Event Notification Report for August 08, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/07/2017 - 08/08/2017
EVENT NUMBERS
52892528935292252891
Power Reactor
Event Number: 52892
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: DONG HWA PARK
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/08/2017
Notification Time: 22:33 [ET]
Event Date: 08/08/2017
Event Time: 20:44 [EDT]
Last Update Date: 08/08/2017
Notification Time: 22:33 [ET]
Event Date: 08/08/2017
Event Time: 20:44 [EDT]
Last Update Date: 08/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
BRICE BICKETT (R1DO)
BRICE BICKETT (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF SECONDARY CONTAINMENT DIFFERENTIAL PRESSURE
"On August 8th, 2017 at 2044 hrs. [EDT] a loss of secondary containment differential pressure (D/P) occurred due to an apparent equipment failure. This caused a reduction in Reactor Building Zone II (Unit 2) D/P to less than the required 0.25 inch WC [water column] per SR [Surveillance Requirement] 3.6.4.1.1.
"Reactor Building Zone II Exhaust Fans were manually swapped and Reactor Building Zone II D/P was restored to greater than 0.25 inch WC by 2112 hrs.
"Reactor Building Zone 1 (Unit 1) and Zone 3 (Units 1&2) ventilation remained in service and stable.
"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) 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.
"On August 8th, 2017 at 2044 hrs. [EDT] a loss of secondary containment differential pressure (D/P) occurred due to an apparent equipment failure. This caused a reduction in Reactor Building Zone II (Unit 2) D/P to less than the required 0.25 inch WC [water column] per SR [Surveillance Requirement] 3.6.4.1.1.
"Reactor Building Zone II Exhaust Fans were manually swapped and Reactor Building Zone II D/P was restored to greater than 0.25 inch WC by 2112 hrs.
"Reactor Building Zone 1 (Unit 1) and Zone 3 (Units 1&2) ventilation remained in service and stable.
"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) 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.
Agreement State
Event Number: 52893
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: HILLIS-CARNES
Region: 1
City: ANNAPOLIS JUNCTION State: MD
County:
License #: MD-03-054-01
Agreement: Y
Docket:
NRC Notified By: CHARLES COX
HQ OPS Officer: DONG HWA PARK
Licensee: HILLIS-CARNES
Region: 1
City: ANNAPOLIS JUNCTION State: MD
County:
License #: MD-03-054-01
Agreement: Y
Docket:
NRC Notified By: CHARLES COX
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/09/2017
Notification Time: 15:27 [ET]
Event Date: 08/08/2017
Event Time: 00:00 [EDT]
Last Update Date: 08/09/2017
Notification Time: 15:27 [ET]
Event Date: 08/08/2017
Event Time: 00:00 [EDT]
Last Update Date: 08/09/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - STOLEN AND RECOVERED MOISTURE DENSITY GAUGE
The following was received from the Maryland Department of the Environment via email:
"On August 8, 2017, Hillis-Carnes, Maryland Licensee MD-03-054-01, notified the Maryland Radiological Health Program (RHP) that a field technician had his van carjacked at the Key's Point temporary job site. His Troxler moisture density gauge model 3430 (serial number 31733) was still in the van and locked. The licensee notified Baltimore police.
"On August 9, 2017, the Maryland Department of the Environment Emergency Response Division was notified by the Baltimore police that the van and the Troxler gauge were recovered at O'Donnell Heights the evening of August 8. An RHP inspector went to the site and took possession of the gauge and is notifying the licensee so they can retrieve it.
"Troxler 3430 has a Cesium 137 sealed source less that 9 milliCuries and a 44 milliCurie AmBe source. No indication of any damage."
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
The following was received from the Maryland Department of the Environment via email:
"On August 8, 2017, Hillis-Carnes, Maryland Licensee MD-03-054-01, notified the Maryland Radiological Health Program (RHP) that a field technician had his van carjacked at the Key's Point temporary job site. His Troxler moisture density gauge model 3430 (serial number 31733) was still in the van and locked. The licensee notified Baltimore police.
"On August 9, 2017, the Maryland Department of the Environment Emergency Response Division was notified by the Baltimore police that the van and the Troxler gauge were recovered at O'Donnell Heights the evening of August 8. An RHP inspector went to the site and took possession of the gauge and is notifying the licensee so they can retrieve it.
"Troxler 3430 has a Cesium 137 sealed source less that 9 milliCuries and a 44 milliCurie AmBe source. No indication of any damage."
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
Part 21
Event Number: 52922
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ELEKTA, INC
Region: 1
City: ATLANTA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GREG REESE
HQ OPS Officer: BETHANY CECERE
Licensee: ELEKTA, INC
Region: 1
City: ATLANTA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GREG REESE
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/24/2017
Notification Time: 06:53 [ET]
Event Date: 08/08/2017
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2017
Notification Time: 06:53 [ET]
Event Date: 08/08/2017
Event Time: 00:00 [EDT]
Last Update Date: 08/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
SILAS KENNEDY (R1DO)
BILLY DICKSON (R3DO)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PART 21 MATERIALS (EMAI)
SILAS KENNEDY (R1DO)
BILLY DICKSON (R3DO)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PART 21 MATERIALS (EMAI)
PART 21 REPORT - ONCENTRA BRACHY SOFTWARE ERROR
The following is excerpted from a report received from the Georgia Department of Natural Resources:
On August 8th, a patient was undergoing a gynecological treatment using a ring applicator with the microSelectron HDR utilizing Oncentra Brachy Software version 4.5.2. On the 2nd of a 4 fraction treatment of ring and tandem, a mistreatment occurred due to inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size. This plan was sent to the TCS [Treatment Control System] and delivered at a 5 mm steps size.
It was intended to treat specific areas, but the delivered areas were 2.5 mm - 60 mm different than intended.
This was confirmed using gafchromic film on a QA plan after treatment was completed.
This event was reported by the State of Mississippi - see related EN 52914.
Elekta identified that this issue occurs when using Applicator Models with a measured source path in combination with a specific afterloader configuration, as follows:
Oncentra Brachy - Version 4.5, 4.5.1, 4.5.2, Applicator Modeling with a measured source path, RDStore default step size 5.0 mm, 10.0 mm
Afterloader - microSelectron HDR/PDR V2, V3/Digital
Applicators - Ring Applicator Sets, Ring CT/MR Applicator sets, Interstitial CT/MR Rings, Vienna CT/MR Rings, Advanced Gynecological Applicator - Venezia with Lunar-shaped ovoids
In Elekta bulletin [IFSN 806-01-BTP-001] the Ring applicator will be used to represent all applicable applicators. Where ring is mentioned also lunar-shaped ovoids apply (Advanced Gynecological Applicator). Where 5.0 mm is used as a default step size this could also be 10.0 mm.
Oncentra Brachy incorrectly handles the placement of the ring applicator models with the measured source path in combination with the microSelectron treatment unit, for which the default step size differs from 2.5 mm.
Three other facilities previously reported this issue and the manufacturer had started working on a bug fix and field notification. All other cases found the issue during QA, so no patients were involved. Veenendaal has put a stop to the delivery of the Applicator Modeling until the Oncentra Brachy v 4.5.3 is released.
An Important Field Safety Notification was sent to all customers concerning the use of ring source paths with applicator modeling on 8/11/17 (IFSN 806-01-BTP-001 attached).
An Oncentra Brachy patch is in process to fix this safety issue.
The following is excerpted from a report received from the Georgia Department of Natural Resources:
On August 8th, a patient was undergoing a gynecological treatment using a ring applicator with the microSelectron HDR utilizing Oncentra Brachy Software version 4.5.2. On the 2nd of a 4 fraction treatment of ring and tandem, a mistreatment occurred due to inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size. This plan was sent to the TCS [Treatment Control System] and delivered at a 5 mm steps size.
It was intended to treat specific areas, but the delivered areas were 2.5 mm - 60 mm different than intended.
This was confirmed using gafchromic film on a QA plan after treatment was completed.
This event was reported by the State of Mississippi - see related EN 52914.
Elekta identified that this issue occurs when using Applicator Models with a measured source path in combination with a specific afterloader configuration, as follows:
Oncentra Brachy - Version 4.5, 4.5.1, 4.5.2, Applicator Modeling with a measured source path, RDStore default step size 5.0 mm, 10.0 mm
Afterloader - microSelectron HDR/PDR V2, V3/Digital
Applicators - Ring Applicator Sets, Ring CT/MR Applicator sets, Interstitial CT/MR Rings, Vienna CT/MR Rings, Advanced Gynecological Applicator - Venezia with Lunar-shaped ovoids
In Elekta bulletin [IFSN 806-01-BTP-001] the Ring applicator will be used to represent all applicable applicators. Where ring is mentioned also lunar-shaped ovoids apply (Advanced Gynecological Applicator). Where 5.0 mm is used as a default step size this could also be 10.0 mm.
Oncentra Brachy incorrectly handles the placement of the ring applicator models with the measured source path in combination with the microSelectron treatment unit, for which the default step size differs from 2.5 mm.
Three other facilities previously reported this issue and the manufacturer had started working on a bug fix and field notification. All other cases found the issue during QA, so no patients were involved. Veenendaal has put a stop to the delivery of the Applicator Modeling until the Oncentra Brachy v 4.5.3 is released.
An Important Field Safety Notification was sent to all customers concerning the use of ring source paths with applicator modeling on 8/11/17 (IFSN 806-01-BTP-001 attached).
An Oncentra Brachy patch is in process to fix this safety issue.
Power Reactor
Event Number: 52891
Facility: PERRY
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAVID O'DONNELL
HQ OPS Officer: VINCE KLCO
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAVID O'DONNELL
HQ OPS Officer: VINCE KLCO
Notification Date: 08/08/2017
Notification Time: 20:22 [ET]
Event Date: 08/08/2017
Event Time: 15:54 [EDT]
Last Update Date: 08/08/2017
Notification Time: 20:22 [ET]
Event Date: 08/08/2017
Event Time: 15:54 [EDT]
Last Update Date: 08/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK JEFFERS (R3DO)
MARK JEFFERS (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH PRESSURE CORE SPRAY SYSTEM SUPPRESSION POOL LEVEL INSTRUMENTATION INOPERABLE
"On August 8, 2017, at 1554 hours [EDT], during restoration from testing of the High Pressure Core Spray (HPCS) Suppression Pool Level High Instrumentation, unexpected as-left indications were found that impacted both of the required channels of instrumentation. Subsequent venting of the instrumentation lines was completed and both channels of instrumentation are reading consistent with previously taken as-found data. The instrumentation was declared OPERABLE at 1635. The initial cause of the unexpected as-left indications appears to be the introduction of air into the instrumentation lines during the calibration activities.
"This is considered a loss of safety function based on both of the HPCS Suppression Pool Level High Instrumentation channels being declared INOPERABLE and the loss of the automatic HPCS suction swap to the Suppression Pool on a high level. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D). The [NRC Resident Inspector] has been notified."
"On August 8, 2017, at 1554 hours [EDT], during restoration from testing of the High Pressure Core Spray (HPCS) Suppression Pool Level High Instrumentation, unexpected as-left indications were found that impacted both of the required channels of instrumentation. Subsequent venting of the instrumentation lines was completed and both channels of instrumentation are reading consistent with previously taken as-found data. The instrumentation was declared OPERABLE at 1635. The initial cause of the unexpected as-left indications appears to be the introduction of air into the instrumentation lines during the calibration activities.
"This is considered a loss of safety function based on both of the HPCS Suppression Pool Level High Instrumentation channels being declared INOPERABLE and the loss of the automatic HPCS suction swap to the Suppression Pool on a high level. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D). The [NRC Resident Inspector] has been notified."