Event Notification Report for May 12, 2025

AGREEMENT STATE REPORT - SOURCE REMOVAL

The following is a summary of information provided by the Georgia Radioactive Material Program (the Department) via email:

On May 2, 2025, the Department was notified via email by the licensee, of an incident where a Kay-Ray Cs-137 source was removed from its installation location by an unauthorized contractor. The source is secured under lock and key and is being stored by the licensee. Upon receipt of further information, the Department will update this report as more information comes in.

Georgia Incident Number: 95

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"The NYSDOH Bureau of Environmental Radiation Protection (BERP) received an email from the radiation safety officer of Westchester County Department of Laboratories and Research (DOLR) on May 1, 2025, to report a leaking Ni-63 electron capture device (ECD) from an Agilent 5890GC [Control Module] that was decommissioned pending disposal. The ECD has been locked in storage and not in service.

"Device: Agilent
"Device Model: 5890GC
"Serial No.: U3284
"Isotope: Ni-63

"The licensee was conducting a leak test and wipe of the decommissioned gas chromatography unit. The wipe test for the ECD housing had removable contamination detected at 7,741 pCi when analyzed using a proportional counter. The device is in the initial stages of returning to Agilent and the licensee was performing the wipe test prior to shipment. The licensee is contacting Agilent for additional guidance.

"NYSDOH BERP is actively monitoring this event under Incident Number 1530. Additional information will be provided to NMED once available."

Event Report ID Number: NYSDOH-25-06

AGREEMENT STATE REPORT - LOST PACKAGES

The following information was provided by the Massachusetts Radioactive Material Unit (the Agency) via email:

"On 4/30/25, four radioactive material packages were to be received by the licensee, Boston University and Boston Medical Center (MA license number 44-0062). Two packages showed up just after 1000 EDT, but one package containing 7mCi of S-35 and another package containing 0.5 mCi of P-32 were not received. The packages were shipped from Revvity Health Sciences, Inc. (MA license number 00-3200).

"An investigation was opened with the common carrier, which is currently ongoing.

"The reporting requirement is within 30 days and is of 105 CMR [Code of Massachusetts Regulations] 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

MEDICAL EVENT

The following is a summary of information provided by the licensee via phone:

On April 28th, 2025, at 1000 EDT, a patient receiving Y-90 Therasphere treatment was prescribed to receive 301 Gy from three different vials. While administering the third vial, not all of the dose was received by the patient which resulted in the patient receiving 71.2 percent of the total expected dose. The cause of the patient not receiving the third full dose is still under investigation. This medical event is being reported as a dose that differs from the prescribed dose by more than 20 percent.

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 NRC regional office has been notified.

AGREEMENT STATE REPORT - EQUIPMENT FAILURE

The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email:

"On April 16, 2025, the University of Pittsburgh informed the Department of an equipment failure event involving its microSelection HDR [high dose-rate] device. It is reportable under 10 CFR 30.50(b)(2).
"A patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR 106.990. During the treatment, a software error occurred, and the computer shut off. This stopped the treatment and retracted the source into the safe/shielded position. The Elekta service engineer was immediately contacted, and a system reboot was performed to bring the HDR machine and computer back to functional status. The authorized user decided to continue treatment with the service engineer remaining immediately available via telephone. After the treatment was resumed, the source was deployed (as verified by room radiation monitor, source indicator at machine console computer, and sound of source movement) but the computer screen did not indicate treatment in progress by visual display and again gave an error message (`software problem detected'). The authorized medical physicist pressed the emergency button and the source was retracted. Per the authorized user physician, the patient's treatment was terminated for the day. Elekta personnel arrived on 4/17/25 and created 1 GB [Gigabyte] space on the local drive for a temporary solution, then permitted UPMC IT [University of Pittsburgh Medical Center Information Technology] personnel to assist. The UPMC IT personnel came onsite and created 230 GB local drive space, which is confirmed to be enough for the long term. Elekta personnel did note that treatment volumes for this location (which require more memory) are exceptionally high compared to other Elekta brachytherapy clinics.

"The cause of this event was possibly a generic issue with insufficient storage space availability, the software error occurred during treatment and the treatment data was not able to be stored in the database, which led to failure.
"The Department will perform a reactive inspection."

Pennsylvania Event Report Number: PA250006

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Washington State Department of Health (the Department) via email:

"On 5/5/2025, at 1320 PDT, the Department was notified of a medical event. This event occurred on the afternoon of Friday, 5/2/2025. This event was discovered by the licensee's radiation safety officer on 5/5/2025. The incident may require reporting under WAC 246-240-651(1)(i)(A). A detailed report will be delivered within 15 days of 5/5/2025."

Medical Isotope: Y-90
Administered Dose: 32 percent of the intended dose.

Washington Incident Number: WA-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.

EN Revision Imported Date: 5/12/2025

EN Revision Text: PART 21 - CIRCUIT BREAKER DEFECT

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

"On March 7, 2025, General Electric Hitachi (GEH) issued 10 CFR Part 21 Communication SC 25-01 for a molded case circuity breaker (MCCB), in accordance with 10 CFR 21.21(b). Testing performed by GEH identified a deviation in two (2) breakers; specifically, GEH part number DD148C6151P004 (Asea Brown Boveri (ABB) part number: TB13030BWE05). These MCCBs failed to instantaneously trip at the designated current and time.

"James A. FitzPatrick Nuclear Power Plant (JAF) completed an evaluation of this deviation in accordance with 10 CFR 21.21(a)(1) on May 6, 2025, and concluded this condition is a defect which could create a substantial safety hazard. The instantaneous trip function of this component protects safety-related buses from tripping on an overcurrent condition.

"JAF was listed as the only affected plant. It was determined that the defect does not exist in any installed plant equipment because bench testing performed prior to installation includes overcurrent trip testing and would have identified this defect. The components affected by this defect have been restricted to prevent them from being installed pending corrective action resolution.

"This letter is submitted as a non-emergency notification in accordance with 10 CFR 21.21(d)(3)(i). Additional details will be provided in a written report within 30 days, in accordance with 10 CFR 21.21(d)(3)(ii).

"There are no new regulatory commitments contained in this letter. The NRC Senior Resident Inspector at JAF has been notified. Should you have any questions regarding this submittal, please contact Mark Hawes, Regulatory Assurance, at (315) 349-6659."

Known affected power plants:
James A. FitzPatrick

FITNESS FOR DUTY EVENT

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

"At 1030 CDT on 5/10/2025, it was determined that a non-licensed supervisor has tested positive for a controlled substance, in violation of South Texas Project's fitness for duty policy. The individual's unescorted access has been revoked.

"The NRC Resident Inspector has been notified."

FITNESS FOR DUTY EVENT

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

"On May 10, 2025, at approximately 1130 EDT, security discovered a full, un-opened can of beer in a rental vehicle inside the protected area. Security took possession of the item and removed it from site."

The NRC Resident Inspector and Connecticut State Department of Energy and Environmental Protection were notified.