Event Notification Report for November 15, 2021

EN Revision Imported Date: 9/20/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE

The following is a synopsis of a report received from the State of Washington, Office of Radiation Protection via email.

On Monday, November 15, 2021 a patient undergoing cancer treatment at University of Washington Medical Center received an under dose of Y-90 TheraSpheres. The details of the intended dose to the liver (target organ) are yet to be provided. They will be forwarded when obtained.

* * * UPDATE ON 9/19/22 AT 1657 EDT FROM JAMES KILLINGBECK TO BRIAN LIN * * *

The following information was received from the state of Washington State Department of Health via email:

"The University of Washington Medical Center reported that a patient received less dose than prescribed during a yttrium-90 microsphere (Nordion/BWXT model TheraSphere) liver cancer treatment on 11/15/2021. In this event, the patient was administered two dosages of yttrium-90 microspheres to treat the patient's liver at two different liver treatment sites.

"One dosage was 51.5 millicuries, which was successfully delivered.

"The other dosage was 34.1 millicuries, but only 24.2 millicuries (about 69 percent) was successfully administered. The prescribed dose was 13,100 rem, but the dose actually administered was only 9,300 rem (about 29 percent less). It appears that the microspheres that were not successfully administered remained mainly in the catheter since the radiation reading of the catheter and syringe after administration of the yttrium-90 microspheres was about 1 mR/hour instead of the usual reading of 0 mR/hour after administration.

"This appears to be an event where the catheter was blocked or clogged because of clumping of microspheres in the catheter. Events like these are discussed in 'NRC Information Notice 2019-12: Recent Reported Medical Events involving the Administration of Yttrium-90 Microspheres for Therapeutic Medical Procedures.' A copy of this information notice was sent to University of Washington officials in hopes that it would help them to fully understand this incident and to help them prevent future incidents from happening."

WA report no.: WA-21-024

Notified R4DO (Deese) and NMSS via email.

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: 12/15/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - LOST OR STOLEN MOISTURE DENSITY GAUGE

The following is a synopsis of information received via telephone:

Upon arriving at a jobsite in West Indianapolis, the technician went to remove a Troxler gauge for use. Upon opening the toolbox in the bed of the truck, the technician found that the Troxler gauge was missing from its case. The toolbox is bolted to the bed of the truck, however the locks for the toolbox and case were found not to be locked.

At the present time, the licensee is not sure whether the Troxler gauge was stolen or possibly left at the last jobsite where it was used this past Saturday. The licensee is dispatching individuals to the last jobsite to search for the Troxler gauge. The licensee has also reported this event to the Indianapolis Police Department.

The Troxler gauge is a Model 3430 moisture density gauge, serial number 23266. The Troxler gauge contains 0.3 GBq of Cs-137 and 1.48 GBq of Am-241.

The licensee will provide updated information when available.

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

EN Revision Imported Date: 12/16/2021

EN Revision Text: MANUAL REACTOR TRIP DUE TO MAIN TRANSFORMER FAULT

"At 1728 EST on 11/15/2021, with Unit 1 in Mode 1 at 47 percent power, the reactor was manually tripped due to a main transformer fault. The trip was not complex, with all systems responding normally post-trip. Operations responded and stabilized the plant. Decay heat is being removed by the emergency feedwater system through the main condenser.

"Due to the Reactor Protection System 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 valid actuation of the emergency feedwater system, this event is being reported as a non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).

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

* * * UPDATE ON 11/16/21 AT 1649 EST FROM BRUCE BENNETT TO KERBY SCALES * * *

"At approximately 0900 [EST] on 11/16/2021, it was identified that mineral oil from the faulted main transformer had surpassed the capability of the oil containment system and discharged into Lake Monticello. It is estimated that less than 50 gallons of mineral oil entered the Lake. The oil is contained with booms and cleanup is ongoing. The EPA National Response Center and the South Carolina Department of Health and Environmental Control have been notified. This is considered a news release or notification to other government agencies; therefore, this event is reportable under 10 CFR 50.72(b)(2)(xi).

"The NRC Senior Resident Inspector has been notified."

Notified R2DO (Miller).

EN Revision Imported Date: 12/16/2021

EN Revision Text: ABNORMAL OCCURRENCE

"University Of Missouri Research Reactor (MURR) Technical Specification (TS) 6.6.c(1) requires notification to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, has occurred. MURR was not in compliance with one (1) of the TS Limiting Conditions of Operations. TS 3.2.g states, 'The reactor safety system and the number (N) of associated instrument channels necessary to provide the following scrams shall be operable whenever the reactor is in operation.' Specifically, the reactor safety scram function that occurs when the differential pressure across the reactor pool reflector (PT-917) instrument channel decreases below 2.52 psi minimum in Mode 1 operation was not operable as required by TS 3.2.g.10.

"On 11/15/21 while the reactor was shut down, Control Room operators shut down the pool coolant system and noticed that the `Reflector Hi-Low Diff Pressure Scram' annunciator alarm did not initiate as pool coolant flow rate decreased to zero. The Control Room operators contacted reactor management, and an investigation was initiated to prove whether or not the safety scram function from the PT-917 instrument channel actuated correctly. Further testing revealed the safety scram signal from the PT-917 instrument channel did not occur due to a failed alarm-meter unit. The alarm-meter unit was replaced with an exact spare, the PT-917 instrument channel was calibrated, and the reactor safety scram functions of the PT-917 instrument channel were retested satisfactorily.

"In accordance with TS 6.6.c(4), the Reactor Facility Director was briefed and gave permission to restart the reactor prior to the reactor returning to operation later on 11/15/21. Currently, MURR is operating at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3)."

The NRC Project manager was notified.