Event Notification Report for March 19, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/18/2025 - 03/19/2025
Agreement State
Event Number: 57630
Rep Org: Arizona Dept of Health Services
Licensee: Banner Univ. Medical Center -Tucson
Region: 4
City: Tucson State: AZ
County: Pima
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Jordan Wingate
Licensee: Banner Univ. Medical Center -Tucson
Region: 4
City: Tucson State: AZ
County: Pima
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Jordan Wingate
Notification Date: 03/26/2025
Notification Time: 18:55 [ET]
Event Date: 03/20/2025
Event Time: 00:00 [MDT]
Last Update Date: 03/26/2025
Notification Time: 18:55 [ET]
Event Date: 03/20/2025
Event Time: 00:00 [MDT]
Last Update Date: 03/26/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
AGREEMENT STATE REPORT- UNPLANNED CONTAMINATION AND MEDICAL EVENT
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On March 26, 2025, the Department received notification from the licensee about a medical event involving Y-90 (Eye90 [microspheres]) that occurred on March 20, 2025. The set up of the delivery device and administration of the Y-90 took approximately 20 minutes. During the delivery, it was noted that there were droplets on the microcatheter. While surveying personnel who were leaving the room, contamination on shoe covers and scrubs was found, which started the shutdown of the room to control [the spread of] contamination. Contamination was found on the delivery table, patient drapes, floor draping, shoe covers, and the lower part of the scrub pants of the physician. All of the contaminated items were collected, and the room was cleaned. In addition, a patient survey was performed, and the reading was significantly lower than expected. The patient was prescribed a dose of 1.72 GBq, but the licensee believes that the patient only received 30 - 55 percent of [the prescribed amount]. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
AZ Event Number: 25-006
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.
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On March 26, 2025, the Department received notification from the licensee about a medical event involving Y-90 (Eye90 [microspheres]) that occurred on March 20, 2025. The set up of the delivery device and administration of the Y-90 took approximately 20 minutes. During the delivery, it was noted that there were droplets on the microcatheter. While surveying personnel who were leaving the room, contamination on shoe covers and scrubs was found, which started the shutdown of the room to control [the spread of] contamination. Contamination was found on the delivery table, patient drapes, floor draping, shoe covers, and the lower part of the scrub pants of the physician. All of the contaminated items were collected, and the room was cleaned. In addition, a patient survey was performed, and the reading was significantly lower than expected. The patient was prescribed a dose of 1.72 GBq, but the licensee believes that the patient only received 30 - 55 percent of [the prescribed amount]. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
AZ Event Number: 25-006
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: 57618
Facility: Monticello
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Tom Johnson
HQ OPS Officer: Ernest West
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Tom Johnson
HQ OPS Officer: Ernest West
Notification Date: 03/19/2025
Notification Time: 16:12 [ET]
Event Date: 03/19/2025
Event Time: 11:36 [CDT]
Last Update Date: 03/19/2025
Notification Time: 16:12 [ET]
Event Date: 03/19/2025
Event Time: 11:36 [CDT]
Last Update Date: 03/19/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Havertape, Joshua (R3DO)
Havertape, Joshua (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 97 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM
The following information was provided by the licensee via phone and email:
"At approximately 1136 CDT on March 19, 2025, with Unit 1 in mode 1 at 97 percent power, a reactor water level transient occurred which resulted in an automatic reactor scram on low reactor pressure vessel water level. The scram was uncomplicated with all systems responding as expected. The cause of the event is under investigation. Containment isolation valves actuated and closed on a valid group 2 signal.
"Operations responded and stabilized the plant in mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.
"This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) due to the reactor protection system actuation while critical, and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group 2 isolation signal.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified. The state of Minnesota as well as Wright and Sherburne counties will be notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At the time of the event, condensate flushing evolutions were ongoing. It should be noted that prior to the reactor scram, a single feedwater pump tripped which would lower reactor water level.
The following information was provided by the licensee via phone and email:
"At approximately 1136 CDT on March 19, 2025, with Unit 1 in mode 1 at 97 percent power, a reactor water level transient occurred which resulted in an automatic reactor scram on low reactor pressure vessel water level. The scram was uncomplicated with all systems responding as expected. The cause of the event is under investigation. Containment isolation valves actuated and closed on a valid group 2 signal.
"Operations responded and stabilized the plant in mode 3. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.
"This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) due to the reactor protection system actuation while critical, and an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A) for the Group 2 isolation signal.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified. The state of Minnesota as well as Wright and Sherburne counties will be notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
At the time of the event, condensate flushing evolutions were ongoing. It should be noted that prior to the reactor scram, a single feedwater pump tripped which would lower reactor water level.