Event Notification Report for April 17, 2019

UNDERVOLTAGE TO A SAFETY RELATED BUS RESULTING IN VALID SYSTEM ACTUATION

"At approximately 0137 CDT, with the Plant [Callaway] in No Mode (Defueled) the "B" Switchyard Bus cleared resulting in a loss of normal power to "A" Train Safety Related Transformer XNB01. This resulted in an under voltage condition on Safety Related Bus NB01. The "A" Emergency Diesel started per design and re-energized Bus NB01. This actuated the shutdown sequencer which first sheds loads including the "A" Spent Fuel Pool Cooling Pump and started "A" Essential Service Water Pump, "A" Component Cooling Water Pump, "A" Control Room A/C and other design loads. No complications were identified. The "A" Switchyard Bus remained energized at all times. The "A" Spent Fuel Pool Cooling Pump was restarted per off normal procedure response at 0149 CDT. Spent Fuel Pool water temperature started at 102 F and rose to 103 F prior to restart. There was no movement of irradiated fuel in progress in the Fuel Building during this time. The plant remains stable in No Mode (Defueled).

"At the time of the loss of "B" Switchyard Bus, the plant was closing Generator Output breaker MDV53 to establish a backfeed alignment. Further investigation is in progress.

"This event is reportable per 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Senior Resident has been notified."

AGREEMENT STATE REPORT - TRITIUM EXIT SIGNS DISMANTLED

The following report was received via e-mail:

"The Department [Arizona Department of Health Services] received notification from the licensee that they dismantled 24 tritium exit signs by removing the outer glass and aluminum housing, and then releasing the glue that held the glass ampules onto the inner plastic. The licensee said they were attempting to reduce the cost of shipping the signs for disposal. The Department has requested additional information and continues to investigate the event.

"The Licensee is:

Arizona License Number- 07-138
Banner Boswell Medical Center
10401 Thunderbird Blvd
Sun City, Arizona 85351"

Arizona Incident: 19-005

None of the vials were damaged and the wipe tests were all negative.

TURBINE TRIP SOLENOIDS FAILURE TO ACTUATE

"At 0812 EDT on 4/17/2019, it was discovered that both sets of turbine trip solenoids were previously unable to actuate within the allowable time frames; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). At the time of discovery, one set of turbine trip solenoids had been restored.

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

EN Revision Imported Date: 11/19/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE OF I-131

The following report was received via email:

"Rhode Island Department of Health was notified on May 2, 2019 by a representative from Rhode Island Hospital of a medical event that occurred during an attempted dosing of 25 mCi of I-131. On April 17, 2019, a patient was administered a capsule of I-131, but was unable to swallow and the capsule began to break down in the patient's mouth. As this was not the prescribed use of the radiopharmaceutical, the staff of Rhode Island Hospital transferred the capsule to a cup as the capsule was breaking down. The cup was then brought to the lead-lined safe in the hospital's nuclear medicine hot lab. During the transfer some of the I-131 that had begun to leak from the capsule spilled onto the floor and contaminated it with I-131.

"The floor of the injection room that had been contaminated with I-131 underwent decontamination. Before decontamination, the maximum counts/min (cpm) per 100 cm squared was equal to approximately 151,000 cpm. After decontamination the maximum amount in any location was 11,000 cpm. Similarly, before the protective covering was laid over the contaminated parts of the floor, the maximum dose rate as read by Ludlum Model 9DP was 70 mR/hour on contact. Rhode Island Hospital's Radiation Safety Officer (RSO) attempted to clean up the spill and then laid protective material over the floor and measured that the dose rate upon contact with a Ludlum Model 9DP ion chamber did not exceed 70 microR per hour. No other persons or surfaces were deemed to be contaminated after surface wipe tests and a thyroid scan bioassay. The following day, April 18, 2019, 25 mCi of I-131 was attempted to be administered orally in liquid form which the patient failed to swallow as well. This did not result in a spill. The State is not performing any additional action at this time.

"The referring physician, patient, and patient's legal guardians were notified that the dose of I-131 was not received to the patient. No overexposure occurred. This event was discovered due to be reported during the October 2021 IMPEP review of the Rhode Island Radiation Control Agency."

Rhode Island Event Number: RI-21-0002

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.