Event Notification Report for June 19, 2017

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON GAUGE

The following report was received by the State of Texas via email:

"On June 20, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that the shutter on a Thermo Fisher model SUP-1C gauge containing a 100 milliCurie source would not close. The gauge is located in a remote location at the facility and does not create an exposure risk to any individual. The manufacturer has been contacted and will be on site today, June 20, 2017, to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

The source is Cs-137. The gauge serial number is TG-564.

Texas Incident #: I 9495

AGREEMENT STATE REPORT - DOSE DELIVERED TO SITE ADJACENT TO INTENDED TARGET

The following State of Utah report was received by email:

"The licensee delivered a 500 cGy fraction of HDR [High Dose Rate] brachytherapy to a site adjacent to the intended target. This treatment was a supplemental boost to external beam radiotherapy, and the mistreated volume was included in the target volume of the external beam plan."

The State of Utah was notified of the event on June 21, 2017 by electronic mail opened at 1125 MDT.

Utah Event Report ID No: will be provided in follow up report.

* * * UPDATE at 1212 EDT ON 8/28/17 FROM SPENCER WICKHAM TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"The licensee name needs to be changed from 'University of Utah, Radiological Health Department' to 'Jordan Valley Medical Center, LP'."

Notified the R4DO (Gaddy) and NMSS Events Notification via e-mail.

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.

PRIMARY CONTAINMENT DECLARED INOPERABLE DUE TO FAILURE OF DRYWELL TO SUPPRESSION CHAMBER VACUUM BREAKER TO FULLY CLOSE

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.'

"At time 2115 CDT on June 19, 2017, one torus to drywell vacuum breaker failed to indicate that it was closed after being cycled for surveillance testing. The vacuum breaker had been cycled open and then closed to satisfy SR 3.6.1.8.2 - Perform a functional test of each required vacuum breaker. Failure of the vacuum breaker to indicate closed after the control switch was taken to the closed position represents a failure to satisfy SR 3.6.1.8.2 and SR 3.6.1.8.1 - Verify each vacuum breaker is closed. Primary containment is allowed to have a bypass area between the drywell and suppression chamber less than or equivalent to a one inch diameter hole. The are of bypass was indeterminate while the vacuum breaker did not indicate fully closed. Primary containment was declared inoperable during the time the vacuum breaker did not indicate fully closed.

"The vacuum breaker control switch was subsequently cycled open and closed one additional time. At time 2311 CDT, the vacuum breaker indicated fully closed. At that time, primary containment was declared operable.

"Currently, all twelve Drywell to Suppression Chamber vacuum relief valves are closed and in the normal line-up.

"The NRC Senior Resident Inspector has been notified."

HIGH PRESSURE COOLANT INJECTION INOPERABLE

"At 2353 CDT on 6/19/2017, while performing the High Pressure Coolant Injection (HPCI) quarterly surveillance following planned maintenance, the HPCI turbine did not start as expected due to the HPCI turbine stop valve failing to open. This issue is being reported under 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function at the time of discovery. Investigation into the failure of the HPCI system to start is in progress. The unit remains at 100% power. The health and safety of the public was not affected.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - LOSS OF Ni-63 GAS CHROMATOGRAPH SOURCE

The following information was received from the Commonwealth of Kentucky via email:

"On July 5, 2017, Murray State University [General License 401-111-20] reported the loss of an electron capture detector (ECD) contained in a Hewlett-Packard gas chromatograph model 6890. The ECD contained 15 mCi of Ni-63, S/N US00000603. The licensee stated they shipped the ECD on 1/14/16 by [common carrier] to Agilent Technologies, Inc. On 6/19/17 Agilent Technology verified with the licensee they had not received the device. The licensee believes the package containing the ECD was picked up with other items shipped that day by mistake."

Kentucky Event Report ID No.: KY170006

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