Event Notification Report for April 22, 2019

CALIFORNIA AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

The following information was excerpted from a report received from the state of California via email:

"[A] potential medical event occurred during an HDR [high dose rate] brachytherapy procedure in which the Tandem Ovoid [was] inserted into the patient. The patient was there to receive the 3rd dose of 8 Gy (for a total of 24 Gy) to the uterus. Instead, because all of the guide tubes were 132 cm instead of 120 cm in length, the entire 8 Gy of this last fraction was delivered to the vagina. They do not believe that the uterus received any of the prescribed 8 Gy, and all of it was delivered to non-target organ. The patient and her treating physician were informed, and she is going to return to the hospital for monitoring. Since this was the last of 3 fractions, the uterus has only received 16 Gy, not 24, while the unplanned dose to non-target organ was 8 Gy.

"A site visit will be conducted Monday, 4/29/2019, [by the California Department of Public Health, Radiologic Health Branch]."

CA 5010 Number: 042319

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.

CONTRACT SUPERVISOR TEST POSITIVE FOR DRUGS ON A FOLLOW-UP TEST

A contract supervisor tested positive for drugs on a follow-up fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a random test administered the next day (see EN #54018).

The licensee notified the NRC Resident Inspector.

MANUAL INITIATION OF THE AUXILIARY FEEDWATER SYSTEM IN RESPONSE TO A LOSS OF FEEDWATER

"At 1324 CDT, on 4/22/2019, with unit 2 in Mode 3 at 0 percent power, an intentional manual initiation of the Auxiliary Feedwater System occurred in response to a loss of feedwater condition. The loss of feedwater condition occurred after the non-safety related Startup Feedwater Pump was secured due to high bearing temperatures. The A Train Auxiliary Feedwater Pump was started per procedure. The Auxiliary Feedwater System started and operated as designed following intentional manual initiation.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the Auxiliary Feedwater System.

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

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the state of Wisconsin via e-mail:

"On April 26, 2019, Wisconsin Department of Health Services (DHS) was notified that at the licensee's Kaukauna facility, a fixed gauge mounted to a coal chute had been damaged and failed with the shutter closed. The incident occurred on April 22, 2019. Maintenance staffs were repairing a valve located above an Ohmart/Vega Corporation Model SHLG-1 fixed gauge containing 5 mCi of Cs-137. The valve failed, rotated downward, and made contact with the shutter actuator handle which severed the handle from the device. The gauge was not in operation at the time of the incident and the shutter remained in the closed position, the licensee's [Radiation Safety Officer] (RSO) stated on the initial phone call that the shutter is now inoperable.

"The maintenance staff called the RSO on the day of the incident and he instructed them to cordon off the area and perform surveys of the device. The surveys indicated that the source was not impacted and the RSO later performed confirmatory surveys that yielded similar results.

"Wisconsin DHS intends to perform a reactive inspection when the licensee's service provider replaces the gauge; the date is still to be determined."

Event Report No.: WI 190001

CONTRACT SUPERVISOR TESTED POSITIVE ON A RANDOM FITNESS-FOR-DUTY TEST

A contract supervisor tested positive for drugs on a random fitness-for-duty test. The contractor's access to the facility has been revoked and his badge was confiscated. Additionally, the supervisor failed a follow-up test administered the previous day (see EN #54017).

* * * RETRACTION ON 4/30/2019 AT 1642 EDT FROM KELLI ROBERTS TO BRIAN LIN * * *

"On April 16, 2019, an individual was selected for a follow-up drug test. The same individual was selected again on April 17, 2019 for a random drug test. The results for both tests were ruled by the Medical Review Officer (MRO) on the same day and ruled positive for the same drug on April 22, 2019. These FFD violations were reported to the NRC on April 22, 2019, as EN #54017 and EN #54018, respectively. As allowed by 10 CFR 26.185(o), the MRO further reviewed the quantitation of the drug in both tests and determined that no further drug use had occurred since the first positive test. Therefore, the MRO concluded that this should be considered one FFD violation, and EN #54018 is being retracted. No changes are needed to EN #54017."

The NRC Resident Inspector has been notified of this retraction.

Notified R2DO (Heisserer) and FFD Group (email).