Event Notification Report for August 27, 2015

SECONDARY CONTAINMENT INOPERABLE

"At 0752 CDT on 8/27/2015, both doors of a Secondary Containment Airlock were reported to be open simultaneously for a period of approximately five seconds. The brief time that the doors were simultaneously open constituted an inoperable condition of Secondary Containment. The airlock interlock was verified to operate correctly, and Secondary Containment has been restored to an operable status."

The licensee has notified the NRC Resident Inspector.

TEXAS AGREEMENT STATE REPORT - COBALT-57 SOURCE LOST DURING SHIPMENT

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

"On August 27, 2015, the licensee notified the Agency [Texas Department of State Health Services] that a 100 milliCurie cobalt-57 source had been ordered by one of its investigators and shipped to the proper address for the licensee, but the source had not been received. The licensee's radiation safety officer (RSO) reported that the investigator had checked around noon on the status of the order with the radiation safety office. The radiation safety staff learned that the investigator had ordered it without following procedure and going through their office, so they had not been aware that the source was supposed to be coming. The RSO reported that upon checking with the common carrier handling the package, the carrier showed the package had been delivered on August 21, 2015, 'in College Station' (no other information documented by the driver), and the carrier provided the name of the person who signed for receipt. The carrier opened an investigation. The RSO contacted the company from whom the source was purchased and verified the shipping address was correct. A search was conducted of the building it should have been delivered to, staff was questioned if they had seen/received it or knew the person who signed for it, and the RSO searched staff and student directories and checked through the university's police department for the signer's name with negative results. At approximately 1630 [CDT], the RSO made the determination the package was missing and reported to the Agency. The RSO stated that a team will begin canvasing other buildings in the morning and efforts will continue to locate the package and identify the signer. Further information will be provided as it is obtained in accordance with SA-300."

Texas Incident #: I-9335

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

BRIEF LOSS OF SECONDARY CONTAINMENT DUE TO BOTH AIRLOCK DOORS OPEN SIMULTANEOUSLY

"On 8/27/2015 at 1347 [EDT], a cart and personnel were being traversed through an airlock in the Unit 2 reactor building and both airlock doors were inadvertently opened at the same time for a brief period of time (approximately one minute).

"Secondary Containment differential pressure was maintained throughout the time period that the doors were opened. The doors serve as a Secondary Containment boundary and at least one in series is required to be closed at all times for Secondary Containment Operability.

"This event is being reported under 10 CFR 50.72(b)(3)(v) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment System."

The licensee notified the NRC Resident Inspector.

* * * RETRACTED ON 10/22/15 AT 1645 EDT FROM ALEX MCLELLAN TO DONG PARK * * *

"NUREG-1022, Revision 3, Section 3.2.7, 'Event or Condition that Could Have Prevented Fulfillment of a Safety Function,' states, in part, that 'events covered in paragraph (b)(3)(v) of this section may include one or more procedural errors, equipment failures, and/or discovery of design, analysis, fabrication, construction, and/or procedural inadequacies.'

"The level of judgment for reporting an event or condition under this criterion is a reasonable expectation of preventing fulfillment of a safety function. A SSC [System, Structure, and/or Component] that has been declared inoperable is one in which the SSC capability has been degraded to the point where it cannot perform with reasonable expectation or reliability. For SSCs within the scope of this criterion, a report is required when:
- There is a determination that the SSC is inoperable in a required mode or other specified condition in the TS [Technical Specification] applicability,
-The inoperability is due to one of more personnel errors, including procedure violations; equipment failures; inadequate maintenance; or design, analysis, fabrication, equipment qualification, construction, or procedural deficiencies, and
-No redundant equipment in the same system was operable.

"Subsequent to the reporting of this condition, Susquehanna Nuclear, LLC performed an investigation of the event. Below are the results.

"When the airlock doors were opened at the same time, they were being operated as designed. Each individual had a 'green' light, which allowed them to open each door. Based on the investigation, the doors were open at the same time for approximately one second. In summary, the inoperability of Secondary Containment was not due to personnel error or a procedure violation.

"At the time of the event, both airlock doors were operable. No equipment failures, inadequate maintenance, or design, analysis, fabrication, equipment qualification, construction, or procedural deficiencies were identified.

"In summary, based on the above, the identified condition is not reportable in accordance with 10 CFR 50.72(b)(3)(v), for an event or condition, that at the time of discovery, could have prevented the fulfillment of a safety function. As such, this 8-hour event notification is being retracted."

The licensee has notified the NRC Resident Inspector. Notified R1DO (Gray).

AGREEMENT STATE REPORT - LOST CS-137 CALIBRATOR CHECK SOURCE

The following information was obtained from the State of Louisiana via email:

"Event date and time: On August 27, 2015, [a licensee employee] reported a lost QC/QA check source utilized to perform the daily constancy on the dose calibrator. He did the daily test at approximately 6:00 a.m. [CDT] with the source. He noticed the source was missing at approximately 1130. His administrator and he used survey meters and searched every possible place where the source could be, but have not located the missing source. [He] reported the source missing to LADEQ Radiation Assessment at 1538 on August 27, 2015.

"The source is an Atomic Labs 102 microCurie Cs-137 check source. The model number given was #11010170 and the serial number was 356013-0001. The source was last leak tested on April 29, 2015, with no leakage detected.

"This site is a medical institution. The source was kept in a locked hot lab in the Nuclear Medicine Department. They surveyed the Nuclear Medicine Dept., the Radiology Department and the waste disposal location. KLS Physics Consultants was called in to help with the search and the reporting requirements.

"Event Location: Ville Platte Medical Center/dba Acadian Medical Center, 3501 Hwy 190, Eunice, LA 70535. The last known location within the facility was during the daily dose calibrator constancy check."

Louisiana Event Report ID No.: LA-150014, T165187

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 REPORT - MEDICAL OVERDOSE

The following was received via email:

"On August 27th 2015, a patient with 21st [Century] Oncology who was prescribed a 67.13 mCi dose of Sm-153 received an 86.9 mCi dose. The resulting over dose was more than 29.5 [percent] of the prescribed dose. The error was discovered through discrepancies in their pharmacies inventory when a new order was created for a new patient.

"On Feb 15, 2016, [21st Century Oncology] were preparing an order for Sm-153 for a new patient. The nurse referred to the last administered Samarium case (August 27, 2015) for information on activity, patient weight and pricing. In order to clarify the relation between dosage and patient weight, he asked the physics staff to perform a second check of the records. When the requested check was done the following error was discovered.

"Upon re-evaluation of the treatment procedure, the physics staff determined that the dosage of 91 mCi received from the pharmacy was not correctly calculated for the patient weight that was specified on the original order. The pharmacy was then requested to fax back the original order (Form J). The fax which they sent confirmed the correct weight of the patient (148 lbs). For this weight a correct calculation would have indicated an activity of 67.13 mCi. Instead the pharmacy had shipped the (incorrect) activity of 91 mCi. The resulting delivered dosage was 29.5 [percent] more than the prescribed dose. Thus [the staff] concluded that a medical event had occurred.

"The Radiation Oncologist notified the referring physician on February 16, 2016. The Radiation Oncologist also will note this communication in the patient's chart."

Florida Incident Number: FL 16-029

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.