Event Notification Report for August 25, 2023

AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT

The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:

"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:

"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.

"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."

Illinois Event Number: IL230018

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

AGREEMENT STATE REPORT - TREATMENT TO WRONG SIDE OF ORGAN

The following report was received via email by the Ohio Bureau of Radiation Protection:

"On July 28, 2023, a patient was scheduled to receive treatment to the right lobe of the liver, however, imaging performed on August 16, 2023 showed the left lobe received the dose. Approximately 83 mCi of Y-90 was delivered, resulting in a dose of 130 cGy (130 Rad) to the wrong treatment site. The patient and referring physician were notified. Future treatment of the left lobe of the liver was planned, but not under this written directive."

Ohio Event Number: OH230009

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.

FITNESS FOR DUTY (FFD) REPORT

The following information was provided by the licensee via email:

A non-licensed contract supervisor failed a test specified by the FFD testing program. The employee's access to the plant has been terminated.

The NRC Resident Inspectors have been notified

FITNESS FOR DUTY (FFD) REPORT - NON-LICENSED SUPERVISOR VIOLATED FFD POLICY

The following information was provided by the licensee via email:

"On August 23, 2023 at 2100 CDT, Grand Gulf Nuclear Station was notified that a non-licensed supervisor violated the station's Fitness for Duty policy. The employee's unescorted access at Grand Gulf Nuclear Station has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 8/28/2023

EN Revision Text: INITIAL PART 21 REPORT - DEFECT WITH EATON/CUTLER HAMMER SIZE 4 AND 5 FREEDOM SERIES CONTACTORS

The following information was provided by Paragon Energy Solutions, LLC via email:

"Pursuant to 10 CFR 21.21(d)(3)(i), Paragon Energy Solutions, LLC is providing this initial notification of a potential defect with Eaton/Cutler Hammer size 4 and 5 freedom series contactors that have been modified to include either a special coil and/or to improve the securing of shading coils. These contactors may have been supplied integral to a motor control center (MCC) cubicle or as spare parts. This condition, if left uncorrected, could potentially cause a substantial safety hazard.

"Paragon completed an initial evaluation of a failure of a size 4 freedom series contactor (PN: NLI-CN15NN3A-T16-MOD-M) supplied to Perry Nuclear Power Plant. The reported failure occurred 26 days following installation into its associated MCC Cubicle. Perry identified the screws holding the contact bar to the push bars had fallen out and were laying in the bottom of the molded base. This allowed the movable contact bar to sit on the stationary contacts and significantly degrade due to arcing and then fail in the energized position. This condition could prevent the contactor from performing its safety function to either energize or de-energize the attached load.

"The loose hardware is most likely a workmanship error since the contactor must be disassembled to complete the special coil and RTV modifications to the shading coils. In the fully re-assembled condition, inspection of this hardware for tightness is not possible."

Affected plants: North Anna, Turkey Point, Harris, and Perry.

* * * UPDATE ON 08/25/23 AT 1448 EDT FROM RICHARD KNOTT TO ERNEST WEST * * *

Paragon Energy Solutions submitted their final report in accordance with 10 CFR 21.21(d)(4).

Paragon reported completion of corrective actions including revising the test inspection procedure to ensure hardware tightness during contactor reassembly, identifying all projects containing the affected contactors and verifying appropriate inspections have been completed, restricted use of test inspection procedures issued prior to 8/2/2023 until a formal review is completed, and issued a technical bulletin (TB-Starter-2023-01 Rev 0) for use by affected clients.

Paragon recommends affected licensees perform the steps contained in Technical Bulletin TB-Starter-2023-01 Rev 0 to verify this condition is not present as part of their next routine maintenance outage associated with the affected in use equipment, and at the earliest opportunity for stock spares.

Affected plants: North Anna, Turkey Point, Harris, and Perry.

Notified R2DO ( Miller), R3DO (Skokowski), and Part 21/50.55 Group via email.

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by West Virginia University Hospital via telephone and email:

"It was determined on 8/21/2023, that during a Y-90 (Yttrium-90) Thera Sphere treatment performed on 8/17/2023, the delivered dose differed from the prescribed dose by more than 20 percent. The prescribed activity was 101.5 mCi and the administered activity was 3.4 mCi.

"At the start of the infusion the authorized user (AU) was unable to deliver the microspheres due to a blood clot in the microcatheter. The AU then decided to abort the infusion and reschedule instead of chancing potential contamination that could occur by changing out the microcatheter.

"The AU had completed the pre-treatment safety checklist with no issues. The AU has made the notification to the referring physician."

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 - STOLEN TROXLER GAUGE

The following information was provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:

"On 8/21/23 at 1751 EDT, BRC received notification from the Blue Marlin Engineering radiation safety officer (RSO) that a Troxler 3430 Gauge (serial number 76 464, Cs-137 77-17679, Am/Be 78-12867) was reported stolen from a work site in Apopka, FL. The RSO does not know when the loss of control occurred. The device was last used at approximately 1100 EDT on 8/21/23 prior to the authorized user (AU) traveling for lunch. Upon returning from lunch, the AU noticed the device was no longer under his control.

"An initial incident report [is planned] to be submitted by the Florida Department of Health on 8/22/23."

* * * UPDATE ON 8/22/23 AT 0814 EDT FROM MONROE COOPER TO ADAM KOZIOL * * *

"RSO believes device was likely stolen, but states there is a possibility it has been filled into a ditch on the work site. Orange County Police Report: 23-51399."

Florida Incident Number: FL23-128

Notified: R1DO (Gray), NMSS (email), ILTAB (email)

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

LOSS OF EMERGENCY ASSESSMENT CAPABILITY

The following information was provided by the licensee via email:

"At approximately 1600 CDT on 8/25/2023, a partial loss of the commercial phone communications system occurred that affects the emergency notification system (ENS) and the functionality of an emergency response facility.

"This is an eight-hour, non-emergency notification of a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii).

"Communications via alternate methods were subsequently established. The telecommunications provider has not provided an estimated repair time.

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