Event Notification Report for January 09, 2018

ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The agency [Illinois Emergency Management Agency, Bureau of Radiation Safety] was notified on 1/16/18 of a medical event that occurred on 1/9/18. Agency personnel were able to contact the licensee and obtain details on 1/17/18. The licensee's RSO advised that he was out of state for a training class and was not informed by his staff until he returned.

"Licensee administered Y-90 Theraspheres to a patient in 2 doses, each treating a separate lobe of the liver. The physician wrote two prescriptions, one for each lobe. One lobe required 10 mCi, in which the entire 10 mCi dose was delivered. The second prescribed dose was for 7 mCi. Upon performing residual measurements, it was discovered that the delivered dose was 28 percent less than the 7mCi specified in the written directive. There were no equipment malfunctions reported, nor were there any medical reasons for the underdose (stasis was not reached). The AU [Authorized User] was notified, as was the referring physician.

"When considering the organ as a whole, three separate fractions were prescribed, under three separate written directives (34 mCi + 10 mCi +7 mCi), yielding a total dose of 94.44 Gy. The administered dose was 93.94 Gy. The resultant composite differential is 50 rem, with 99.5% of the desired dose administered to the organ. A written report is pending from the licensee."

Illinois Item No.: IL180012

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.

AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE SHUTTER FAILED TO CLOSE

The following information was received via E-mail:

"The licensee reported that a shutter on a fixed gauge (Isotope Measuring Systems, Inc. model 5221-02) containing five (5) five curies of Americium-241 sealed sources had one of the five shutters on the device fail to close during device calibration on January 9, 2018. This failure was reported to the Iowa Department of Public Health (IDPH) on January 10, 2018. The licensee has contacted the manufacturer and a service representative will arrive on site Thursday, January 11, 2018 to assess the cause of the shutter failure. IDPH will provide additional information to the NRC after receiving the manufacturer service representatives field report."

AGREEMENT STATE REPORT - LOST SOURCE/UNRECOVERABLE

The following was received via email:

"The RSO [Radiation Safety Officer] called in a preliminary notification at 4:05 PM [CST] on 01/09/2018. The notification was, Citgo Petroleum Corp (CPC) had lost a XRF unit overboard while working in the Calcasieu River (CR) in Lake Charles, LA. [The RSO] stated the Citgo had a Dive team working in the CR to recover the XRF unit. On 01/10/2018 recovery efforts continued. On 01/11/2018 the update indicated the Dive Team effort was unsuccessful and the individuals from CPC would continue the recovery effort. The NRC notification of the 'LOST SOURCE/ UNRECOVERABLE' is being made by LDEQ with this report.

"The XRF device, a Niton, Model XLP-703A, loaded with a Cd-109 source with the decayed activity of 12.34 mCi. The Cd-109 source S/N is 10722 and was last leak tested on 10/27/2017. The unit was being used for analysis when it slipped from the operator's control into the CR. A Dive Team Contractor was contacted and an effort made efforts to recover the device on 01/10/18 and 01/11/2018. The sonar and diving search effort was unsuccessful. The source was not recovered, the Dive Team abandoned the effort, and CPC will continue attempts to recover the device.

"On 01/11/2018 CPC notified they had lost a XRF Device, Niton Model XLP-703A in the CR that has not been recovered. The battery pack remained with the operator and the shielded device with the Cd-109 source sank into the CR. Scaled back recovery efforts for the device will continue. It is unlikely that the XRF device will be recovered.

"This lost Cd-109 source is in a shielded device with river water shielding. This lost source does not pose a health and safety threat to the General Public or the Employees of CPC.

"LA Event number: LA-180002"

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

EN Revision Imported Date : 03/09/18

EN Revision Text: BOTH TRAINS OF CONTAINMENT AIR RETURN FANS INOPERABLE

"During normal power operations at 100 percent power on Unit 2, both trains of Containment Air Return Fans (CARF) were declared inoperable at 19:28 [EST] on January 9, 2018 due to a common issue with control power fuses. The fuses potentially could not handle the in-rush current upon re-energizing the circuits. This condition resulted in a loss of a reasonable expectation that the Unit 2 Containment Air Return Fans would meet their design safety function and mitigate an accident. This loss of safety function is reportable under 10CFR50.72(b)(3)(v)(D), 8 hour report. The site entered T.S. 3.0.3 at 19:28 and exited at 20:54 when repairs to 2B CARF were completed. 2A CARF repairs are complete. There was no impact on the health and safety of the public or plant personnel. The senior NRC Resident Inspector has been notified."

The licensee verified this problem does not affect unit-1.

* * * RETRACTION AT 0939 EST ON 03/08/2018 FROM JUSTIN BLACK TO TOM KENDZIA * * *

"A subsequent evaluation determined that the fuses for the Containment Air Return Fans (CARFs) would be able to perform their safety function and were operable at the time of discovery. The limiting safety condition for the fuses is the return to power following a Loss of Offsite Power (LOOP). The evaluation determined that the fuses would satisfy their safety function upon re-energizing the circuits if a LOOP occurred and would not impact the ability of the CARFs to perform their safety function. The subject fuses were replaced on January 9, 2018."

The Licensee notified the NRC Senior Resident Inspector.

Notified the R2DO (Musser).

Original EN Text: BOTH TRAINS OF CONTAINMENT AIR RETURN FANS INOPERABLE

"During normal power operations at 100 percent power on Unit 2, both trains of Containment Air Return Fans (CARF) were declared inoperable at 19:28 [EST] on January 9, 2018 due to a common issue with control power fuses. The fuses potentially could not handle the in-rush current upon re-energizing the circuits. This condition resulted in a loss of a reasonable expectation that the Unit 2 Containment Air Return Fans would meet their design safety function and mitigate an accident. This loss of safety function is reportable under 10CFR50.72(b)(3)(v)(D), 8 hour report. The site entered T.S. 3.0.3 at 19:28 and exited at 20:54 when repairs to 2B CARF were completed. 2A CARF repairs are complete. There was no impact on the health and safety of the public or plant personnel. The senior NRC Resident Inspector has been notified."

The licensee verified this problem does not affect unit-1.

AGREEMENT STATE REPORT - SOURCE CABLE DAMAGED IN HIGH DOSE RATE AFTERLOADER UNIT

The following information was received via E-mail:

"On January 9, 2018, the licensee informed the Department [Pennsylvania Department of Environmental Protection] of a problem with their Flexitron HDR [high dose rate] unit. It is reportable per 10 CFR 30.50(b )(2).

"After a service provider completed a source exchange on an Elekta Flexitron Model 136149A02 HDR remote afterloader unit containing 9.6 curies of iridium-192 on Friday morning, January 5, 2018, the unit was tested for operation three times and worked properly. At approximately 1400 EST on the January 5, 2018, a hospital physicist was starting his QA procedures on the unit. At that point, the source would not come out of the safe position and he received an error code. The physicist then contacted the service provider and he returned to the site. The service provider tried multiple tasks to get the source to engage, all were unsuccessful. He felt there was some form of obstruction or possibly a drive issue. He then scheduled to be onsite January 9, 2018 with a fellow engineer to further investigate the issue. They discovered the source cable was badly frayed and could not be safely removed and placed into the existing transport containers. Currently, the source and cable have been taped in place so they will not move and the device has been locked in its storage closet at the facility. The Department is in contact with the hospital Radiation Safety Officer and further information is not available at this time.

"The Department will perform a reactive inspection. More information will be provided as received."

PA Event Report ID No: PA180001

EN Revision Imported Date : 03/01/18

EN Revision Text: UNANALYZED CONDITION IDENTIFIED DURING NATIONAL FIRE PROTECTION ASSOCIATION 805 IMPLEMENTATION

"On January 9, 2018, at 1759 CST, during review of NFPA 805 requirements and circuit analysis, it was determined that the NFPA 805 analysis and Fire Safe Shutdown Modeling did not consider all fire-induced failures. As such, a condition could possibly exist during a postulated fire where both safety related electrical trains could be impacted.

"This notification is to report a condition involving the fire safe shutdown analysis. The condition could result in an adverse impact on the ability of operators to respond to a postulated fire in these areas. Therefore, this notification is being made pursuant to 10 CFR 50.72(b)(3)(ii)(B), any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.

"Compensatory fire watches have been established in the affected areas."

The licensee notified the NRC Resident Inspector.


* * * RETRACTION FROM ANTONIO BENFORD TO HOWIE CROUCH AT 1752 EST ON 2/28/18 * * *

"Following additional refinements to the NFPA 805 Fire PRA Model, the circuits which initiated the initial report of an unanalyzed condition have now been evaluated and have proven that no significant degradation to plant safety existed. Therefore, EN 53159 is being retracted.

"The NRC Resident Inspector has been notified."

Notified R2DO (Michel).

Original EN Text: UNANALYZED CONDITION IDENTIFIED DURING NATIONAL FIRE PROTECTION ASSOCIATION 805 IMPLEMENTATION

"On January 9, 2018, at 1759 CST, during review of NFPA 805 requirements and circuit analysis, it was determined that the NFPA 805 analysis and Fire Safe Shutdown Modeling did not consider all fire-induced failures. As such, a condition could possibly exist during a postulated fire where both safety related electrical trains could be impacted.

"This notification is to report a condition involving the fire safe shutdown analysis. The condition could result in an adverse impact on the ability of operators to respond to a postulated fire in these areas. Therefore, this notification is being made pursuant to 10 CFR 50.72(b)(3)(ii)(B), any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.

"Compensatory fire watches have been established in the affected areas."

The licensee notified the NRC Resident Inspector.