Event Notification Report for May 22, 2019

LOST SOURCE DURING SHIPMENT

The following is a synopsis of an event received via phone call:

During a shipment from Pasadena, TX to Billings, MT, a 4 milliCurie Cobalt-60 (Co-60) source was lost in transit. The last known location was Memphis, TN. It was shipped on May 17, 2019 and was identified lost on May 22, 2019. The shipper and the common carrier are investigating.

* * * UPDATE ON 05/25/2019 AT 1045 EDT FROM MONTY POPE TO JOANNA BRIDGE * * *

The following is a summary of a phone call with Mr. Pope:

On May 24, 2019, the source that was misplaced by the common carrier was able to be located. New shipping documents are being generated.

Notified R1RDO (Arner), R4RDO (GEPFORD), ILTAB (e-mail), NMSS Events (e-mail) and CNSNS Mexico (email).

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.p

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

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

"[The licensee] was asked to perform density testing of the roadway at the intersection of US Hwy. 26 and SE Firwood in Sandy, Oregon. [The licensee's client], Fall Line Construction, is working for DEPCOM Power.

"At approximately 1115 [PDT], [the gauge user] was asked to move [his] vehicle by the construction workers onsite. [The user] moved the Nuclear Densometer to a place where [he] believed would be safe from equipment onsite.

"While [the user] was parking (approximately 400 feet away), [he] saw some construction workers waving down the bulldozer operator who had backed into [the] Nuclear Densometer.

"[The user] checked to see if the gauge had been damaged. The lead shield had not been damaged. The handle for the gauge had been bent. Due to this deformation, the [source] was stuck in the safe position.

"[The user] tested the gauge with [a] Geiger counter and there appeared to be no excessive radiation coming from the gauge.

"The gauge was loaded back into the transport box and returned to the permanent storage place. The gauge will be sent out for repair either today or tomorrow."

The gauge is a Troxler model 3440, SN 26146, containing 9 mCi of Cs-137 and 44 mCi of Am-241:Be.

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERE TREATMENT

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

"The University of Iowa Radiation Safety Officer notified the Iowa Department of Public Health (IDPH) on May 23, 2019, of a possible medical event that had occurred at the University of Iowa Hospital on May 22, 2019. The event occurred during a therapeutic Yttrium-90 (Y-90) microsphere (TheraSphere) administration to the liver. The signed written directive from the authorized user was 1.37 GBq (37.03 milliCuries). During the administration, it appeared that the spheres were being administered without incident until the point at which the flow of spheres ceased. The interventional radiologist determined that stasis had been reached, which prevented the remainder of the prescribed dose from being administered and appeared to be the only explanation for what happened. Based on the final survey reading of the source vial and tubing in the waste container, the initial determined dose was 0.586 GBq (15.84 milliCuries) which is 42% of the written directive.

"The following morning, May 23, 2019, routine imaging of the patient indicated no Y-90 activity in the patient's liver or abdominal areas. A second whole-body scan to determine any migration of activity was also negative for Y-90. The University of Iowa Radiation Safety Staff initiated an investigation into the location of the remainder of activity that was not remaining in the dose vial by surveying the procedure room and patient's room which were background levels and verified correct imaging protocol for the patient. The dose vial was re-surveyed and was found to contain all the original activity and no Y-90 TheraSpheres.

"The licensee's preliminary probable cause is an occluded needle in the vial that could have prevented either the flow of saline into the source vial, or the flow of microspheres out of the vial to the patient. The authorized user, the interventional radiologist, and the patient have been informed of the issue with this administration. No direct harm to the patient has occurred because no radioactivity had been delivered to the patient.

"This is a preliminary report and IDPH will be conducting an investigation to provide additional updated information. Items to initially get resolved include but are not limited to the licensee's issue with how dosages are measured before and after the procedure, independently verifying that no dose had been delivered to the patient, examine the integrity of the tubing and needles used in the procedure, and communication with the manufacturer about the circumstances surrounding this event and if they or the NRC are aware of any similar events."

NMED Report No.: IA190001

* * * RETRACTION AT 1641 EDT ON 5/30/19 FROM STUART JORDAN TO JEFF HERRERA * * *

The following retraction was received from the Iowa Bureau of Radiological Health via email:

"The Iowa Department of Public Health requests to retract the NRC Event Notification No. 54084 (Item No. IA190001) that was transmitted to the NRC Operations Center on May 24, 2019. After conversations with the licensee's radiation safety officer and review of information provided by the licensee we have determined that no detectable amount of Y-90 TheraSpheres was administered to the patient, and therefore no dose was delivered. Based on a discussion with NRC Region III Office, we have determined that the circumstances surrounding this incident do not meet the reportable medical event described in 10 CFR 35.3045."

Notified the R3DO (Daley), NMSS Events (via email).

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.

MANUAL REACTOR TRIP DUE TO FAILURE OF MAIN FEEDWATER REGULATING VALVE

"On May 22, 2019, at 0233 EDT, Watts Bar Nuclear Plant (WBN) Unit 2 reactor was manually tripped due to a failure of the #2 Main Feedwater Regulating Valve during power ascension following a refueling outage. Concurrent with the reactor trip, the Auxiliary Feedwater system actuated as designed.

"All Control and Shutdown rods fully inserted. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and Steam Dumps. Unit 2 is in a normal shutdown electrical alignment.

"This reactor trip and system actuation is being reported under 10 CFR 50.72(b)(3)(iv)(A) and 10 CFR 50.72(b)(2)(iv)(B).

"There was no impact to WBN Unit 1.

"The NRC Senior Resident has been notified."

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"On 5/22/2019, the 'A' Control Structure Chiller (Div I) tripped due to a loss of [motor control center] MCC 0B136. The 'B' Control Structure Chiller was already inoperable due to Div II [Emergency Service Water] ESW being out of service for planned maintenance. With the loss of Control Structure HVAC System the ability to maintain temperatures in various spaces including relay rooms, Control Room Floor Cooling and Emergency Switchgear rooms was lost. The 'B' Control Structure Chiller was restarted at 0251 EDT and cooling was reestablished to the required areas, however the 'B' chiller is not considered operable at this time.

"Units 1 and 2 entered [Technical Specification] TS 3.0.3 at 0256 EDT and a controlled shutdown of both units commenced, Unit 2 at 0340 EDT and Unit 1 0350 EDT.

"This constitutes a TS required shutdown and requires a 4 hour [Emergency Notification System] ENS notification in accordance with 10 CFR 50.72(b)(2)(i). The failure also requires an 8 hour ENS notification in accordance with 10 CFR 50.72(b)(3)(v) due to the loss of a safety function."

The licensee needs to restore the 'B' loop of ESW to exit the Limiting Condition of Operation (LCO). The licensee is currently performing a flow surveillance, once complete and assuming the data is acceptable, the licensee will be able to exit the LCO.

The units are in a normal electrical lineup.

The licensee will be notifying the state of Pennsylvania FEMA Operations Center.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE ON 05/22/2019 AT 1302 FROM SCOTT MYRTHEL TO THOMAS KENDZIA * * *

"On 5/22/2019 at 0601 EDT Susquehanna Steam Electric Station reported a shutdown had been commenced at 0340 EDT for Unit 2 and 0350 EDT for Unit 1 due to inoperability of both control structure chillers. Power has been restored to MCC 0B136, and at 0901 EDT the 'A' control structure chiller was declared operable and LCO 3.0.3 was exited. Power reduction for both units was halted at 0901 EDT and preparations for power restoration initiated. As of 1255 EDT on 5/22/2019, Unit 1 power is 94% and Unit 2 power is 92%."

Notified the R1DO (Arner).