Event Notification Report for February 20, 2018

FITNESS FOR DUTY - CONTRACT SUPERVISOR SUBVERTS FITNESS FOR DUTY TEST

"At 0925 [EST] on February 20, 2018, a non-licensed supervisory contractor subverted a random Fitness for Duty test. The contractor's site access has been terminated.

"The NRC Resident Inspector was notified."

DOSE TO PATIENT LESS THAN THE INTENDED DOSE

A patient was administered the radiopharmaceutical Xofigo which contains Radium Dichloride (Ra-223 CL2). The dosage is based on patient weight. The patient was administered 119.1 microCi. The patient was then weighed and found to weigh greater than 25 percent more than the weight used to calculate the dosage. This was the fourth treatment session of six prescribed. The referring physician's intended dose would have been 159 microCi, based on the patient's actual weight. This misadministration is being characterized as a personnel error.

The patient and the physician have been notified and treatment will continue.

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.

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK

The following information was received via E-mail:

On February 21, 2018, the licensee notified the Agency that on February 20, 2018, routine inspection and maintenance was being performed on a Berthold model LB 8010 gauge containing a 20 millicurie cesium-137 source that was in storage at its facility. During shutter check, the shutter was stiff during opening and then it would not close. The shutter was stuck in the open position. The licensee reported that the storage area is segregated from work areas and no one has received any exposure as a result of this event. The few employees with access to the area where the gauge is located have been notified of the situation. The manufacturer was contacted and repair scheduled. Information will be provided as it is obtained and in accordance with SA-300.

Texas Incident #: I-9544

TRANSPORT OF POTENTIALLY CONTAMINATED PERSON TO A MEDICAL FACILITY

"At 0956 CST on 2/20/2018, an employee working in a non-contaminated section of the Radiological Control Area was transported offsite for a personal medical issue. The required radiological survey was not completed prior to the employee being transported offsite by ambulance. A radiological protection technician accompanied the employee and completed a survey during the transfer to the hospital, confirming no contamination of the employee.

"This event is reportable pursuant to 10 CFR 50.72(b)(3)(xii).

"The NRC Resident Inspector has been notified."

ALL THREE AUXILIARY FEEDWATER PUMPS INOPERABLE DUE TO HELB DOOR BEING OPEN

"At 1225 CST, all three Auxiliary Feedwater [AFW] pumps were declared inoperable at the Callaway Plant upon discovery that a door (DSK13311) credited for protection of equipment from the effects of a high-energy line break (HELB) hazard had come partially open due to vibration harmonics from the running turbine-driven Auxiliary Feedwater pump (TDAFP). Immediate investigation identified that play in the mechanism that holds the door closed had rendered it susceptible to movement from the vibration harmonics.

"The affected HELB door specifically protects safety-related instruments that provide a swap-over signal upon detection of a low suction pressure condition for the AFW pumps and thereby automatically effect a suction transfer for the AFW pumps from the condensate storage tank (normal/standby source) to the Essential Service Water (ESW) system (credited safety-related source).

"All of the AFW pump suction transfer instrument channels were declared inoperable. Per Technical Specifications (TS) 3.3.2, 'Engineered Safety Feature Actuation System (ESFAS) Instrumentation,' the applicable Condition(s) and Required Action(s) for inoperable AFW pump suction transfer instrumentation only addresses a single channel being inoperable. Thus, the condition of having all three instrument channels inoperable required entry into TS Limiting Condition for Operation (LCO) 3.0.3. At the same time, however, with the automatic suction transfer capability rendered inoperable, all three AFW pumps, i.e., the TDAFP and the 'A' and 'B' motor-driven AFW pumps, were declared inoperable. Although LCO 3.0.3 was applicable, entry into the Required Actions of LCO 3.0.3 was suspended per the Note attached to Required Action E.1 of TS 3.7.5, 'Auxiliary Feedwater (AFW) System,' which states, 'LCO 3.0.3 and all other LCO Required Actions requiring MODE changes are suspended until one AFW train is restored to OPERABLE status.'

"At 1336 CST, Operations took actions to prevent the TDAFP from running, so the remaining [AFW Pumps] could be returned to Operable status. Operations then declared the affected instrumentation and the 'A' and 'B' motor-driven AFW pumps Operable. This allowed LCO 3.0.3 and Conditions A, B, D, and E under TS 3.7.5 to be exited. With only the TDAFP inoperable, TS 3.7.5 Condition C and its Required Actions remain in effect.

"Due to the degraded HELB door rendering all three AFW pumps inoperable, the unidentified condition is being reported as an unanalyzed condition that significantly degraded plant safety [per 10 CFR 50.72(b)(3)(ii)(B)] as well as a condition that could have prevented the fulfillment of the safety functions of structures or systems that are needed to shut down the reactor and maintain it in a safe shutdown condition, remove residual heat, and mitigate the consequences of an accident [per 10 CFR 50.72(b)(3)(v)(A), (B), and (D), respectively].

"The NRC Senior Resident Inspector has been notified."


* * * RETRACTION ON 4/4/2018 at 1109 EDT FROM JONATHAN LAUF TO DAVID AIRD * * *

"Event Notification (EN) # 53223, made on 2/20/2018, is being retracted because new information has been obtained that negates the original basis for reporting the unanalyzed condition. Specifically, an evaluation of the HELB that is postulated to occur in the TDAFP room has determined that without crediting door DSK13311 for protection, the affected safety-related instruments would not be exposed to environmental conditions beyond their analyzed capability.

"This resulted in a conclusion that the unanalyzed condition of door DSK13311 being open did not prevent the affected safety-related instruments or their supported AFW pumps from performing their required safety functions to shut down the reactor and maintain it in a safe shutdown condition, remove residual heat, and/or mitigate the consequences of an accident, nor did it significantly degrade plant safety. Consequently, the condition did not meet the criteria for an 8-hour notification per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(A), (B), or (D)."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Drake).