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At 0358 EST, on 12/16/2019, with Unit 1 in Mode 1 at 100 (percent) power and Unit 2 in Mode 1 at 47 (percent) power, a valid actuation of the Emergency Diesel Generators (EDG) occurred. The reason for the emergency diesel generator auto start was that the normal feeder breaker from the 1C 6.9KV Unit Board to the 1B-B 6.9KV Shutdown Board (SDBD) tripped due to the breaker's 51G relay actuating causing an under-voltage signal on the 1B-B 6.9KV Shutdown Board. All 4 Emergency Diesel Generators automatically started as designed when the 6.9KV Shutdown Board under-voltage signal was received.

The 1B-B 6.9KV Shutdown Board was automatically energized from the 1B-B 6.9KV Diesel Generator. All required 6.9KV loads were sequenced back on to the 1B-B 6.9KV Shutdown Board as designed after the board was energized from its emergency diesel generator. The remainder of the electrical system is in normal alignment.

This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Emergency Diesel Generators. There was no impact to the health and safety of the public or plant personnel. The NRC Senior Resident has been notified.

The following report was received from the Virginia Department of Health via email: On November 25, 2019 a licensee reported that the shutter of a fixed gauge used to measure the level of material inside a process vessel might have failed to close during the semi-annual radiological testing. The gauge is a Ronan Engineering, Model SA1-F37, serial number M7407, containing 40 mCi of Cs-137. The shutter arm is actuating, but the radiation reading at approximately 3 inches below the source remained the same (0.8 mR/hr) when the shutter was opened and closed. The source is located approximately 10 feet from the ground level and is only accessible by a stepladder. There are no routine activities that bring employees in close proximity to the source. There was no public exposure or environmental release from this event. The licensee has contacted the manufacturer for further investigation. The Virginia Office of Radiological Health will review the licensee's written report and determine additional actions to be taken. Event Report ID No.: VA-19-006

• * * RETRACTION ON 12/2/19 AT 1255 EST FROM ASFAW FENTA TO KERBY SCALES * * *

The following was received from the Virginia Department of Health via email: Please retract the incident report that was submitted on November 26, 2019. The licensee was advised by Ronan Engineering to take measurements directly from the detector side by closing and opening the shutter instead of taking a reading at approximately 3 inches below the source. On November 27, 2019, the licensee retested the shutter by measuring directly to the detector side and found 0.4 mR/hr when the shutter was opened and 0.2 mR/hr when the shutter was closed. The licensee reported to the agency that the gauge was working properly. There was no problem on the gauge; rather, it was an error on the measurement technique.

The following report was received from the Vermont Department of Health via email: Medical Event: Y90 resin Sir-Spheres treatment infusion aborted due to kinked microcatheter. 99.5 (percent) of the drawn dose was not delivered to the treatment site. Contamination of IR (interventional radiology) suite floor detected. Contamination of infusion paraphernalia (gloves, shoe covers, gauze, towels) detected. Contaminated items were contained and floor was decontaminated to acceptable levels by RSO (Radiation Safety Officer). Date of Event: 11/18/2019 11/18/19 AU (Authorized User) notified referring physician and patient of the medical event 11/19/19 RSO contacted State of Vermont 11/19/19 NRC contacted for clarification of event 11/20/19 RSO contacted Sirtex Incident Details: Terumo Progreat, I.D. 0.027(inches) (0.7mm), 130cm length, was used initially to access treatment site. Boston Scientific, I.D. 0.021(inches) (0.5mm), 130cm length, was used to access treatment site after unsuccessful attempt with Progreat. IR (Interventional Radiologist) Fellow assembled the delivery device. The original dose measurement was 2.2 mR/hr at 1230 (EST). The Nalgene with undelivered dose vial and the second Nalgene with delivery catheter were measured in exactly the same setup as original dose measurement. The total residual in the 2 Nalgene containers were 1.9 mR/hr + 0.25 mR/hr = 2.15 mR/hr at 1430. With 2 hours decay correction, the Nalgene containers reading should be 2.15 x 1.02 = 2.19 mR/hr. 2.19 / 2.2 = 0.995 or 99.5 (percent) for Vial + Catheter. Therefore, about 0.5 (percent) of the drawn dose (44.3 mCi) was lost. 0.5 (percent) of 44.3 mCi is 0.2 mCi (This is the calculated amount of Y90 lost) The DAVYR (Dosimetry and Activity Visualizer for Y-90 Radioembolization) application provides the following liver dose calculation based on the partition model: Liver = 27.5 Gy for a 1.5 GBq (or 40.5 mCi) dose delivery. This is based on 100 (percent) of prescribed dose being delivered. In the worst-case scenario where all the lost activity (0.2 mCi) was delivered to the patient, the liver dose calculation is: Liver = 27.5 Gy x (0.2 mCi / 40.5 mCi) = 0.14 Gy (or 14 rem) The only way to properly measure the bags of contaminated paraphernalia (towels, gloves, gauze, shoe covers) in the same setup as the original dose measurement would involve transferring the contents into several Nalgene containers. This can be done next day to properly account for lost Y90 activity. Medical event criteria - the byproduct material administration has to meet the following (10 CFR 35.3045): 1. The dose differs from a dose that would have resulted from the prescribed dosage by more than 50 rem to an organ or tissue. The unintended dose to any organ or tissue from the lost 0.2 mCi Y90 would be similar to the Liver dose calculated above (14 rem) and does not exceed 50 rem difference. Note: The highest delivered dose to Liver from the lost Y90 is calculated to be 14 rem. This is below the target dose of 110 Gy (or 11,000 rem) and does exceed the 50 rem difference; however, this was a medical safety decision resulting from unforeseen microcatheter kinking due to patient anatomy. 2. The total dose delivered differs from the prescribed dose by 20 (percent) or more. Yes, the total dose delivered is calculated to be about 0.2 mCi and is much below the prescribed dose of 40.5 mCi. A medical safety decision to abort the infusion was due to an unforeseen device event (kinked microcatheter) that prevented the safe delivery of Y90 microspheres.

• * * UPDATE ON 11/26/19 AT 0738 EST FROM FRANCIS ONEILL TO OSSY FONT * * *

The following update was received from the Vermont Department of Health via email: As a follow up to Event Number 54408, Y-90 Sirsphere event, the calculated dose to the unintended organ, the pancreas, is 14 Rem or 0.14 Gray. Notified R1DO (Henrion) and NMSS Events Notification 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 Text: CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE The following report was received from the Georgia Radioactive Materials Program via email: A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU (authorized user) that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO (Radiation Safety Officer). The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks. The RSO took the scrub pants and sock and shoes and placed them in an area for DIS (decay in storage). He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area. The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water. The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event.

• * * UPDATE AT 1733 EST ON 11/26/2019 FROM IRENE BENNETT TO JEFF HERRERA * * *

The following is a synopsis of a report received from the Georgia Radioactive Materials Program via email: On October 30, 2019 a reactive inspection was performed by the Georgia Radioactive Materials Program. The areas of contamination were verified to have a physical barrier to prevent inadvertent entry and signs posted to warn individuals of the contaminated areas. The Grady Memorial Hospital Radiation Safety officer (RSO) stated that the lab will not re-open until the contamination level reaches background, approximately 80 days from the time of the incident. The RSO temporarily removed the authorized user from administrating any therapeutic doses indefinitely. The RSO reported that there will be proper training for authorized users, technologists and residents who are involved in administering radioactive materials. A technologist will be required to be present in the room where I-131 is administered. Instructions will be added about not opening or breaking capsules containing radioactive materials to hospital procedures and refresher training will encompass the procedures. The physician did not think a bioassay was necessary for the patient as they were not exposed. Notified the R1DO (Henrion) and NMSS via email.

The following report is a summary of the information received via phone call: On 10/6/19, the radiation safety officer (RSO) noticed that one of the company vehicles appeared to have been broken into and the windows were smashed. The RSO conducted an inventory of the density gauges and determined that one of them was missing. The RSO then contacted local law enforcement (LLEA) and reported the incident. LLEA arrived on site at approximately 1640 EDT to obtain the incident information. The incident is still under investigation. The gauge information is as follows: Manufacturer: Humboldt Model: 5001 Serial Number: 2529 Source Quantity/Activity: Am-241/Be - 50 milliCuries Cs-137 - 10 milliCuries.

• * * UPDATED ON 10/7/19 AT 1404 EDT FROM CHRIS GENDUSO TO KERBY SCALES * * *

The Pavement Inspection Technologies RSO reported that the gauge was recovered intact. Notified R1DO (Dentel), ILTAB and NMSS Events (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

At approximately 1400 EDT, on 6/30/19, a company technician discovered that his personal vehicle was stolen from his residence driveway in Tolland, CT. The vehicle contained a Troxler density gauge locked in the trunk of the vehicle. The technician contacted the Connecticut State Police and reported the stolen vehicle and the stolen density gauge. The state police are still investigating the issue. The nuclear density gauge is a Troxler model 3440, serial number 69523, containing 10 mCi of Cs-137 and 40 mCi of Am-241.

• * * UPDATE ON JULY 9, 2019 AT 1008 EDT FROM HABIB CHAUDHARY TO BETHANY CECERE * * *

On July 8, 2019, a State Trooper found the gauge in a portable restroom in Highland Park in Hartford, CT. Connecticut Department of Energy and Environmental Protection determined the gauge was intact. The licensee's radiation safety officer is sending the gauge for leak testing. Notified R1DO (Dimitriadis), and ILTAB and NMSS Events Notification (via email).

• * * UPDATE ON JULY 9, 2019 AT 1652 EDT FROM SHAWN CHAUDHARY TO CATY NOLAN * * *

The Connecticut Department of Energy & Environmental Protection representative stated that he surveyed the gauge and cleared it since no damage was done. Tri State has also visually inspected and surveyed the gauge and found it to be intact and not tampered with. For extra precautions, a leak test of the gauge was taken and sent to a certified lab. The gauge will not be used until we have received the results from the lab. Moving forward, all technicians have been instructed to make every attempt to drop off their gauge at Tri State Materials Testing Lab's designated gauge room every day at the end of their field work. If they cannot make it back due to weekend and night work, they must store the gauge at their home securely to prevent this type of incident recurrence. Notified R1DO (Dimitriadis), and ILTAB and NMSS Events Notification (via 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

The following report was received from the Georgia Department of Natural Resources via email: A TheraSphere Y-90 patient did not receive the full dose to the target organ that was prescribed. The administered dose differed from the prescribed dose by more than 20 (percent). The prescribed activity to be delivered to the patient was 2.15 GBq (58 mCi). The calculated delivered activity to the patient was 1.01 GBq (27.3 mCi). The delivered activity was determined by comparing pre-and post-administration survey meter measurements of the administration equipment, as per standard TheraSphere procedure. Radiological Analysis: Prescribed dose to target volume (liver): 127 Gy Administered dose to target volume (liver): 59.8 Gy Discussion and Outcome: On May 28, 2019, it was brought to the radiation safety officer's attention that a Y-90 TheraSphere administration had not delivered the full prescribed activity to the patient as intended. Upon further discussion it was noted that the performing physician noticed after connection of the line between the micro-catheter and the delivery vial that multiple air bubbles had become trapped in the line. He then created a closed system manifold using a three-way stopcock and syringes to effectively bleed out air bubbles and flush back as much of the dose as possible to the patient. The closed system prevented any spillage or contamination, and residual dose was retained in the syringes and stopcocks. Despite these actions taken by the physician, a post-administration assay of the waste container showed that the full desired activity had not made it out of the delivery equipment and into the patient. The procedure was a segmentectomy, and (the) patient will be re-evaluated in one month's time to determine if an additional therapeutic administration will be needed. Root Cause: Human error: Air was likely trapped somewhere in the system during the initial setup of the equipment. Operator technique failed to completely purge the lines of this air. Air bubbles in the line were not visible or not noticed prior to the connection of the line. Efforts to eliminate the air and deliver the full dose to the patient were then not successful. Corrective Actions and Actions to Prevent Further Occurrences: The nature of this event and the likely cause has been discussed with all staff involved in these procedures. A refresher training session has been scheduled for staff involved in these procedures. This training will be provided by a representative from BTG/TheraSphere starting on June 10, 2019. An additional step will be added to the procedure to visually and verbally confirm that there is no detectable air in the line between the micro-catheter and the dose vial prior to connection.

• * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/30/20 AT 1323 * * *

The NMED report number from the original report was removed. The new NMED report number was not obtained. NRC Event number 54684 was also created for this event and was deleted from the database. Notified R1DO (Schroeder) and NMSS Event Notification (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.