Event Notification Report for August 31, 2018

DOSE ADMINISTRATION PREVENTED BY KIT MALFUNCTION

A patient was prescribed 86.9 milliCuries Yittrium-90 Theraspheres to the liver, but a malfunction in the kit prevented the Theraspheres from travelling to the dose location. There was no contamination detected on the patient or equipment. The patient was notified and rescheduled for this procedure next week. The manufacturer of the kit was notified and the hospital pulled all kits in that lot.

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.

UNPLANNED LOSS OF STEAM LINE MONITOR CHANNELS

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) as a Loss of Emergency Preparedness Capabilities at Palo Verde Nuclear Generating Station (PVNGS) Unit 2. On August 31, 2018, at approximately 0544 Mountain Standard Time (MST), the Unit 2 control room experienced an unplanned loss of Steam Generator #1 steam line monitor (RU-139), Channels A and B.

"This main steam line monitor is used in the PVNGS Emergency Plan to perform dose assessment in the event of a steam generator tube rupture.

"The NRC Resident Inspectors have been notified."

MANUAL REACTOR SCRAM DUE TO MAIN CONDENSER DEGRADATION

"This notification is being provided in accordance with 10 CFR 50.72(b)(2)(iv)(B).

"On August 31, 2018 at 2105 CDT, Unit 2 Reactor Manual Scram signal was inserted due to Main Condenser vacuum degrading. The turbine was tripped following the scram. Main Condenser vacuum is at 6 inches of backpressure slowly improving following the scram and turbine trip. During the scram, one Control Rod (30-31) did not fully insert. Control Rod 30-31 has been manually inserted to position 00 with the first position identified as position 24. Plant is in a stable condition with reactor pressure being maintained by the Turbine Bypass valves. Reactor water level is being controlled with feedwater. Investigation into the cause of the elevated condenser in leakage is in progress.

"The Senior NRC Resident has been notified."

TRITIUM EXIT SIGNS DESTROYED IN A FIRE

On August 31, 2018, an intense fire in Glacier National Park destroyed a building and with it six (6) exit signs containing Tritium (H-3). The intensity of the fire was such that the building has been reduced to ash. The remains of the building are still on site.

After a discussion with Region IV, the licensee determined that the loss of the exit signs was reportable in accordance with 10 CFR 31.5.

The licensee notified the Department of the Interior, National Park Service, Intermountain Regional Office in Denver CO, of the event.

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