Event Notification Report for May 11, 2021

EN Revision Imported Date: 5/11/2021

EN Revision Text: AGREEMENT STATE REPORT - MISADMINISTRATION OF PHARMACEUTICAL

The following report was received via fax from the Alabama Department of Public Health, Office of Radiation Control

"On April 28, 2021, Alabama licensee Druid City Hospital (DCH) Regional Medical Center, RML 219, reported that a patient received an estimated 119.49 millicuries of sodium pertechnetate on April 27, 2021 around 12:00pm [CDT]. The patient was prescribed 30 millicuries of sestamibi. The effective dose was estimated to be 5747.4 mrem (5.7474 rem). The Agency is continuing to investigate."

Alabama Event 21-15

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.

EN Revision Imported Date: 5/11/2021

EN Revision Text: AGREEMENT STATE REPORT - TROXLER GAUGE HIT BY CONSTRUCTION GRADER.

The following was reported by the State of Nevada:

"An authorized user (AU) and portable nuclear gauge were run over by grader while using the gauge. The AU and gauge were blocked from the driver's view by the grader wheel. The AU was exposed to the source for approximately thirty (30) minutes while the source rod was extended. The source rod remained intact however it cannot be pulled back into the shielded position due to the bent source rod.
The radiation safety officer (RSO) placed the source rod into a concrete cylinder to limit the dose to responders. Then the gauge and the cylinder were placed in a fifty-five (55) gallon drum. It was sealed and transported back to the storage facility. The licensee is working with Troxler to make arrangements to return the gauge.

"On contact readings of the transport drum were no higher than 0.6 mR/hr and 0.260 mR/hr at one meter. No contamination was found on the gauge, shipping container or the RSO's hands.

"The licensee has been requested to ship the AU's dosimeter for immediate processing due to the long exposure. Will update AU exposure once results are received. The AU is expected to recover."

Nevada Item Number: NV210006.

* * * UPDATE ON 5/6/21 AT 1149 EDT FROM COREY CREVELING TO THOMAS HERRITY * * *

The following information was received from the State of Nevada via E-mail:

"The State of Nevada Radiation Control Program received notification that the authorized user reported in Event Number 55233, that was struck by a grader while using a portable gauge died on May 5, 2021."

Nevada Item Number: NV210006.

Notified R4DO (Deese), IRMOC (Gott) and NMSS Coordinator (Rivera-Capella). NMSS Events Notification via email.

* * * UPDATE ON 5/6/21 AT 1909 EDT FROM COREY CREVELING TO THOMAS HERRITY * * *

The following information was received from the State of Nevada via E-mail:

"This is to follow up from our discussion earlier this morning and I have attached the AU's dosimetry report as requested. Based on the report, exposure did not contribute to his death, and the Nevada Radiation Control Program will not be issuing a press release. As of right now the cause of death remains related to injuries from being struck by the road grader."

The radiation dosimetry report for period April 4, 2021 to June 30, 2021 showed 3 mRem.

Notified R4DO (Deese); IRMOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via email.

EN Revision Imported Date: 5/11/2021

EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION

"This telephone notification is provided in accordance with 10 CFR 50.73(a)(1) to report an invalid actuation of containment isolation valves in more than one system required by 10 CFR 50.73(a)(2)(iv)(A).

"On March 10, 2021, at 0815 [CST], during the Unit 2 Refueling Outage (L2R18), while performing a test to verify functionality of an isolation relay following replacement of the relay, a Group 4 isolation signal was actuated. The Group 4 isolation logic affects both the Reactor Building Ventilation (VR) and Containment Vent and Purge (VQ) system [for both units]. All equipment responded as designed to the Group 4 isolation, including startup of Standby Gas Treatment (SBGT) to maintain secondary containment pressure [for both units]. Investigation determined that the cause of the isolation was an inadvertent contact of the self-retracting grip jumper between two adjacent terminals that caused a short to ground and a blown fuse during the test performance. The fuse was replaced and systems restored as needed for the plant condition.

"The containment isolation was not due to actual plant conditions or parameters meeting design criteria for containment isolation. Therefore, this is considered an invalid actuation.

"The NRC Resident Inspector has been informed of this notification."

FITNESS FOR DUTY - DISCOVERED VULNERABILITY IN FITNESS FOR DUTY PROGRAM

On May 10, 2021, Callaway determined that a violation of 10 CFR 26.4(c) occurred. A licensee employee was assigned to perform Emergency Response Organization (ERO) duties that required that employee to be subject to the Fitness for Duty (FFD) program. However, the individual had been removed from the FFD program. The individual's unescorted access to the plant had been temporarily removed, but the individual was still required to report to the Emergency Operations Facility in accordance with the emergency plan procedures. The individual's ERO qualification has been deactivated. A review determined that this condition did not apply to any other ERO responders. This discovery is reported pursuant to 10 CFR 26.719(b)(4).

The NRC Senior Resident Inspector has been notified of the event.