Event Notification Report for February 19, 2020

AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT

"On February 20, 2020, the Radiation Safety Officer for the Licensee notified this Agency of a medical event involving yttrium-90 Theraspheres. The prescribed dose was 120 Gy but only 85.2 Gy was administered with the remaining intended dose left in the tubing. The remainder could not be flushed out and the procedure was halted. The Licensee will meet with the manufacturer next week at the Licensee's facility to address this issue. This investigation is ongoing. More information will be provided when obtained in accordance with SA-300."

Texas Incident Number: I-9745

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.

NOTIFICATION OF UNUSUAL EVENT DUE TO FIRE IN CONTROL BUILDING

"At 0957 EST on February 19, 2020, a Notification of Unusual Event [NOUE] has been determined to be present at the Watts Bar plant Unit 1 under criteria HU4 for a fire potentially degrading the safety of the plant (fire for more than 15 minutes).

"The NRC Senior Resident Inspector has been notified for this event."

Notified DHS SWO, FEMA Operations Center, CISA IOCC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 02/19/2020 AT 1151 EST FROM ANDREW WALDMANN TO DONALD NORWOOD * * *

The fire was declared extinguished at 1033 EST. The NOUE was terminated at 1126 EST. The investigation into the cause of the fire is in progress.

Notified R2DO (Musser), NRR EO (Miller), and IRD MOC (Kennedy). Additionally, notified DHS SWO, FEMA Operations Center, CISA IOCC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * RETRACTION ON 2/20/2020 AT 1453 EST FROM MICHAEL BUTHEY TO RICHARD L. SMITH * * *

"Watts Bar Nuclear Plant (WBN) is retracting Event Notice 54531 (NOUE notification) based on the following additional information.

"WBN reported a condition that was determined to meet the definition of a FIRE in the plant Emergency Preparedness Implementing Procedures (EPIP) based on indications available to the decision-maker at the time the declaration was made. A fire, without observation of flame, is considered present if large quantities of smoke and heat are observed.

"Moderate quantities of smoke were observed coming from an electrical cabinet not required to support safe plant operation. Once Fire Brigade personnel were able to access the affected room, no evidence of flame or significant heat was observed. Plant personnel ultimately determined that an overheated electrical component (transformer) resulted in the smoke. As such, the actual conditions did not meet the EPIP definition of a fire."

The NRC Resident Inspector has been notified of this retraction.

Notified R2DO (Musser), NRR EO (Miller), and IRD MOC (Kennedy).

MANUAL REACTOR TRIP DUE TO LOSS OF CONTROL OF STEAM GENERATOR WATER LEVEL

"At 0936 EST on February 19, 2020, the Watts Bar Unit 1 reactor was manually tripped while operating at 100 percent power in response to loss of control of water level for steam generator number 3. All control and shutdown bank rods inserted properly in response to the manual reactor trip. All safety systems including Auxiliary Feedwater actuated as designed. The plant is stable with decay heat removal through Auxiliary Feedwater and Steam Dump Systems. There is no impact to Unit 2.

"The manual actuation of the Reactor Protection System (RPS) is being reported as a four-hour report under 10 CFR 50. 72(b)(2)(iv)(B).

"The expected actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight-hour report under 10 CFR 50.72 (b)(3)(iv)(A).

"The NRC Senior Resident Inspector has been notified for this event."

AGREEMENT STATE REPORT - LOSS OF DEVICES CONTAINING AM-241

The following was received from the Tennessee Division of Radiological Health via email:

"During a recent inventory at Blues City Brewery, the environmental health and safety manager discovered that two devices [Industrial Dynamics CI-2GV/3] were missing. Devices had been out of use for 1 - 2 years. Actual activity [of the Am-241 sources] are unknown at this point. The activity will be reported during the follow-up report."

Incident Report No.: TN-20-038

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