Event Notification Report for April 25, 2025

MEDICAL EVENT

The following information was provided by the licensee's radiation safety officer (RSO) via phone:

During an audit performed on 04/16/2025, it was discovered, that on 01/24/2025, a patient had received a dose to the liver that was greater than 20 percent of the prescribed dose. The prescribed activity was 24.3 mCi of Y-90 microsphere, an equivalent dose of 21.95 grays to the liver. The spreadsheet containing the activity verification incorrectly listed the activity as 26.9 mCi. The actual activity administered to the patient was 29.8 mCi, an equivalent dose of 26.9 grays, which is 22.6 percent (4.95 grays) greater than the prescribed dose to the liver. The RSO intends to contact the patient and doctor.

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 report was received by the Pennsylvania Bureau of Radiation Protection [the Department] via email:

"On April 16, 2025, a patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR [high-dose radiation] [remote afterloader]. During the procedure, a software error that retracted the source occurred. The unit was rebooted, and the treatment was restarted. However, 17 seconds into restarting, the unit failed to show the next dwell position, so the treatment was terminated. Approximately 48 percent of the prescribed dose was administered to the patient. No harm is expected to the patient and both the physician and patient were notified. The patient treatment plan will be updated accordingly.

"The official cause is still under investigation. The service engineer will be onsite April 17, 2025, to troubleshoot the HDR. The Department will perform a reactive inspection. More information will be provided as received."

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.

Pennsylvania Event Report Number: PA250004

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The radiation safety officer for Northwestern Memorial Healthcare contacted the Agency on 4/17/2025 to report a medical underdose. Initial information indicated an underdosing of Y-90 TheraSpheres of 54 percent. The patient reportedly tolerated the procedure well and no further treatment is scheduled. The administering physician reported an issue with vasoconstriction of the target artery. The licensee confirmed that the patient and referring physician were notified. The licensee did not meet reporting requirements, which will be addressed during a reactive inspection to be conducted on 4/21/2025."

The intended activity was 17.03 mCi (630.11 MBq) and the administered activity was 7.84 mCi (290.08 MBq).

Illinois Reference Number: IL250016

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 - FAILURE OF EXIT PORTAL MONITOR

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

"The corporate radiation safety officer for Isomedix Operations, Inc. (IL-01123-02) contacted the Agency on 4/18/2025 to report that during routine monthly testing of the exit portal monitor conducted on 4/17/2025, on the Co-60 pool irradiator (irradiator 192), the monitor failed to respond to radiation. The issue was immediately identified as corrosion on the cable-to-probe connection and was subsequently repaired, tested, and found to be functional. There was no report of exposure to personnel or loss of control. The licensee reported the failure within 24 hours as required by 346.830(a) and will submit a written report within 30 days as required."

Illinois Item Number: IL250017

EN Revision Imported Date: 4/25/2025

EN Revision Text: FITNESS FOR DUTY REPORT

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

"A non-licensed supervisor had a confirmed positive fitness-for-duty follow-up test. The employee's unescorted access has been terminated. This report is being made pursuant to 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been notified."


* * * RETRACTION ON 04/24/25 AT 1742 EDT FROM BRIAN STANISZEWSKI TO JOSUE RAMIREZ * * *

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

"This is to retract event notification 57676.

"On April 22, 2025, Columbia Generating Station notified the NRC (event notification 57676) under 26.219(b)(2)(ii) of a non-licensed supervisor with a confirmed positive fitness-for-duty follow-up test.

"Subsequent to the notification the medical review officer (MRO) has reversed their decision of a positive test result based on additional research and information provided by the certifying scientist of the laboratory.

"Due to this, the original notification (57676) is being retracted."

The NRC Resident Inspector has been notified.

Notified R4DO (Rollins) and FFD Group (email).

EN Revision Imported Date: 4/24/2025

EN Revision Text: OFFSITE NOTIFICATION

The following is a summary of information provided by San Onofre Nuclear Generating Station (SONGS) via phone and email:

At 1554 PDT on 4/23/25, SONGS was notified of mineral oil spills that occurred in two separate locations from one transformer being delivered to SONGS. A total of 10-25 gallons of oil leaked. One leak location was on site and has been cleaned up. The second location was on state park property and has been isolated with absorbent material put down. A remediation company will remove the affected soil from the second location. The transformer has been drained and removed from the site. This report is being submitted due to offsite notifications to the San Diego Department of Environmental Health and the California Office of Emergency Services.

The NRC regional office has been notified.

PART 21 REPORT - SOLENOID VALVE FAILS TO OPERATE AFTER EXTENDED DE-ENERGIZATION

The following is a summary of the information provided by ASCO via email:

This report relates to the failure of a single air-operated valve identified by Dominion Energy at North Anna due to failure of the associated solenoid valve. The solenoid valve periodically failed to reposition, or only partially repositioned, after periods of extended de-energization.

As part of testing, the ASCO NP8321 solenoid valve series and all ASCO NP-series solenoid valves were qualified to sit in a normally energized position and were not tested for extended periods of de-energization. The U-cup seal was tested and ASCO determined that this U-cup seal experienced performance limitations at low air operating pressures (below 40 psi) and the valve did not shift completely to an energized state.

An alternative valve (NP8300) is recommended by ASCO for this customer application. In the interim, ASCO recommends increasing the inlet air pressure to the valve to at least 80 psi not to exceed the maximum 150 psi to conservatively ensure proper operation of the NP8321 series valve in a de-energized state.

ASCO concludes based on design and known operating experience that only the NP8321 model valve exhibits this condition.

ASCO does not have adequate knowledge of the actual installation and operating condition of this valve to determine whether this condition would create a `substantial' safety hazard as defined in 10 CFR 21.3. The report is intended to provide investigation results and recommendations. Each end user needs to perform their own evaluation based on the information provided in this notification.

Bryan Causey
Quality Engineer
Bryan.Causey@Emerson.com

The only plant known to be affected at the time of the report is North Anna.