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Event Notification Report for November 10, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/07/2014 - 11/10/2014

** EVENT NUMBERS **


50583 50584 50585 50600 50601

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Non-Agreement State Event Number: 50583
Rep Org: VARIAN MEDICAL SYSTEMS
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 45-30957-01
Agreement: Y
Docket:
NRC Notified By: RICHARD PICCOLO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2014
Notification Time: 17:15 [ET]
Event Date: 10/29/2014
Event Time: 13:30 [EDT]
Last Update Date: 10/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BRICE BICKETT (R1DO)

Event Text

STUCK SOURCE IN A VARIAN HIGH DOSE RATE AFTERLOADER

Staff at the New Milford Cancer Center in New Milford, CT were performing their daily quality assurance checks on their Varian Medical Systems high dose rate (HDR) afterloader when the 7.2 Ci (estimated) Ir-192 source became stuck in the safe position. New Milford contacted the vendor who dispatched a support team to investigate.

The Varian RSO surveyed the area and found the dose rate at 5 cm was 1.5 mR/hr which was within normal parameters with the source in the shielded position. While attempting to free the source, it became stuck outside of the shielded position. Dose rates increased to 20 mR/hr at the entrance to the maze, 280 mR/hr at the turn (approximately 15 feet from the HDR) and 5.4 R/hr at 0.5 meters. The service manager was able to use the emergency hand crank to return the source to its shielded position. During the retrieval, the RSO received 9 mR while the service manager received 27 mR.

Based on past issues and current symptoms, Varian technicians replaced the drive mechanism and will be installing a new source wire.

Once all repairs are made, the HDR will be placed into service with the Varian team on hand during the first post-maintenance use.

Varian, an NRC licensee, is making this report since New Milford Cancer Center (license number 0617892-01) did not exceed any reporting thresholds due to this event.

The vendor has notified R1 (Modes). See similar events in Event Notifications 46695 and 46758.

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Non-Agreement State Event Number: 50584
Rep Org: BEAUMONT HEALTH SYSTEM
Licensee: BEAUMONT HOSPITAL ROYAL OAK
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2014
Notification Time: 18:17 [ET]
Event Date: 10/30/2014
Event Time: 10:00 [EDT]
Last Update Date: 10/30/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)

Event Text

PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

"This is a notification of a medical event that occurred on October 30, 2014 at 1000 EDT in which the Y-90 SIR-Sphere dose delivered to the patient's posterior portion of the right lobe of the liver was more than the prescribed dose by 20 percent or more (10 CFR 35.3045). This patient had a dual administration, with the correct dose administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy). The medical event occurred before this, when the patient who was prescribed a dose of 0.39 GBq (64.5 Gy) was administered a dose that was 20.5% more than the prescribed dose. The posterior portion of the right lobe of the liver was administered 0.47 GBq (77.5 Gy), which was the intended dose for the anterior portion of the right lobe of the liver. The total dose to the right lobe of the liver (both posterior and anterior portions) was 0.90 GBq (142 Gy) compared to the planned dose of 0.91 GBq (143.6 Gy). Our color coding procedure failed to prevent this error. The radiopharmacy staff had applied the green colored dot to the QMP [Quality Management Program] and Dose Planning Forms appropriate for the posterior portion of the right lobe. The medical physicist applied the green colored dot to the checklist intended for the anterior portion of the right lobe rather than to the checklist intended for the posterior portion of the right lobe. The error was not caught during the time out prior to the dose administration. Upon completion of the first of the dual administrations, the medical physicist identified and reported the error to the authorized user and RSO. A time out was called and the decision was made to prepare a new Y-90 SIR-Sphere dosage for the anterior portion of the right lobe in accordance with the written directive. The correct dose was then administered in accordance with the written directive to the anterior portion of the right lobe of the liver (0.43 GBq and 53.4 Gy).

"To prevent this from occurring, the color coding procedure was revised by the Radiopharmacy and modeled after their blood labeling process. The check list was revised to instruct the medical physicist that 'If dual administration case, verify correct color dots on QMP form, dose plan, and checklist.' Before a dual administration case is started, the dose planning page with the correct corresponding color dot will be pulled from the paperwork and placed in the control room. This allows the AU [authorized user], physicist, and remaining team (techs, nurses) to see the plan clearly. Once the physician (AU) gains access to the first treatment site, they will give the verbal notice to the physicist, so they can assemble the corresponding dose. With the finished assembly in place table side, the AU and physicist will verify the dose intended for the location. As it pertains to this case, the physician would say, 'We are in the posterior right lobe, the dosage is 0.52 GBq and is labeled with the orange dot, correct?' The QMP was revised to include these revised procedures. No adverse effect is expected for the patient. Both the patient and the referring physician were notified on October 30, 2014."

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.

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Agreement State Event Number: 50585
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: MATERIALS TESTING LABORATORY, INC.
Region: 1
City: BROOKLYN State: NY
County:
License #: C2274
Agreement: Y
Docket:
NRC Notified By: FAX
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/31/2014
Notification Time: 15:54 [ET]
Event Date: 10/31/2014
Event Time: 12:15 [EDT]
Last Update Date: 10/31/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
CANADIAN NUCLEAR SAF (FAX)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was obtained from the State of New York via fax:

"New York State Department of Health was notified on October 31, 2014 by the Radiation Safety Officer of Materials Testing Laboratories, Inc. of the theft of a moisture/density device from a locked vehicle on Friday October 31, 2014. The device is identified as a Troxler Model 4640, serial no. 722 containing 8 millicuries of Cesium 137. The device was apparently being stored within the locked vehicle. The transport case was tethered to the frame of the vehicle with the cable locked to the hasp of the carrying case. The operator of the device discovered that the back lift gate to the 2009 Chrysler Aspen SUV was opened and the lock was removed from the carrying case. The device was stolen from the transport case. Nothing else in the vehicle was stolen.

"Local law enforcement have responded and are investigating."

New York Event ID No.: NY-14-04

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

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Power Reactor Event Number: 50600
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROBERT WARNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/06/2014
Notification Time: 18:22 [ET]
Event Date: 11/06/2014
Event Time: 11:16 [MST]
Last Update Date: 11/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
GEOFFREY MILLER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 20 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO DROPPED CONTROL ELEMENT ASSEMBLY

"On November 6, 2014 at 1116 Mountain Standard Time (MST), Control Element Assembly (CEA) 15 dropped fully into the core while all other CEAs remained fully withdrawn. Limiting Condition for Operation (LCO) 3.1.5 Condition A was entered for one CEA misaligned from its group which requires restoration of the CEA within 2 hours. An initial power reduction was performed upon receipt of the deviation in accordance with technical specifications. The CEA could not be aligned within 2 hours and LCO 3.1.5 Condition C was entered at 1316 MST which requires entry into Mode 3 within 6 hours. Power reduction continues as necessary to comply with technical specifications.

"No major equipment was inoperable prior to the event that contributed to the event. No emergency classification was required per the Emergency Plan. No automatic essential safety feature actuations occurred and none were required. The Emergency Diesel Generators did not start and were not required. Safety related buses remain energized. The offsite power grid is stable. Other LCOs were entered as required by technical specifications."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY RYAN LANE TO JEFF ROTTON AT 0012 EST ON 11/07/2014 * * *

"Efforts to repair the CEA control system and realign CEA 15 with the other CEAs in its regulating group were unsuccessful. Shutdown of Unit 2 was completed at 1636 [MST] in accordance with normal operating procedures to comply with the shutdown requirements of LCO 3.1.5 Condition C. Unit 2 is currently stable in Mode 3 with the reactor coolant system at normal operating temperature and pressure. All equipment responded as expected with the exception of steam generator # 2 economizer feedwater regulating valve which remained 3 percent open. The economizer feedwater isolation valves to both steam generators were manually closed to isolate the economizer feedwater flow paths. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event.

"The NRC Resident Inspector has been informed of the Unit 2 shutdown."

Notified R4DO (Miller)

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Power Reactor Event Number: 50601
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: CURTIS BRAY
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/07/2014
Notification Time: 11:13 [ET]
Event Date: 11/07/2014
Event Time: 08:47 [EST]
Last Update Date: 11/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMNES CAMERON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO LOSS OF FEEDWATER

"The Perry Nuclear Power Plant experienced an automatic reactor scram due to a loss of feedwater, which resulted in receiving valid reactor vessel water Level 3 and Level 2 initiation signals. The High Pressure Core Spray system and the Reactor Core Isolation Cooling system started and injected. Reactor water level and pressure have been stabilized in the required bands. The motor feed pump automatically started and is being used to control reactor vessel water level. The High Pressure Core Spray and Reactor Core Isolation Cooling systems have been returned to the standby mode. As a result of receiving a reactor vessel water Level 2 signal a Balance of Plant containment isolation signal was received. All systems isolated as required and the plant is restoring isolated systems in accordance with plant procedures.

"During the scram, all rods fully inserted into the core. Decay heat is being removed via turbine bypass valves to the main condenser. The electrical grid is stable and is supplying plant loads. An emergency diesel generator [Division 3 High Pressure Core Spray] started, as designed, as a result of the reactor vessel water Level 2 signal. No safety relief valves lifted as a result of the transient.

"The plant is stable with cooldown and depressurization to Mode 4 in progress. The cause of the loss of feedwater is under investigation.

"The NRC Resident Inspector has been notified. The State of Ohio and local officials will be notified."

Page Last Reviewed/Updated Monday, November 10, 2014
Monday, November 10, 2014