Event Notification Report for August 18, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/17/2015 - 08/18/2015
Non-Agreement State
Event Number: 51341
Rep Org: MCLAREN MCCOMB
Licensee: MCLAREN MCCOMB
Region: 3
City: MT. CLEMENS State: MI
County:
License #: 21-04080-01
Agreement: N
Docket:
NRC Notified By: PRAVEEN DALMIA
HQ OPS Officer: JEFF HERRERA
Licensee: MCLAREN MCCOMB
Region: 3
City: MT. CLEMENS State: MI
County:
License #: 21-04080-01
Agreement: N
Docket:
NRC Notified By: PRAVEEN DALMIA
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/19/2015
Notification Time: 13:31 [ET]
Event Date: 08/18/2015
Event Time: 10:35 [EDT]
Last Update Date: 08/24/2015
Notification Time: 13:31 [ET]
Event Date: 08/18/2015
Event Time: 10:35 [EDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RICHARD SKOKOWSKI (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
FLEXITRON SOURCE LODGED IN CHECK RULER
On August 18, 2015, at 1035 EDT as a part of acceptance of a new Flexitron mHDR Unit, [Mt. Clemens Regional Medical Center d/b/a McLaren McComb] tested the source position accuracy using a position check ruler. Licensee programmed the source so that it would go to certain positions. The positions were initialized at 1034 EDT. The source was being watched with the room monitor camera and the camera was zoomed in on the position and not the entire ruler. The source was viewed moving out and passing the positions. The source was supposed to dwell two seconds in each position. After 10 seconds, the cable was seen retracting. At 1035 an error message was received from the machine. The camera was zoomed out and noticed the cable was stuck in the ruler and the source was lodged somewhere between the faceplate and the groove in the ruler. At this point the service engineer from Elekta was there and he looked at the situation and the door had been decided to be opened so the source could be retracted to resolve the situation. With the door open, the room monitor was showing radiation present so we closed the door. At this point, the service engineer engaged the emergency switch and tried to add additional force to the source to retract. This was unsuccessful. Contacted the Elekta Radiation Safety Officer (RSO) for advice. The Elekta RSO suggested to go into the room and retract the source manually. The service Engineer and the Director for Radiation Services then entered the room to secure the ruler with the source in it inside the lead pig sitting right next to the mHDR unit. The plan for securing the source and ruler was discussed and approved with the Elekta RSO.
The event was planned and timed. It took 11 seconds from opening the door to securing the source inside the pig. The source cable was secured to the pig. The pig was secured inside a cabinet and the room was secured to prevent unauthorized entry.
The exposure around the container was 50 mR/hr at the surface and 18 mR/hr at one meter away. Lead bricks were placed around the cabinet to reduce the exposure and the dose was measured at <1mR/hr at the lead bricks where the door is located.
The Device is an Elekta Nucletron Flexitron
Serial Number: 00225
Source: Ir-192, 12.21 Ci on 7/30/2015
Serial Number: D363E-0477
Model Number: 136.147
This event was also reported by the device manufacturer, ELEKTA, at 0948 EDT on 08/19/2015 NRC License No. 10-35096-01- SEE EN # 51330
* * * UPDATE PROVIDED BY MARK YUDELEV TO JEFF HERRERA AT 1519 EDT ON 08/24/2015 * * *
The following additional information summary was excerpted from a detailed time line provided by licensee via email:
"McLaren Macomb was in the middle of a project to replace a microSelectron v2 HDR unit with a Flexitron unit. The installation was scheduled to be completed on Friday, August 14, 2015, with training and commissioning to begin immediately. However, the dedicated camera for source position verification was pending shipment and installation by the vendor. In light of this missing camera, a Source Position Ruler was borrowed from our sister facility at Karmanos Cancer Institute in Detroit, MI to check the source position accuracy with Gafchromic film as part of acceptance procedures.
"On August 18, 2015, the source position check ruler was connected to the Flexitron channel five using matching transfer tubes. The plan was created for the source to dwell at positions 360 (most proximal), 370, 380, 390, 395, and 400mm (most distal) within the ruler for two seconds each. In the absence of dedicated Elekta camera, the CCTV camera for in-room patient monitoring was used. The camera was zoomed on the part of the ruler where the source was expected to dwell. The plan was executed successfully with the source position check ruler two times. On the third attempt, the source got wedged inside the ruler and could not be retracted into the HDR safe. No patient was involved in this incidence and the event did not result in any unplanned exposure to any personnel."
"[During source retrieval] , the total time from entering the room until the source was secured inside the emergency container was 11.16 seconds, which would result in total exposure of 140 mRem to the whole body. The survey around the lead container showed an exposure rate of 8 mR/hr at the top, 48 mR/hr at the side and 18 mR/hr 3 feet away. The background radiation recorded by the meter was 0.002 mR/hr. The power to the unit was removed. The radiation survey meter recorded background radiation at the console area and patient access hall about 20 feet away from HDR door.
"The door to the HDR room was secured. The automatic door switch to the HDR room was disabled, and the door knob inside the room turned so that the keypad to unlock the door was deactivated. The electrical door opener was also disengaged from inside the room. As such, one could only enter the room using a dedicated key. There are only two copies of the key which are in the possession of the Authorized Medical Physicists[AMP]. A 'Do Not Enter' sign, along with the AMPs name and mobile phone number, was placed on the door.
"The emergency container was placed inside the HDR cabinet into the back corner and the cabinet locked. The survey meter showed an exposure rate of 5 mR/hr at the cabinet door. A wall was built around the emergency container using 8 inch x 5 inch x 2inch steel bricks. This reduced the exposure rate at the cabinet door to about 1 mR/hr."
Notified R1DO(DeFrancisco), R3DO(Skokowski) and NMSS Events Notification (via email).
On August 18, 2015, at 1035 EDT as a part of acceptance of a new Flexitron mHDR Unit, [Mt. Clemens Regional Medical Center d/b/a McLaren McComb] tested the source position accuracy using a position check ruler. Licensee programmed the source so that it would go to certain positions. The positions were initialized at 1034 EDT. The source was being watched with the room monitor camera and the camera was zoomed in on the position and not the entire ruler. The source was viewed moving out and passing the positions. The source was supposed to dwell two seconds in each position. After 10 seconds, the cable was seen retracting. At 1035 an error message was received from the machine. The camera was zoomed out and noticed the cable was stuck in the ruler and the source was lodged somewhere between the faceplate and the groove in the ruler. At this point the service engineer from Elekta was there and he looked at the situation and the door had been decided to be opened so the source could be retracted to resolve the situation. With the door open, the room monitor was showing radiation present so we closed the door. At this point, the service engineer engaged the emergency switch and tried to add additional force to the source to retract. This was unsuccessful. Contacted the Elekta Radiation Safety Officer (RSO) for advice. The Elekta RSO suggested to go into the room and retract the source manually. The service Engineer and the Director for Radiation Services then entered the room to secure the ruler with the source in it inside the lead pig sitting right next to the mHDR unit. The plan for securing the source and ruler was discussed and approved with the Elekta RSO.
The event was planned and timed. It took 11 seconds from opening the door to securing the source inside the pig. The source cable was secured to the pig. The pig was secured inside a cabinet and the room was secured to prevent unauthorized entry.
The exposure around the container was 50 mR/hr at the surface and 18 mR/hr at one meter away. Lead bricks were placed around the cabinet to reduce the exposure and the dose was measured at <1mR/hr at the lead bricks where the door is located.
The Device is an Elekta Nucletron Flexitron
Serial Number: 00225
Source: Ir-192, 12.21 Ci on 7/30/2015
Serial Number: D363E-0477
Model Number: 136.147
This event was also reported by the device manufacturer, ELEKTA, at 0948 EDT on 08/19/2015 NRC License No. 10-35096-01- SEE EN # 51330
* * * UPDATE PROVIDED BY MARK YUDELEV TO JEFF HERRERA AT 1519 EDT ON 08/24/2015 * * *
The following additional information summary was excerpted from a detailed time line provided by licensee via email:
"McLaren Macomb was in the middle of a project to replace a microSelectron v2 HDR unit with a Flexitron unit. The installation was scheduled to be completed on Friday, August 14, 2015, with training and commissioning to begin immediately. However, the dedicated camera for source position verification was pending shipment and installation by the vendor. In light of this missing camera, a Source Position Ruler was borrowed from our sister facility at Karmanos Cancer Institute in Detroit, MI to check the source position accuracy with Gafchromic film as part of acceptance procedures.
"On August 18, 2015, the source position check ruler was connected to the Flexitron channel five using matching transfer tubes. The plan was created for the source to dwell at positions 360 (most proximal), 370, 380, 390, 395, and 400mm (most distal) within the ruler for two seconds each. In the absence of dedicated Elekta camera, the CCTV camera for in-room patient monitoring was used. The camera was zoomed on the part of the ruler where the source was expected to dwell. The plan was executed successfully with the source position check ruler two times. On the third attempt, the source got wedged inside the ruler and could not be retracted into the HDR safe. No patient was involved in this incidence and the event did not result in any unplanned exposure to any personnel."
"[During source retrieval] , the total time from entering the room until the source was secured inside the emergency container was 11.16 seconds, which would result in total exposure of 140 mRem to the whole body. The survey around the lead container showed an exposure rate of 8 mR/hr at the top, 48 mR/hr at the side and 18 mR/hr 3 feet away. The background radiation recorded by the meter was 0.002 mR/hr. The power to the unit was removed. The radiation survey meter recorded background radiation at the console area and patient access hall about 20 feet away from HDR door.
"The door to the HDR room was secured. The automatic door switch to the HDR room was disabled, and the door knob inside the room turned so that the keypad to unlock the door was deactivated. The electrical door opener was also disengaged from inside the room. As such, one could only enter the room using a dedicated key. There are only two copies of the key which are in the possession of the Authorized Medical Physicists[AMP]. A 'Do Not Enter' sign, along with the AMPs name and mobile phone number, was placed on the door.
"The emergency container was placed inside the HDR cabinet into the back corner and the cabinet locked. The survey meter showed an exposure rate of 5 mR/hr at the cabinet door. A wall was built around the emergency container using 8 inch x 5 inch x 2inch steel bricks. This reduced the exposure rate at the cabinet door to about 1 mR/hr."
Notified R1DO(DeFrancisco), R3DO(Skokowski) and NMSS Events Notification (via email).
Power Reactor
Event Number: 51329
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN BAKER
HQ OPS Officer: MARK ABRAMOVITZ
Region: 1 State: NY
Unit: [2] [] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN BAKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/18/2015
Notification Time: 19:38 [ET]
Event Date: 08/18/2015
Event Time: 13:31 [EDT]
Last Update Date: 08/18/2015
Notification Time: 19:38 [ET]
Event Date: 08/18/2015
Event Time: 13:31 [EDT]
Last Update Date: 08/18/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ANNE DeFRANCISCO (R1DO)
ANNE DeFRANCISCO (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
RESIDUAL HEAT REMOVAL HEAT EXCHANGER OUTLET VALVES UNANALYZED CONDITION
At 1331 hours [EDT] on August 18, 2015 with the plant in mode 1, IP2 entered TS [Technical Specification] 3.0.3 upon determination by the Shift Manager that MOV-746 and 747 at the outlet of the Residual Heat Removal (RHR) Heat Exchangers may not (fully) open on an Sl [Safety Injection] signal if there was a degraded grid voltage (where the voltage at the 480V Safeguards Buses is below the minimum drop-out value of 415V and above the loss-of-voltage value of 206.6V). The MOV 746 and 747 valves are normally closed so the Sl signal with degraded voltage present could cause the fuses to fail. The time when the fuses would fail and the extent to which the MOVs open has not yet been analyzed. Immediate corrective actions was taken to replace the fuses with fuses that would not fail. The RHR trains were restored to an operable condition at 1419 and 1431 hours. This event is potentially reportable under 10 CFR 50. 72(b)(3)(ii) and 10 CFR 50.72(b)(3)(v) since the condition has not yet been fully analyzed but has been corrected.
"The plant remained at 100% power during the time of this event. All technical specification requirements were followed."
The licensee will notify the NRC Resident Inspector and the State.
At 1331 hours [EDT] on August 18, 2015 with the plant in mode 1, IP2 entered TS [Technical Specification] 3.0.3 upon determination by the Shift Manager that MOV-746 and 747 at the outlet of the Residual Heat Removal (RHR) Heat Exchangers may not (fully) open on an Sl [Safety Injection] signal if there was a degraded grid voltage (where the voltage at the 480V Safeguards Buses is below the minimum drop-out value of 415V and above the loss-of-voltage value of 206.6V). The MOV 746 and 747 valves are normally closed so the Sl signal with degraded voltage present could cause the fuses to fail. The time when the fuses would fail and the extent to which the MOVs open has not yet been analyzed. Immediate corrective actions was taken to replace the fuses with fuses that would not fail. The RHR trains were restored to an operable condition at 1419 and 1431 hours. This event is potentially reportable under 10 CFR 50. 72(b)(3)(ii) and 10 CFR 50.72(b)(3)(v) since the condition has not yet been fully analyzed but has been corrected.
"The plant remained at 100% power during the time of this event. All technical specification requirements were followed."
The licensee will notify the NRC Resident Inspector and the State.
Non-Agreement State
Event Number: 51330
Rep Org: ELEKTA, INC.
Licensee: ELEKTA, INC.
Region: 1
City: ATLANTA State: GA
County:
License #: 10-35096-01
Agreement: Y
Docket:
NRC Notified By: DEBRA BENSON
HQ OPS Officer: JOHN SHOEMAKER
Licensee: ELEKTA, INC.
Region: 1
City: ATLANTA State: GA
County:
License #: 10-35096-01
Agreement: Y
Docket:
NRC Notified By: DEBRA BENSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/19/2015
Notification Time: 09:48 [ET]
Event Date: 08/18/2015
Event Time: 10:18 [EDT]
Last Update Date: 08/24/2015
Notification Time: 09:48 [ET]
Event Date: 08/18/2015
Event Time: 10:18 [EDT]
Last Update Date: 08/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
KENNETH RIEMER (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
KENNETH RIEMER (R3DO)
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
FLEXITRON SOURCE LODGED IN CHECK RULER
"On the morning of August 18, 2015, the Elekta Field Service Engineer (FSE) was called to the [Customer's facility, McLaren Cancer Institute Macomb, in Mt. Clemens, MI] to investigate an obstruction error involving a 10.2 Ci Ir-192 source and a Flexitron HDR. The facility was using a microSelectron source position check ruler to check the source positioning of the Flexitron source. The source became lodged in the check ruler. The system E-stop was unable to retract the source.
"The FSE placed the check ruler and stuck source assembly into the customer's microSelectron HDR (mHDR) Emergency Service container (ESC) in order to secure the radioactive material in a shielded container. He then tried to manually retract the source back into the Flexitron unit which was also unsuccessful.
"Elekta RSO [Radiation Safety Officer] and FSE engaged the assistance from Senior Technical Support in Veenendaal [Netherlands]. After several troubleshooting attempts, the final decision was to remove the source tail in its entirety from the Flexitron unit. During the whole process, the source cable, check ruler and transfer tube remained secured in the emergency service container.
"Currently, the customer's mHDR ESC, which contains the source cable assembly, is secured and being bunkered inside the facility's 'dog house.' The survey readings of the ESC obtained by the customer physics staff were 50 mR/hr at the surface hot spot and 18 mR/hr at 1 meter.
"The FSE has checked the mechanical condition of the Flexitron unit and has loaded a dummy source. The unit is functioning properly.
"Elekta has reached out to their source manufacturer for assistance in transporting the source assembly in its entirety out of the facility.
"Elekta has escalated this case to the complaint handling department at Elekta/Nucletron B.V. for investigation. Further information will be forwarded upon receipt."
There were no over exposures or contamination involved with this event.
* * * UPDATE AT 1331 EDT ON 08/19/15 FROM PRAVEEN DALMIA OF MT. CLEMENS REGIONAL MEDICAL CENTER TO JEFF HERRERA * * *
This event was reported by Mt. Clemens Regional Medical Center d/b/a McLaren McComb, Mt. Clemens, MI. NRC License No. 21-04080-01 - See EN # 51341
Notified R1DO (DeFrancisco), R3DO (Riemer) and NMSS Events Notification Group via email.
"On the morning of August 18, 2015, the Elekta Field Service Engineer (FSE) was called to the [Customer's facility, McLaren Cancer Institute Macomb, in Mt. Clemens, MI] to investigate an obstruction error involving a 10.2 Ci Ir-192 source and a Flexitron HDR. The facility was using a microSelectron source position check ruler to check the source positioning of the Flexitron source. The source became lodged in the check ruler. The system E-stop was unable to retract the source.
"The FSE placed the check ruler and stuck source assembly into the customer's microSelectron HDR (mHDR) Emergency Service container (ESC) in order to secure the radioactive material in a shielded container. He then tried to manually retract the source back into the Flexitron unit which was also unsuccessful.
"Elekta RSO [Radiation Safety Officer] and FSE engaged the assistance from Senior Technical Support in Veenendaal [Netherlands]. After several troubleshooting attempts, the final decision was to remove the source tail in its entirety from the Flexitron unit. During the whole process, the source cable, check ruler and transfer tube remained secured in the emergency service container.
"Currently, the customer's mHDR ESC, which contains the source cable assembly, is secured and being bunkered inside the facility's 'dog house.' The survey readings of the ESC obtained by the customer physics staff were 50 mR/hr at the surface hot spot and 18 mR/hr at 1 meter.
"The FSE has checked the mechanical condition of the Flexitron unit and has loaded a dummy source. The unit is functioning properly.
"Elekta has reached out to their source manufacturer for assistance in transporting the source assembly in its entirety out of the facility.
"Elekta has escalated this case to the complaint handling department at Elekta/Nucletron B.V. for investigation. Further information will be forwarded upon receipt."
There were no over exposures or contamination involved with this event.
* * * UPDATE AT 1331 EDT ON 08/19/15 FROM PRAVEEN DALMIA OF MT. CLEMENS REGIONAL MEDICAL CENTER TO JEFF HERRERA * * *
This event was reported by Mt. Clemens Regional Medical Center d/b/a McLaren McComb, Mt. Clemens, MI. NRC License No. 21-04080-01 - See EN # 51341
Notified R1DO (DeFrancisco), R3DO (Riemer) and NMSS Events Notification Group via email.