Event Notification Report for October 10, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/09/2024 - 10/10/2024
EVENT NUMBERS57359 57369 57370
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: 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."
Part 21
Event Number: 57370
Rep Org: North Anna Power Station
Licensee: North Anna Power Station
Region: 2
City: Mineral State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Robert Page
HQ OPS Officer: Kerby Scales
Notification Date: 10/09/2024
Notification Time: 17:07 [ET]
Event Date: 10/08/2024
Event Time: 17:53 [EDT]
Last Update Date: 10/09/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Suber, Gregory (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 - DEGRADED VOLTAGE DUE TO A LOOSE TERMINAL CONNECTION SCREW
The following information was provided by the licensee via phone and email:
"This is a non-emergency notification submitted in accordance with 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 20 days.
"On October 8, 2024, North Anna Power Station (NAPS) determined a manufacturing defect affecting the normal AC supply molded case switch for the Unit 1, 1-IV battery charger was reportable under Part 21. On July 29, 2024, the 1-IV battery charger was declared inoperable due to the AC input voltage reading approximately 250 VAC on the B-C phases and A-C phases. The A-B phase voltage was normal at 480 VAC. Troubleshooting determined the normal AC supply molded case switch was the cause of the degraded voltage due to a loose terminal connection screw on the 'C' phase load side of the contacts.
"The NRC Senior Resident Inspector has been notified."
Battery Manufacturer: Ametek Solidstate Solutions
Switch Manufacturer / Model: Eaton / J250K
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee plans to inspect all battery chargers on both units to verify they don't have loose terminal screws. They are unaware of this issue affecting any other site.