Event Notification Report for November 05, 2019

AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN

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

"On November 5, 2019, the licensee notified the Agency that during routine, 6-month leak tests and shutter operation checks [at their Freeport, TX location], it found the shutter on one of its Vega, model SHF-2B, fixed nuclear gauges was stuck in the open position. The gauge contains a 1,000 milliCurie cesium-137 source (SN 0325CR). The gauge normally operates with the shutter in the open position. The gauge is mounted on the side of a vessel and there is no risk of exposure to any individual. The licensee has contacted a service company to schedule repairs. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident # I-9722

TWO DIESEL GENERATORS CONCURRENTLY INOPERABLE

"On November 5, 2019 at 1811 CST, station service water A and the Division 1 diesel generator (DG) were declared inoperable based on the results of an engineering evaluation of a Class 3 piping leak. This was determined to be a potential inability to fulfill a safety function due to concurrent inoperability of two emergency diesel generators. Division 3 DG was inoperable due to planned maintenance on November 4, 2019 at 0000 CST.

"This event is being reported an 8-hour non-emergency notification per 10 CFR 50.72 (b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function (Accident Mitigation).

"Division 3 DG and high pressure core spray have been restored, and the fulfillment of the accident mitigation safety function has been restored.

"The NRC Senior Resident Inspector has been notified."

* * * RETRACTION ON 11/11/19 AT 1739 EST FROM GABRIEL HARGROVE TO BETHANY CECERE * * *

"This was initially reported under 10 CFR 50.72(b)(3)(v)(D). However, subsequent engineering evaluation determined that the condition did not affect safety system operability. The evaluation determined that the leakage was within allowable limits and piping structural integrity was not challenged at this time nor in the past three years.

"The Division 1 DG and SSW A were at the time of discovery OPERABLE and EN54371 is being retracted."

The licensee will notify the NRC Resident Inspector.

Notified R4DO (Drake).

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Commonwealth of Pennsylvania via email:

"The Department [Pennsylvania Department of Environmental Protection] received notification from a licensee on November 6, 2019 that on October 8, 2019 they performed a prostate seed implant on a patient including seventy (70) stranded I-125 seeds that were implanted into the prostate treatment volume. They were Best Medical, Model 2301, Lot 48917, at 0.350 mCi per seed and 24.5 mCi total activity. The patient had an appointment on November 5, 2019 for a 30-day post-plan analysis. The CT from November 5, 2019 noted 2 seeds that were outside the prostate volume in the peril-prostatic fat. The post-plan analysis showed that 68 of 70 seeds are within the treatment volume and 94.4 percent of the treatment volume is covered by the prescription dose, which are within appropriate specifications for a prostate seed implant. The two seeds in question are considered discontinuous from the treatment volume. The licensee believes when the needle was retracted, the strand of seeds drug back with the needle and was deposited inferior from their intended location. An analysis was performed by the licensee and no adverse effects to the patient are expected. Both the patient and referring physician were notified. The Department will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA190026

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 ON 11/19/19 AT 1148 EST FROM JOHN CHIPPO TO THOMAS KENDZIA * * *

The following was received from the Commonwealth of Pennsylvania via fax:

"As a result of a reactive inspection by the Department and an extensive review by the licensee, the licensee has determined the tissue containing the two seeds is within the contiguous peril-prostatic fat, which is actually physically adjacent to or touching the prostate, therefore this is not a reportable event. Further, changes noted in the radiograph taken on the day of the implant and the post-plan CT can be accounted for by the difference in patient positioning; from the lithotomy position for the implant image to the supine position for the post-plan image."

Notified the R1DO (Cahill) and NMSS Event Notification via email.

TEXAS AGREEMENT STATE REPORT - GAUGE SHUTTERS STUCK OPEN

The following information was received from the State of Texas via email and phone call:

"On November 18, 2019, the licensee's radiation safety officer (RSO) notified the Agency [Texas Department of State Health Services] that on November 5, 2019, during routine shutter checks on fixed nuclear gauges at their facility, it was discovered that shutters on three Ohmart model SHD-30 gauges and one Ohmart model SHD-45 gauge were stuck in the open position. These gauges normally operate with the shutters in the open position. There is no increased risk of exposure to any individual. The RSO stated the shutter checks were performed on November 5, 2019, but an email was not sent to the RSO until November 8, 2019. The RSO did not see the email until today, November 18, 2019. After seeing the email, the RSO immediately contacted a service company who responded and was onsite during the RSO's call to the Agency.

"Gauge and source information:
Ohmart Model SHD-30 - 120 mCi Cs-137 - SN: M5149
Ohmart Model SHD-30 - 120 mCi Cs-137 - SN: M5150
Ohmart Model SHD-30 - 120 mCi Cs-137 - SN: M6017
Ohmart Model SHD-45 - 375 mCi Cs-137 - SN: M5189

"The RSO also reported that two other gauges, one SHD-30 and one SHD-45, have broken handles that need repair. The shutters on these two gauges can still be operated.

"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No: 9725