Event Notification Report for February 06, 2025

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

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

"On January 28, 2025, during an investigation, the licensee reported that, on one occasion, there was a spill involving americium-241 which required access to a room to be restricted for more than 24 hours at its facility. The licensee's radiation safety officer (RSO) stated the spill came from a small bucket located in an area where access was controlled for source security reasons. After the spill, the access was secured due to the americium spill. The RSO could not remember some of the information related to the event. The RSO agreed to submit a written report to the department within 24 hours. No individuals were contaminated and no other area was contaminated beyond the room where the event occurred. An update to this report will be provided once the additional information is received."

The activity level of the spill was not reported.

Texas Incident Report #: 10163
Texas NMED # TX250007

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Ohio Department of Health via email:

"On January 28, 2025, the Ohio Department of Health, Bureau of Environmental Health and Radiation Protection was notified by University Hospitals of Cleveland that during a therapeutic infusion of Pluvicto (Lu-177) [that was administered on January 27, 2025], 60.9 mCi of a total dose of 295 mCi was extravasated in the patient's right arm antecubital area [i.e. not the intended treatment site]. The licensee calculated a 0.61 Gy dose to the skin near the extravasation site based on imaging taken from 20 minutes to 22 hours post-infusion. At 22 hours post infusion, 0.46 mCi remained around the injection site based on imaging. The authorized user believes the material has drained through the lymphatic system to the prostate."

Ohio Item Number: OH250001

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 REPORT - MEDICAL EVENT

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

"The Agency was contacted after hours on 01/29/2025 by Rush University Medical Center to advise of a reportable underdose of radioactive material [that occurred on 1/29/2025]. Reportedly, the patient received only 40 percent of the prescribed therapeutic dose of Y-90 microspheres. Inspectors completed a reactive inspection [on 01/29/2025] and are awaiting additional details from the licensee. The patient will be re-treated and no adverse consequence is anticipated. Updates to this report will be made as they become available."

Illinois Item Number: IL250004

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 REPORT - ORPHAN SOURCE

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

"On the afternoon of 01/29/2025, Agency staff responded to a radiation portal alarm at Alter Metal Recycling in Rockford, IL. The source of the alarm was found to be a generally licensed dew point measuring device, containing a radium-226 source [with 7 microcuries of activity]. A smear was taken and indicated no contamination. The device was impounded by the Agency, pending contact with the device owner and proper disposal. Updates to this report will be made as they become available."

Illinois Item Number: IL250005


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

AUTOMATIC REACTOR TRIP

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

"At 1002 EST, on February 5, 2025, with Unit 2 in mode 1 at 100 percent power, the reactor automatically tripped due to lowering 'B' steam generator level. All control rods fully inserted into the core and the auxiliary feedwater system automatically started as designed in response to the full power reactor trip. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response.

"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves. Unit 1 is not affected and remains at 100 percent power and stable. Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the auxiliary feedwater system.

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

FITNESS FOR DUTY

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

A non-licensed employee supervisor had a confirmed positive during a random fitness for duty test. The employee's unescorted access to the plant has been revoked.

The NRC Senior Resident Inspector has been notified.