Event Notification Report for July 07, 2025

EN Revision Imported Date: 8/11/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was provided by the Georgia Radioactive Materials Program via email:

"The licensee called and stated that during a post treatment review with the physician conducted today, it was identified that a patient receiving yttrium-90 therapy on July 7, 2025, was underexposed due to a kink in the catheter. The prescribed dose was 0.439 GBq (11.853 mCi), but the administered dose was determined to be 0.177 GBq (4.779 mCi). This represents a 40.32 percent deviation from the prescribed dose, which exceeds the 20 percent reporting threshold. Upon further review of the patient's treatment history, it was additionally discovered that two prior underdosing events occurred on August 20, 2024, and September 30, 2024. Both events were also attributed to catheter kinking and involved dose delivery to small treatment volumes in limited target areas. [The licensee] stated that a formal written report detailing all three underdosing events, along with supporting documentation, will be submitted via email on Monday, August 4, 2025."

* * * UPDATE ON 8/8/2025 AT 1047 EDT FROM ANASTASIA BENNETT TO TENISHA MEADOWS * * *

The following is a summary of information provided by the Georgia Radioactive Materials Program via email:

The licensee provided three updated official incident reports, including two prior underdosing events that occurred on August 20, 2024, and September 30, 2024.

The July 7, 2025, incomplete Y-90 dose delivery was attributed to clumping of the microspheres within the microcatheter. As part of corrective actions, the specific type of microcatheter involved in this incident has been discontinued for use in Y-90 procedures.

During the administration of Y-90 microspheres on August 20, 2024, the prescribed dose was 0.224 GBq (6.0 mCi) and the administered dose was 0.150 GBq (4.1 mCi).

During the Y-90 treatment performed on September 30, 2024, the prescribed dose was 0.290 GBq (7.83 mCi) and the administered dose was 0.166 GBq (4.5 mCi).

Both the August 20, 2024, and September 30, 2024, underdosing events were attributed to anatomical limitations. Specifically, a small treatment volume and narrow treatment vessels, which restricted adequate flow of microspheres. As part of the corrective actions taken, it was determined that more than 30 psi of pressure is required to deliver microspheres into small vessels. Therefore, future cases involving small treatment vessels will consider the use of delivery systems capable of generating higher pressure to ensure effective dose administration.

Notified R1DO (Henrion) and NMSS Events Notification (email)

Georgia Incident Number: 105

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.

DAMAGED GAUGE

The following information was provided by the licensee via phone:

On July 7, 2025, at 1550 EDT, a density technician was taking a measurement when they were struck by construction equipment. The individual was transported to the hospital for medical attention and the gauge was damaged by the construction equipment. The radiation safety officer responded to the site, pulled the gauge out of the ground, and verified that the source was still intact at the tip of the rod. The gauge was placed in a drum filled with sand and transported to a radioactive material storage facility owned by the licensee. The next morning, InstroTek was contacted to plan disposal of the gauge. There was no additional exposure to the technician or the public during the event and all radiation and contamination surveys of the site were below background levels. The damaged gauge is an InstroTek Explorer 3500 (S/N 3257) and contains 10 mCi of Cs-137 and 40 mCi of Am-241.

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Minnesota Department of Health (MDH), Radioactive Materials Unit via email:

"On Monday, July 7, 2025, at 1000 [CDT], the licensee discovered a gauge with a stuck shutter. The gauge is a Texas Nuclear fixed gauge with a 200 mCi Cs-137 source. Maintenance was planned on the apron feeder near the gauge. The maintenance group requested the electrical group close the shutter on this gauge. The electrical crew was unable to close the shutter after multiple attempts and decided to remove the gauge and place it in a container containing lead plates. The radiation safety officer (RSO) took readings 1 foot from the top and sides of the container. The highest reading was 0.3 mR/hr. The container was labeled as radioactive material and taped off with red tape. The RSO reached out to QAL-TEK to dispose of the unit. QAL-TEK stated they may be able to come out in less than two weeks."

Minnesota Event Report ID: MN250004

EN Revision Imported Date: 7/23/2025

EN Revision Text: RESIDUAL HEAT REMOVAL COMPLEX PUMP ROOM DAMPER FULLY CLOSED

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

"On 7/7/2025 at 1545 EDT, one of the division 2 residual heat removal (RHR) complex pump room dampers was noted to be full-closed instead of at the expected full-open position based on outside air temperatures. An operator walkdown confirmed that the division 2 RHR pump room temperature controller was attempting to open the damper. Per plant procedures, the affected RHR service water (RHRSW), emergency equipment service water (EESW), and emergency diesel generator service water pumps (DGSW) were declared inoperable. Division 2 EESW supports the safety function for all division 2 safety systems, including high pressure coolant injection (HPCI). Therefore, HPCI was also declared inoperable. Since HPCI is a single-train safety system, this meets the criterion for event notification per 10 CFR 50.72(b)(3)(v)(D). The damper will be blocked to the position required based on current and projected outside air temperature, this will return the systems to operable. The cause of the damper failure is unknown and under investigation."

The NRC Resident Inspector has been notified.

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Multiple technical specification limiting conditions for operation (LCOs) were entered as a result of this event. Fermi Unit 2 expects to be able to exit the LCOs within the required timeframes.

* * * RETRACTION FROM JOSH MORSE TO BRIAN P. SMITH AT 1616 EDT ON JULY 22, 2025 * * *

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

"Following the initial event notification, further analysis of the condition identified that since the residual heat removal complex room temperature (85 degrees F) was less than the limit bounded by a calculation (<104 degrees F), and the dampers were blocked in a position in accordance with plant procedures within 24 hours of the event, there is reasonable assurance that the high pressure coolant injection (HPCI) system would be able to perform its safety function. Therefore, HPCI is considered operable for the condition.

"No other concerns were noted during the event. HPCI remained operable and there was no loss of safety function. The event did not involve a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident under 10 CFR 50.72(b)(3)(v)(D).

"Therefore, the NRC non-emergency 10CFR50.72(b)(3)(v)(D) report was not required and the NRC event report 57804 can be retracted and no licensee event report under 10 CFR 50.73(a)(2)(v)(D) is required to be submitted."

Notified R3DO (Zurawski)

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On July 7, 2025, at about 0710 CDT, a report was made by the licensee that an Istrotek model 3500 moisture density gauge containing a 10 mCi Cs-137 source and a 40 mCi Am241/Be source had been discovered stolen at 0518 CDT on July 7, 2025, from the bed of a pickup truck at the residence of an employee in Fort Worth, Texas. The securing chains and locks had been breached overnight and the gauge taken.

"The gauge handle was secured by a lock; no immediate public health issue is anticipated.

"A report was made to the Fort Worth Police Department."

Texas incident number: 10208

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