Event Notification Report for April 12, 2018

TEXAS AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA PIGTAIL CONNECTOR FAILED

The following information was obtained from the state of Texas via email:

"On April 13, 2018, the Agency [Texas Department of State Health Services] received notice that a radiography camera had an equipment failure yesterday, April 12, 2018. The radiography crew was on a temporary jobsite and was setting up for a job. When the radiographer tried to connect the guide tube, the pigtail on the cable broke and the camera/cable was unusable. The radiographer contacted his radiation safety officer who informed the crew to bring the camera back to the office. The source did not leave the camera. No exposure to an individual occurred. The camera was a Spec-150, #2489 with an Iridium-192 source, G60 -VC1403 at 80 Curies. The manufacturer will be sent the equipment and a full report will be provided by the radiation safety officer within the next few days. Updates will be provide as received in accordance with SA300."

Texas Incident #9558

* * * UPDATE ON 04/25/2018 AT 1103 EST FROM ART TUCKER TO STEVEN VITTO * * *

"The Agency contacted the licensee and the licensee stated the connector on the source pig tail had separated from the pig tail. The licensee stated the manufacturer is currently inspecting the equipment. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO(Vasquez) and NMSS Events Notification via email.

AUTOMATIC REACTOR TRIP

"At 0920 EDT on April 12, 2018, the Watts Bar Unit 2 reactor automatically tripped while operating at 100 percent power. All control and shutdown bank rods inserted properly in response to the automatic reactor trip. All safety systems including Auxiliary Feedwater actuated as designed. The plant is stable with decay heat removal through Auxiliary Feedwater and Steam Dump Systems.

"The cause of the automatic reactor trip is being investigated.

"The automatic actuation of the Reactor Protection System (RPS) is being reported as a four-hour report under 10 CFR 50.72 (b)(2)(iv)(B).

"The expected actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight-hour report under 10 CFR 50.72 (b)(3)(iv)(A).

"The NRC Senior Resident Inspector has been notified for this event."

The plant is currently stable at normal operating temperature and pressure. The grid is stable and the plant is in its normal shutdown electrical lineup. Unit 1 was unaffected by the Unit 2 trip.

POTENTIALLY DEGRADED ITEMS RELIED ON FOR SAFETY

"GNF-A's [Global Nuclear Fuels - Americas] Fuel Manufacturing Operation maintains a safe geometry Radwaste accumulation tank to receive certain liquid discharges from operations. During the annual shutdown work activities and routine inspections, an accumulation of material was identified in a safe geometry Radwaste accumulation tank.

"The accumulation appears to have occurred due to reduced recirculation flow, an engineered feature that mixes the contents of the tank as part of a density control. The accumulation of material is an indication that the tank density control had degraded.

"Plant operations attempted to remove and quantify the material per normal requirements. On 4/12/18 at approximately 1900 [EDT], GNF-A determined that the material could not be quantified in a timely manner.

"In the absence of quantification, GNF-A has conservatively determined that this condition is a failure to meet performance requirements and is therefore reporting it within 24 hours of discovery pursuant to Part 70 Appendix A (b)(2).

"Additional controls on the tank geometry remained intact and at no time was an unsafe condition present. In addition, there are no sources that could result in a rapid addition of uranium to the system.

"Additional corrective actions, extent of condition, and extent of cause are being investigated."

The licensee will be notifying their NRC Program Manager (Vukovinsky), the Radiation Protection Section at North Carolina Department of Health and Human Services, and Hanover County Emergency Management Agency.

FITNESS-FOR-DUTY REPORT INVOLVING DISCOVERY OF KOMBUCHA TEA INSIDE THE PROTECTED AREA

"At 1148 EDT on April 12, 2018, a 16.2 ounce bottle of Kombucha tea was found in a small refrigerator in the Administration Building inside the Protected Area. The bottle was found to have a small amount missing from the contents. Kombucha tea is a fermented tea containing trace amounts of alcohol, and is legally sold without restrictions. Dominion Energy Nuclear Connecticut had previously notified its workforce that Kombucha tea was prohibited from being consumed or carried onsite. The owner has not yet been determined. This is considered an alcoholic beverage and is being reported pursuant to the requirements of 10 CFR 26.719 as a 24 hour report."

The NRC Resident Inspector, the State of Connecticut, and local authorities have been notified.

AGREEMENT STATE REPORT - WRONG RADIOPHARMACEUTICAL USED

The following is information received via e-mail:

"April 19, 2018, [the licensee] called to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event.' The report and attachments were left in a voice mail at 8:18 pm [CDT]. The event occurred under the [Slidell Memorial Hospital] SMH Therapeutic and Diagnostic Radioactive Material License, LA-0783-L02. The event involved 5.4 mCi Tc-99m-Myoview administered to a patient who was scheduled for a lung scan utilizing [approximately] 5.4 mCi Tc-99m-MAA. The technologist depended on the unit dose for 'STAT' used to be MAA and did not verify the unit dose label. This medical event occurred on 04/12/2018.

"The technologist states that a Myoview cardiac dose was in a pig labelled MAA for a lung scan. The pharmacy pulled the dose records, verified the bar coding and determined the technologist was at error.

"[The licensee] provided dose calculations for the heart scan dose utilizing 5.4 mCi Tc-99m-Myoview as 0.224 rad effective dose equivalent and highest organ dose of 0.972 rad to the wall of the gallbladder.

"There were corrective actions [to] retrain the technologist in patient dose verification prior to injection and request their pharmacy change their label fonts to magnification and bolding the unit dose labels. The referring physician and the patient were notified of the error.

"LDEQ [Louisiana Department of Environmental Quality] considers this incident still open and subject to investigation to determine if this event was caused by the facility personnel or if it is an error caused by the pharmacy personnel."

Louisiana Event Report ID No.: LA-180007, T 184299