Event Notification Report for March 04, 2025

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the Maryland Department of the Environment (MDE) via email:

"On February 20, 2025, an incident involving a sealed radioactive source [leaking source] at the PET/CT Department of Johns Hopkins Imaging, Bethesda was reported to the MDE. The issue was identified during a routine leak test conducted by the facility's health physics consultant, Krueger Gilbert Health Physics. The sealed vial source, Cs-137 (Serial Number 16694, activity 0.199 mCi as of March 1, 2002), was used for quality control of the Capintec CRC dose calibrator.

"Upon detection of the issue, the sealed source was immediately withdrawn from service, placed in a polythene zip-lock bag, and securely stored in the hot lab. A comprehensive contamination survey was conducted by collecting wipe samples from the dose calibrator, handling tools, storage container, storage area, and other relevant locations. The survey results confirmed no detectable radioactive contamination.

"As a precautionary measure, the licensee was instructed to maintain the sealed source in double-sealed polythene packaging within a secure container. The licensee is currently awaiting a return kit for the proper disposal of the source through an authorized agency or supplier. Upon completion of the disposal process, all relevant documentation will be submitted to MDE.

"MDE will provide follow up to this reactive investigation until the source is securely disposed."

AGREEMENT STATE REPORT - MEDICAL EVENT

The following summary was received via phone from the Nebraska Division of Radioactive Materials (DHHS-NE):

At 0830 CST on February 24, 2025, DHHS-NE was notified by the licensee of a medical underdose occurring during the morning of February 21, 2025. A patient received a Y-90 treatment of 47.25 mCi intended for the right lobe of the liver. However, only 74 percent of the intended dose reached the right lobe of the liver. DHHS-NE is continuing to follow up on the event.

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 FROM BRYCE DAVIDSON TO BRIAN P. SMITH AT 1657 EST ON FEBRUARY 25, 2025 * * *

DHHS NE informed the Headquarters Operations Center that upon further review the Y-90 treatment that underdosed the patient involved shunting and therefore is not a medical event. The event thus is not reportable.

Notified R4DO (Roldan-Otero) and NMSS Events Notification (email)

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY CAMERA

The following report was received via email by the Tennessee Division of Radiation Health:

"During a scheduled work visit to the TVA Cumberland City facility, a radiography crew was descending an outside set of stairs covered with ice. The worker slipped on the stairs and released the camera which dropped approximately 20 feet to the ground. The team surveyed the area to ensure it was safe to approach the device. After ensuring the device was secured, it was placed into an overpack and transferred back to the licensee's facility. A minor amount of damage was incurred to the rear of the device. The team had no indication that the source was compromised.

Manufacturer: QSA Global
Model: Sentinel 880D
SN: D9269
Source: Ir-192; 89.6 Ci
Source Model: 424-9
Source SN: 12835P

"Corrective actions or reports as well as additional information will be updated with a NMED report within 30 days."

State Event Report ID No.: TN-25-014

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the California Department of Health (CDPH) via email:

"The radiation safety officer for Hoag Hospital in Irvine called the California Office of Emergency Services to report a potential medical event that occurred during a research treatment that involved a targeted alpha radionuclide therapy. The authorized user prescribed 289 microcuries of Ac-225 in the form of FPI-2265 also known as [225Ac] PMSA imaging therapy; however, the Biodex pump used to administer the dose leaked, and only approximately 80 microcuries were administered.

"The treatment was for metastatic castrate resistant prostate cancer primarily located in bone marrow. CDPH will conduct an investigation of the circumstances of the medical event."

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.

HPCI DECLARED INOPERABLE

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

"At 1044 EST, Unit 2 high pressure coolant injection (HPCI) system was declared inoperable per technical specification 3.5.1.C.1 during planned surveillance testing due to test equipment failure and subsequent inadvertent isolation of the outboard HPCI turbine exhaust line vacuum breaker primary containment isolation valve. The test equipment was removed, and the vacuum breaker isolation valve was re-opened. HPCI was restored to operable status at 1351.

"Due to inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72.(b)(3)(v)(D).

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

DEGRADED CONDITION

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

"At 1803 EST on 03/03/25, it was determined that the reactor coolant system pressure boundary does not meet American Society of Mechanical Engineers (ASME) section XI, Table IWB-341 0-1, 'Acceptable Standards' due to a through wall leak where the thimble tube connects to penetration number 6. The cause of this event is currently being investigated. This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A).

"The NRC Resident Inspector has been notified."