Event Notification Report for December 30, 2024

MEDICAL EVENT

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

The licensee's radiation safety officer (RSO) was notified on 12/20/2024, at approximately 1130 CST of a medical event that occurred at Franciscan Health Munster in Munster, IN on 10/28/2024. A patient was prescribed a Y-90 TheraSphere treatment with a prescribed dose of 23.5 Gbq. The calculated administrated dose was 18.32 Gbq. This indicates an approximate 22 percent underdose. The licensee is continuing to investigate.

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 12/26/2024 AT 0907 EST FROM WALEED AL-NAJJAR TO SAMUEL COLVARD * * *

The following information was provided by the licensee via phone:

The event is being retracted due to the following reasons. The activity initially documented as prescribed corresponded to the quantity requested from the manufacturer. This activity is intended to decay to a specific dose by the time the procedure occurs. On the day of the procedure, the prescribed dose was 110 Gy, while the dose delivered was 89.1 Gy. The difference between these amounts is less than 20 percent, thus not subject to reporting.

Notified R3DO (Nguyen), and NMSS Events Notification (email).

AGREEMENT STATE REPORT - LOST SOURCES

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

[Eight tritium exit sign were determined to be lost by the licensee.]

"Manufacturer: Safety Light Corp
"Model Number: 880-12-6 [Quantity: 2]
"Model Number: 2040 [Quantity: 6]
"Isotope and activity: H-3, 11.5 Ci each

"Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))"

Colorado Event Report ID No.: CO240033

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

PART 21 - INTERIM REPORT FOR REGULATING TRANSFORMER

The following is a synopsis of information provided by AMETEK Solidstate Controls Inc. (AMETEK) via email:

During regulating transformer system operations, the transformer may be experiencing short circuiting between coils to ground.

Visual inspection for severe darkening or charring of coils, magnetic shunts, or core, and/or the use of thermal probes or infrared guns monitoring for excessive temperatures greater than 180 degrees Celsius or 355 degrees Fahrenheit may detect affected regulating transformer systems.

Affected systems exhibit signs of transformer insulation system deterioration, increased audible noise from the units, blackening on any areas of the transformer, or signs of electrical shorting between windings or coil to core.

The cause of the short circuiting is unknown. Component failure impact analysis and regulating transformer system electrical testing are in progress.

Recommend all units currently in service with internal components, which include but are not limited to capacitors, wire harnesses, and transformer materials, with temperatures in excess of 180 degrees Celsius or 355 degrees Fahrenheit be removed from service.

COMPONENT DESCRIPTION:
The AMETEK SCI model numbers listed are for regulating transformers that are intended to take in AC power at 460 VAC plus or minus 10 percent and output AC power at 120 VAC plus or minus 2 percent with low harmonic distortion.

Models: 85-IS0075-12 and 85-IS0150-14

AFFECTED PLANTS:
Southern Nuclear Company - Vogtle
Constellation Energy - Ginna