Event Notification Report for June 12, 2019

LOSS OF CONTROL ROOM EMERGENCY AIR TEMPERATURE CONTROL SYSTEM

"At 0849 (EDT), a significant air leak on an inline air filter was identified. At 0908, the leak on the filter was isolated. A subsequent review of this situation determined that this air leak impacted operation of the A Train of the Control Room Emergency Air Temperature Control System (CREATCS) which is required to be operable in accordance with Technical Specification 3.7.10. At the time of this event, the B Train of CREATCS was out of service for planned maintenance.

"With both trains of CREATCS out of service, both Watts Bar Units entered a condition that could have prevented fulfillment of a safety function. This condition was terminated when the leaking air filter was isolated. This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).

"NRC Resident Inspector has been notified."

HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE

"At 2127 EDT on June 12, 2019, during routine testing, the HPCI turbine experienced an overspeed trip and then subsequently restarted and ramped to the required speed. As a result, the response time of the system exceeded the 60-second acceptance criteria, thereby rendering the system inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Reactor Core Isolation Cooling (RCIC) System and Automatic Depressurization System (ADS) are operable.

"The safety significance of this event is minimal. Troubleshooting activities are in progress.

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

AGREEMENT STATE REPORT - LOST AMERICIUM/BERYLLIUM SOURCE

The following report was received from the Texas Department of State Health Services (the Agency) via email:

"On June 12, 2019, the licensee's Radiation Safety Officer (RSO) notified the Agency that while performing an in-depth audit, he became aware that a 250 millicurie americium-241/beryllium source (SN: T-128) they had been licensed for was not present at their main site. Records for the source indicate the last leak test was performed in September 2017, but the source was not recorded on quarterly inventories in 2018. The RSO has been unable to find any records of transfer or disposal. The RSO is continuing record searches and interviews as well as physical searches of the licensee's facilities. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: 9686

* * * UPDATE ON 06/21/2019 AT 1605 EDT FROM KAREN BLANCHARD TO THOMAS KENDZIA * * *

The following was received from the Texas Department of State Health Services via email:

"On 6/21/2019, licensee notified the Agency that it located the missing source at one of its facilities."

Notified the R4DO (O'KEEFE), and the NMSS Events Notification, ILTAB, and CNSNS (Mexico Nuclear Safety Commission) 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

AGREEMENT STATE REPORT - LEVEL GAUGE SHUTTER FUNCTIONAL PROBLEMS

The following was received from the Louisiana Department of Environmental Quality via email:

"On 06/13/2019, Honeywell (HW) reported that they detected [on 6/12/19] malfunctions/operational difficulties of shutters on [three level density] gauges installed on processes during the annual inspection and operational checks/tests. The gauge shutters would not function as designed by the manufacturer due to the operational environment and need of routine maintenance. HW called a service contractor, RONAN Engineering, to evaluate these situations and determine the best courses of action to correct the problems.

"The sources and devices will remain installed on the processes until any repairs and maintenance are completed. This is not a radiation exposure hazard and does not pose a health and safety situation for the HW employees or the general public.

"The level gauges are RONAN Engineering S/N M7549, 50 mCi Cs-137, S/N HH113 50 mCi Cs-137 and M7666 100 mCi Cs-137 sources.

"This event is being reported to the NRC OP CENTER as required by Regulatory Requirement 10 CFR Part 30.50(b)(2) & LAC 33:XV 340.B."

Event Report ID No.: LA-190009


* * * UPDATE FROM JOSEPH NOBLE TO DONALD NORWOOD AT 0932 EDT ON 06/28/2019 * * *

The following information was received via E-mail:

The last paragraph of the initial report above should be changed to read as follows:

"This event is being reported to the NRC Operations Center as required by regulatory requirement 10 CFR 30.50(b)(2) and LAC 33:XV 341.B."

Notified R4DO (Groom) and NMSS Events Notification E-mail group.

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE REPORT - FAILURE TO REPORT UNDERDOSE TO PATIENT

The following was received from the state of Ohio via email:

"During a routine inspection an unreported medical event [that occurred in 2019] involving Yttrium-90 'SirSpheres' was discovered. During patient treatment the licensee encountered increasing resistance to the delivery of the microspheres, leading the licensee to believe the patient had reached stasis. After further investigation the licensee determined the cause of the resistance was clogging of the microcatheter. The dose delivered to the patient was 79.2 percent of the prescribed dose. A subsequent treatment was given to the patient to make up for the underdose. At the time the licensee's procedures did not consider this as a reportable event. The reportable event procedures have been updated."

Ohio Item Number: OH210001

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.