Event Notification Report for February 13, 2025

AGREEMENT STATE REPORT - EQUIPMENT FAILURE

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

"The Agency was notified on 2/18/25, by the radiation safety officer for OSF St. Anthony in Rockford, IL of an apparent equipment failure with their high dose rate therapy unit that occurred on 2/13/25. Reportedly, the device was unable to extend the 5.33 Ci Ir-192 source, resulting in the administration being aborted. No dose was delivered to the patient. Inspectors are performing a reactive inspection tomorrow, 2/19/25."

Source: Sealed Source Brachytherapy
Serial Number: 24-01-2930-001-112224-11727-14

Illinois Item Number: IL250008

TECHNICAL SPECIFICATION DEVIATION

The following is a summary of information obtained from the licensee by phone:

On February 13, 2025, at 1009 EST, the licensee violated Technical Specification 3.2.3 when conducting a $2.00 reactor pulse while one of the required reactor power measurement channels was in bypass, therefore, the pulse power was not recorded. The pulse was completed per procedure, and the reactor was shutdown and secured. The incident was reported to supervision, and the pulse data was reviewed. The peak observed temperature during the pulse aligned with the expected peak temperature for the conducted pulse, but the peak power was not captured by the system. After review of the data, continued operation was authorized. There is no assessed safety impact due to this event.

Training will be conducted to clarify the Technical Specification requirements to prevent this issue in the future.

NRC Project Managers have been notified.