Event Notification Report for April 15, 2019

AGREEMENT STATE REPORT - LEAKING INTRAVASCULAR BRACHYTHERAPY DEVICE IDENTIFIED

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

"UW [University of Washington] Radiation Safety (RS) conducts semi-annual sealed source leak test during the months of April and October. After analyzing a leak test for a Sr-90 Intravascular Brachytherapy (IVB) device it was found to be leaking. Details provided by the University of Washington radiation safety office are as follows:

"'The results of the sample's analysis were reviewed and it was discovered that a sample for one of the IVB source trains indicated contamination at 3737 cpm. A second sample of both IVB source trains was obtained. The sample for the 40 mm source train indicated 177 cpm and the sample for the 60 mm source train indicated 7998 cpm. The RS staff member discussed the contamination with the Radioactive Materials Compliance Manager (RMCM) and the Radiation Safety Officer (RSO). It was then discovered that the leak test procedure specified in the Novoste Beta-Cath User's Manual was not performed correctly. A swab of the water sample obtained during the leak test was analyzed rather than the whole 5 ml of water. The RS staff member performed another leak test of both IVB source trains, and analyzed the 5 ml water samples (The results are provided below). The IVB device was placed out of service and removed from Radiation Oncology. The RS staff member contacted the RSO at Best Vascular who requested the sources and items used for the leak testing be returned to Best Vascular for investigation.

"'Radiation Safety counted the 5 ml water samples using one of their liquid scintillation counters (LSC) [Packard Tricarb 2900TR - S/N 426395]. Using an efficiency of 100 percent for Sr-90 (Beckman Coulter's Isotope Booklet for Liquid Scintillation Counters - 2002) the activity calculated was:

"'40 mm source train: 396 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 6.6 Bq

"'60 mm source train: 17429 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 290 Bq

"'The activity level of the 60 mm source train leak test sample exceeded the limit of 185 Bq. The contamination in the leak test for the 40 mm source train is believed to be a result of cross contamination from the 60 mm source train leak test.'"

WA Event Report ID No.: WA-19-013

TRANSPORT OFFSITE TO MEDICAL FACILITY OF POTENTIALLY CONTAMINATED INDIVIDUAL

"At 0511 CDT on 4/15/2019, transport of a potentially radiologically contaminated person from the Monticello Nuclear Plant to a local hospital was performed prior to conducting a radiological survey as a prudent measure to ensure timely medical support. At 0658 CDT a radiological survey determined that the individual and their clothing were not contaminated.

"This is reportable under 10 CFR 50.72(b)(3)(xii). The NRC Resident Inspector has been notified."

PART-21 NOTIFICATION - SNUBBER HYDRAULIC FLUID BATCH CONTAINS PARTICULATES

The following report was received via fax:

"Pacific Gas and Electric notified Curtiss Wright [CW] Enertech that they observed white particulate in SF-1154 fluid in three containers. The white particulate was found settled at the bottom of the containers. The fluid was dedicated and supplied by CW Enertech in November 2016 The fluid was traced back to Momentive Batch 14ELVS145.

"The momentive batch 14ELVS145 was previously reported by Lake Engineering Company (Ref NRC ML17212A628 and ML17128A465). The white particulates/semisolid material was identified as phenyl cyclic precipitate. The safety hazard that could be created by this defect is the blockage of snubber bleed port as reported by Duane Arnold (Ref ML070300154). This blockage could prevent the snubber from unlocking after a seismic event, thus preventing the snubber to allow for system movement during normal operations.

"In addition, evaluation performed by Lake Engineering Company has found that all of the solids are dissolved back into the fluid when heated to 110 [degrees] fahrenheit. With all solids dissolved, there is no potential safety hazard with this fluid."

Affected sites: Fermi, Shearon Harris, Beaver Valley, Diablo Canyon, Watts Bar, Perry, and Almaraz (Spain).

Curtiss-Wright point of contact: Rosalie Nava, 714-528-2301 ext 1872

See also EN 43071 dated 1/3/2007

OFFSITE NOTIFICATION - ON SITE FATAILITY

"At 2355 CDT on 4/15/19, life-saving activities by offsite medical personnel for a Farley employee were terminated. The coroner declared the individual deceased at the plant site at 0130 CDT.

"The fatality is not believed to be work-related and the individual was inside of the Radiological Controlled Area.

"This is a four-hour notification, non-emergency for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Resident Inspector has been notified."

The licensee will be notifying the Occupational Safety and Health Administration due to the on-site fatality.

The licensee will perform a radiological survey of the individual prior to transportation offsite.