Event Notification Report for January 18, 2019

AGREEMENT STATE REPORT - MISADMINISTRATION OF RADIUM-223 TO PATIENT

The following was received via e-mail:

"On January 18, 2019, the Texas Department of State Health Services was contacted by the licensee's radiation safety officer (RSO) and notified that they had a treatment error occur at their facility. The error occurred to a patient who was to be treated with multiple fractions of radium-223. The treatment was to relieve bone pain in the patient. The dose from each fraction was based on the weight of the patient. The fraction activity was determined to be 75 microCuries based on the weight in pounds of the patient involved. The technician involved with administering the dose mistook the weight units and ordered the fraction dose based on the patients weight measured in kilograms. As a result the patient was administered 165 microCuries of radium-223 instead of the 75 microCuries. The error was discovered as they were preparing to administer the second dose (The date of the first dose was not provided). The RSO stated the patient and prescribing physician have been contacted and notified of the error. The RSO stated the patient would not experience any adverse effects from the dose received. The RSO stated the patient's treatment going forward is being reviewed. The RSO stated they would provide a written report next week.

"At 1530 hours the Agency contacted the RSO and confirmed the dose to the patient. The RSO stated the dose to the bones from the activity given would be 693 rad instead of 315 rad.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Department of State Health Services Incident Number 9651

* * * RETRACTION AT 1558 EST ON 2/21/2019 FROM ART TUCKER TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"This event was determined not to be a reportable event. It does not meet the reportability criteria. Dosage on the written directive, signed by the prescribing physician/authorized user, was the dosage administered to the patient."

Notified the R4DO (Deese) and NMSS (via e-mail).

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.

PROCESS GAUGE CLOSED SHUTTER INDICATION NOT FUNCTIONAL

A process gauge shutter indication did not properly indicate that the shutter was in the closed position. A survey was performed and verified that the shutter was indeed in the closed position. The system has been locked out to prevent access and the licensee stated that repairs to the gauge shutter are in progress.

Gauge Model No.: DMC-AM-5A
Source: Am-241
Activity: 1.0 Curies
Serial Number: 1979LQ

REACTOR COOLANT SYSTEM WELD DOES NOT MEET ACCEPTANCE CRITERIA

"This is a non-emergency notification from Waterford 3.

"On January 18, 2019, a relevant indication was detected in the performance of Phased Array Ultrasonic Examinations of A600 Dissimilar Metal Piping Welds during planned inspections. The indication was observed during the analysis of data recorded of the Reactor Coolant System (RCS) Loop 2A Reactor Coolant Pump Suction Drain Nozzle to Safe-End Butt Weld (11-007). This indication does not meet applicable acceptance criteria under American Society of Mechanical Engineers (ASME) Section XI. The plant was in Mode 6 (Refueling) at 0 percent power for a planned refueling outage at the time of discovery. The condition will be resolved prior to plant startup. This condition has no impact to the health and safety of the public. This report is being made in accordance with 10 CFR 50 .72(b)(3)(ii)(A), 'Any event or condition that results in: (A) The condition of the nuclear power plant, including its principal safety barriers, being seriously degraded,' because an indication was found that did not meet acceptance criteria referenced in ASME Section XI , IWB-3514-2 and Code Case N-770-2, 3132.

"The NRC Resident Inspector has been notified.

"Reference: CR-WF3-2019-01041"

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF I-125 SEED

The following is a summary of emails received from the Georgia Department of Natural Resources (the state):

On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal.

The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital.

On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed.

Corrective actions include to document seeds acquired for implantation on a single sheet of paper.

Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity.

The incident was closed on 03/04 2019.

Incident Report No.: GA-2019-10

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

PART 21 REPORT - IMPROPER ANTI-ROTATION KEY DIMENSION ON GLOVE VALVE

"This notification is being submitted pursuant to the guidelines of 10 CFR Part 21 to report that a 24" Class 150 Globe valve for RHRSW HX Isolation MOV, E1150F068A at Detroit Edison - Fermi 2, failed to fully open due to the failure of the anti-rotation key.

"The site notified WVC [Weir Valves and Controls] USA on January 18th of this issue involving a new bonnet that was installed which included a key bushing/key assembly. The new bonnet used was from an originally supplied valve assembly on WVC USA order 0010001147-10 with a quantity of one, Detroit Edison Company PO 4700732583. The key is welded on top and bottom in the key bushing keyway to hold the key in place. After a month in service, during operation, the welds failed which caused the key to drop out or be driven out from the key bushing by friction/vibration. Upon review of the design it was found that the key and key slot were not dimensioned properly for a tight fit allowing a larger than recommended gap between key and keyway. This gap allowed the operational torque loads to put the welds in bending which caused the welds to fail. Loss of the key renders the valve inoperable to open or close.

"The site has currently restored the key bushing/key assembly with new keys with proper fit and welds to ensure the key is retained.

"[WVC USA] has performed an extent condition review and has concluded that one other operating site, Georgia Power - SNC, Hatch Unit 1 1WVC USA order 0010000081-10 (55544A), Southern Nuclear Operating Co PO SNG10025571 has a similar key/key bushing assembly. There was a quantity of six valve assemblies shipped for this purchase order. The site has been contacted to evaluate the fit of the key bushing/key assembly.

"Engineering has determined that improper design clearance was the cause of failure. [WVC USA is] performing corrective actions to ensure future re-occurrences cannot occur in design engineering."

Affected sites include: Fermi Unit 2 and Hatch Unit 1.

For additional information, contact:

Allen Fisher
Director of Engineering
allen.fisher@mail.weir
978-825-845