Event Notification Report for December 05, 2019

OFFSITE NOTIFICATION DUE TO DECEASED MANATEE IN OWNER CONTROLLED AREA

"This 4-hour non-emergency notification to the NRC is being made on a notification to another government agency per 10 CFR 50.72(b)(2)(xi).

"On 12/5/2019, at 0719 EST, a deceased manatee was identified in the Owner Controlled Area. The Federal Fish and Wildlife Service and the Florida Fish and Wildlife Conservation Commission (FWCC) were notified on 12/5/2019, at 1220 EST.

"Miami-Dade County was notified on 12/5/2019, at 1245 EST. A courtesy call to the Florida Department of Environmental Protection was made on 12/5/2019, at 1300 EST.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - MEDICAL MIS-ADMINISTRATION

The following report was received from the Georgia radioactive materials program environmental protection division via email:

"Augusta University Medical Center had an incident yesterday (December 5, 2019) in the Interventional Radiology (IR) Suite during a Y-90 TheraSphere procedure.

"The Y-90 TheraSphere delivery was performed in the usual fashion, per TheraSphere protocol, with 3 flushes of the administration vial. Both delivery and nuclear medicine pre-procedure preparation was performed per standard radiopharmaceutical (TheraSphere) protocol. During administration, the remaining undelivered dose became stuck/trapped in the transport vial and could not be administered.

"About 40 percent of the prescribed radiation dose was delivered to the patient, which is less than the criteria in Rule 391-3-17-.05.(115)a.1(i), which states, 'The total dose delivered differs from the prescribed dose by 20 percent or more.'

"A small amount of the Y-90 microspheres spilled onto the administration table, which was covered with absorbent towels. Augusta University staff isolated the contamination, scanned all IR Suite staff to ensure the contamination was not spread outside the immediate area, and called for assistance with clean-up. All contamination was located and cleaned-up, and all swipes have been counted and the results show no residual contamination in the suite or on any equipment in the suite. All radioactive material has been collected and is being stored and managed as radioactive waste.

"A formal written notification to your office will be submitted within 15 days of the event. This formal written notification will include all of the information required by Rule 391-3-17-.05.(115)."

Georgia Incident No.: 22

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.

FIRE DOOR DISCOVERED UNLATCHED

The following was received via email from Cooper Nuclear Station:

"At 0810 [CST], on 12/5/19, Operations personnel discovered BLDG-DOOR-R209, FIRE DOOR BETWEEN CRITICAL SWITCHGEAR ROOMS F & G, was unlatched. The door was immediately latched upon discovery. Based on door logs, the door separating the two critical switchgear rooms was inadvertently left unlatched for approximately 5 minutes. This door is a Steam Exclusion Boundary (SEB) door. It is required to be closed and latched when the Auxiliary Steam Boiler is in service due to Auxiliary Steam piping passing through Critical Switchgear Room 'G'. If a steam line break was to occur with the door unlatched, steam could render both Critical Switchgear busses inoperable.

"This is being reported under 10 CFR 50.72(b)(3)(ii)(B), Unanalyzed Condition, and 10 CFR 50.72(b)(3)(v), Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (B) remove residual heat and to (D) mitigate consequences of an accident.

"There was no impact on the health and safety of the public or plant personnel."

The door closes automatically and appeared to have been left unlatched by the last person passing through. The door was tested and latches as required.

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 12/30/2019 AT 1129 EST FROM DAVE VANDERKAMP TO ANDREW WAUGH * * *

CNS is retracting the 8-hour notification made for event notification 54425 which occurred on December 5, 2019 at 0810 CST. Subsequent engineering evaluation demonstrates the essential equipment located in critical switchgear room 'F' would have remained within the design limits in the event of a postulated auxiliary steam line break in critical switchgear room 'G' with door R209 open. As a result, the safety function would have been maintained and there was no unanalyzed condition that would significantly degrade plant safety.

The licensee notified the NRC Resident Inspector. Notified R4DO (Warnick).

EN Revision Imported Date: 1/14/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following information was received from the state of Minnesota via email:

"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.

"Fairview Southdale Hospital (FSH) reported the loss of two I-125 seeds (IsoAid model IAI-125A) used for localization of non-palpable lesions. Each seed contained an activity of 11.1 MBq (300 microCi). The seeds were discovered to be missing from their decay-in-storage area while placing a new seed in storage on 12/5/2019. FSH staff decided to count the seeds that were in the storage pig. There should have been 20 seeds, but only 18 seeds were counted. FSH conducted an investigation and determined that the two seeds were lost. Corrective actions included conducting daily radiation surveys of all areas of the breast center hot laboratory."

Minnesota event number: 200001

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