Event Notification Report for April 28, 2025

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

AGREEMENT STATE REPORT - STUCK SOURCE

The following is a summary of information provided by the Arkansas Department of Health via email:

On Thursday, April 17, 2025, at 1309 CDT, the licensee submitted a notification that on Wednesday, April 16, 2025, at 1730 CDT, they had experienced a radiography source failure to retract. The radiation safety officer (RSO) was notified. They arrived onsite at 1930 CDT with retrieval tools and shielding and was able to retract the source into the camera by 2330 CDT. The location was in an isolated area of the Union Pacific rail yard with concrete abutments that afforded shielding of the source. Exposures were limited to 134 millirem to the RSO, 36 millirem to the radiographer, and 11 millirem to the trainee. There was no exposure to the public.

The exposure device is a SPEC 150, serial number 2240, with a SPEC model G-60 source, serial number FL1805, with 33 curies of Ir-192.

The cause was determined to be a kink or crimp in the guide tubing preventing the source from retracting. The investigation is ongoing, and reporting will proceed in accordance with SA-300.

Arkansas Event Number: AR-2025-002

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.

FITNESS FOR DUTY - ALCOHOL CONTAINER FOUND IN PROTECTED AREA

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

"On April 24, 2025, at approximately 2321 CDT, an empty 100 mL alcohol bottle was found in the protected area by a contract employee. Site security was notified and took possession of the bottle which was removed from the protected area.

"The NRC Resident Inspector was notified."