Event Notification Report for May 13, 2025

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 The authorized medical physicist pressed the emergency button and the source was retracted.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.

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information is a summary provided by the Nevada Department of Health and Human Services (the Department) via phone and email:

On May 6, 2025, the licensee reported to the Department a stuck open shutter on a Berthold LB 7440 gauge (150 mCi Cs-137, serial number 794). The fixed gauge remains installed pending the arrival of a contractor to replace the failed shutter.

Area surveys at 1 foot were 0.2 mR/hr. The gauge is in the wet mill and has little, if any, foot traffic by it. Due to the location and survey results being unchanged from normal operation, there is no additional exposure expected to the mine or mill staff until the gauge can be repaired by the contractor. The ladder to the gauge has been blocked and the walkway has been cordoned off.

This is the third occurrence in less than a year (6/18/2024, 7/8/2024, 5/6/2025) of the same model with the shutter being stuck in the open position. The licensee was reminded to report the failure to the manufacturer in accordance with the operations and maintenance manual for the gauge.

Nevada Item Number: NV250004

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.

AUTOMATIC REACTOR TRIP

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

"At 1353 CDT on May 12, 2025, with Unit 2 in Mode 1 at 100 percent power, the reactor automatically tripped due to a turbine trip caused by a loss of the electrohydraulic control (EHC) system. The trip was not complex, with all systems responding normally post-trip with the exception of the turbine bypass valves due to the loss of EHC.

"Operations responded and stabilized the plant. At 1407 with Unit 2 in Mode 3, there was a second automatic reactor trip due to a low reactor water level transient caused by manually opening and closing a main steam relief valve. Reactor water level is being maintained via feed water pump. Decay heat is being removed by discharging steam [via main steam line drains] to the main condenser. Units 1 and 3 are not affected.

"Due to the reactor protection system (RPS) actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"Additionally, due to the actuation of RPS and groups 2, 3, 6, and 8 of the primary containment isolation system, this event is being reported as an eight-hour, non-emergency notification per 50.72(b)(3)(iv)(A).

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