Event Notification Report for February 25, 2019

AGREEMENT STATE REPORT - UNINTENDED DOSE TO NON-TARGET TISSUE

The following was received from the state of California:

"The licensee reported an unintended dose to non-target tissue of a patient from an HDR [High Dose Rate] treatment, apparently due to mispositioning of the uterus-ovary applicator. The unintended dose occurred on the final of four fractions. The target tissue received the intended dose in each of the four fractions, but non-target tissue of the bowel received in excess of 50 rem and 150 percent of the expected dose to the non-target bowel tissue from the four fractions combined, with the excess non-target bowel dose occurring in the final fraction due to the mispositioned applicator.

"The licensee will submit a 15-day written report to the California Department of Public Health-Radiologic Health Branch (CDPH-RHB) in accordance with 10 CFR 35.3045(d), and will include the calculated dose to the non-target tissue of concern. That report will be forwarded to NRC by CDPH-RHB.

"The referring physician was informed of the unintended dose to the non-target bowel tissue."

CA 5010 Number: 022719

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.

* * * RETRACTION AT 1644 EDT ON 03/27/2019 FROM ROBERT GREGER TO JOANNA BRIDGE * * *

The following was received via e-mail:

"The licensee determined that a dose volume of 5 cc was appropriate for the unintended tissue exposure (instead of 2 cc). Based on the 5 cc tissue volume, the dose was less than the Medical Event reporting criteria contained in 10 CFR 35.3045(a)(3). Please note that the original event submittal by California erroneously referenced the applicable regulatory reporting requirement as 10 CFR 35.3045(a)(1)(iii)."

Notified R4DO (Kozal) and NMSS Events.

FITNESS-FOR-DUTY - LICENSEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL

A non-licensed, licensee supervisory employee failed a for-cause FFD test for alcohol.

The individual's authorization for site access has been denied.

The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The following information was received via e-mail:

"On February 25, 2019, the Agency [Texas Department of State Health Services] received a report from the licensee's technical representative stating that the shutter on an Ohmart Vega model SH-F1 gauge, containing a 50 millicurie cesium-137 source, failed to shut during maintenance when the handle broke off. Open is the normal operation position of the gauge shutter. No licensee employee received any exposure as a result of this event. The gauge will be repaired in September 2019 during an outage. Additional information will be sent in accordance with SA-300."

Texas Incident #: 9659

AUTOMATIC REACTOR SCRAM DUE TO GENERATOR TRIP

"At 0024 EST on 2/25/19, with Unit 1 in Mode 1 at 74 percent power, the reactor automatically tripped due to a generator trip. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Reactor water level is being maintained via the feed system. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The generator trip is under investigation, but is believed to be due to grid perturbations.