Event Notification Report for November 01, 2018

AGREEMENT STATE REPORT - MISADMINISTRATION DUE TO BATCH ERROR

The following information was received by the State of Florida:

"At noon [on 11/7/18], [Akumin] called [the State of FL Bureau of Radiation Control] to report that both Akumin Hollywood and Akumin Aventura View ordered F-18 Fluciclovine, and received packages that were labeled as F-18 Fluciclovine, but were subsequently notified by their radiopharmaceutical vendor PET NET Solutions-Ft Lauderdale, on Thursday, November 1, 2018 that due to a 'batch error,' the packages actually contained F-18 FDG [Fludeoxyglucose]."

Three patients were reported as receiving the incorrect radiopharmaceutical. Activity reported as approximately 10 mCi.

Florida Incident: FL18-137

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.

DISCOVERY OF INDICATIONS THAT DID NOT MEET ACCEPTANCE CRITERIA ON ONE REACTOR VESSEL HEAD PENETRATION

"On 11/01/2018, during the Beaver Valley Power Station Unit No. 2 (BVPS-2) refueling outage, while performing examinations of the 66 reactor vessel head penetrations, it was determined that one penetration could not be dispositioned as acceptable per ASME Code Section XI. Penetration 27 will require repair prior to returning the vessel head to service. The indication was not through wall and there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. The examinations were being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D) and ASME Code Case N-729-4 to find potential flaws/indications before they grow to a size that could potentially jeopardize the structural integrity of the reactor vessel head pressure boundary. The other 65 penetrations will be examined during the 2R20 [current] refueling outage.

"The plant is currently shutdown and in Undefined Mode. The reactor vessel head is not currently installed. Repairs are currently being planned and will be completed prior to startup.

"This is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A) since the as-found indications did not meet the applicable acceptance criteria referenced in ASME Code Case N-729-4 to remain in-service without repair.

"The NRC Resident Inspector has been notified."

UNANALYZED CONDITION DUE TO MODIFICATION NOT ADDED TO PROCEDURE

"On November 1, 2018, at approximately 1300 EDT, Fermi 2 identified that a Station Blackout (SBO) procedure was deficient as a result of a modification installed during a recent refueling outage. A review identified that the performance of the SBO procedure could have resulted in a challenge to having an alternate AC source available within one hour as outlined in the Updated Final Safety Analysis Report (UFSAR) 8.4.2. The alternate AC source was always available to be manually aligned in accordance with other standard operating procedures. The modification did not affect the function for Appendix R alternative shutdown.

"Immediate actions are underway to revise the impacted procedure. The health and safety of the public was not affected as offsite power has remained available since the modification was installed. Investigation into the cause and corrective actions is ongoing.

"Fermi 2 is reporting this event as an unanalyzed condition pursuant to the requirements of 10 CFR 50.72(b)(3)(ii)(B)."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 12/28/18 AT 1228 EST FROM JEFFREY MYERS TO JEFFREY WHITED * * *

"The purpose of this notification is to retract a previous report made on November 1, 2018 (EN 53712) under 10 CFR 50.72(b)(3)(ii)(B). Subsequent to the initial notification, the event, site procedures, and the NRC guidance in NUREG-1022 pertaining to 10 CFR 50.72(b)(3)(ii)(B) were reviewed further. The evaluation determined that at the time of the event, there were multiple methods defined in existing station procedures to establish an available alternate AC source within one hour as outlined in the Updated Final Safety Analysis Report (UFSAR) 8.4.2.

"Under these circumstances, the event does not represent an unanalyzed condition under 10 CFR 50.72(b)(3)(ii)(B). Therefore, EN 53712 can be retracted and no Licensee Event Report (LER) under 10 CFR 50.73(a)(2)(ii)(B) is required to be submitted.

"The licensee has notified the NRC Resident Inspector."

Notified R3DO (Riemer).