires taking corrective actions to ensure the barriers capability. No leak path signal was identified during ultrasonic testing or bare metal visual inspections.

"The plant was in cold shutdown at zero percent power and defueled for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage. This condition has no impact to the health and safety of the public.

"This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier. This is the only indication that is currently present; however, if additional indications are found, they will also be repaired prior to the plant startup.

"The NRC Senior Resident Inspector has been notified."