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Event Notification Report for June 21, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/20/2019 - 6/21/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54114
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: RWLS LLC Region: 4 City: ANDREWS State: TX County: License #: L06307 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: JEFF HERRERA	Notification Date: 06/12/2019 Notification Time: 13:11 [ET] Event Date: 06/12/2019 Event Time: 00:00 [CDT] Last Update Date: 06/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WARNICK (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL) - CNSNS (MEXICO) (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AMERICIUM/BERYLLIUM SOURCE

The following report was received from the Texas Department of State Health Services (the Agency) via email:

"On June 12, 2019, the licensee's Radiation Safety Officer (RSO) notified the Agency that while performing an in-depth audit, he became aware that a 250 millicurie americium-241/beryllium source (SN: T-128) they had been licensed for was not present at their main site. Records for the source indicate the last leak test was performed in September 2017, but the source was not recorded on quarterly inventories in 2018. The RSO has been unable to find any records of transfer or disposal. The RSO is continuing record searches and interviews as well as physical searches of the licensee's facilities. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: 9686

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

Agreement State	Event Number: 54115
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: HOLMES REGIONAL MEDICAL CENTER, INC. Region: 1 City: MELBOURNE State: FL County: License #: 0545-2 Agreement: Y Docket: NRC Notified By: MATTHEW G. SENISON HQ OPS Officer: JEFF HERRERA	Notification Date: 06/12/2019 Notification Time: 15:45 [ET] Event Date: 06/11/2019 Event Time: 00:00 [EDT] Last Update Date: 06/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN CHERUBINI (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT DOSAGE GREATER THAN PRESCRIBED

The following report was received from the State of Florida Bureau of Radiation Control via email:

"This morning, HRMC Inc. [Holmes Regional Medical Center] called to report a misadministration of Y-90 TheraSpheres to a patient, 77 y/o female. Prescribed activity was 0.304 GBq, prescribed dose was 120 grey. Administered activity was 3.0 GBq, awaiting confirmation of administered dose, BRC [Bureau of Radiation Control] assumes administered dose will be 10 times prescribed dose based on 10 times administered activity. Lot # 1999265. An authorized physician discussed this incident with the patient and a few family members. This was intended to be a one time treatment. This appears to meet the criteria for an abnormal occurrence."

Florida Incident Number: FL19-078

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.

Power Reactor	Event Number: 54127
Facility: WATTS BAR Region: 2 State: TN Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: BRIAN MCILNAY HQ OPS Officer: THOMAS KENDZIA	Notification Date: 06/20/2019 Notification Time: 17:59 [ET] Event Date: 06/20/2019 Event Time: 13:40 [EDT] Last Update Date: 06/20/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL	Person (Organization): RANDY MUSSER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INOPERABILITY OF CONTAINMENT SHIELD BUILDING

"At 1340 EDT on June 20, 2019, a breach in excess of allowable margin in the Unit 2 Shield Building annulus was identified. T.S. LCO 3.6.15, Condition A was entered. The breach is expected to be repaired within the 24 hours allowed LCO time.

"No other equipment issues were identified.

"The Shield Building ensures that the release of radioactive material from the containment atmosphere is restricted to those leakage paths and associated leakage rates assumed in the accident analysis during a Loss of Coolant Accident (LOCA).

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(C).

"NRC Resident Inspector has been notified."

The breach consists of a tear in a flexible boot seal for a penetration associated with the suction path for gas treatment fans. There is no release of radioactive material associated with this event.

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