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Event Notification Report for July 23, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/22/2015 - 07/23/2015

** EVENT NUMBERS **


51229 51230 51233 51235 51247 51250 51253

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Agreement State Event Number: 51229
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CAROLINAS MEDICAL CENTER NORTHEAST
Region: 1
City: CONCORD State: NC
County:
License #: 013-0028-3
Agreement: Y
Docket:
NRC Notified By: DAVID P. CROWLEY
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/14/2015
Notification Time: 14:20 [ET]
Event Date: 07/09/2015
Event Time: [EDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - IMPLANT BRACHYTHERAPY OVERDOSE

The following report was received from the North Carolina Department of Health and Human Services via email:

"Narrative event description: I-125 Prostate seed implant medical event occurred when physicist ordered the incorrect activity and number of seeds. The patient plan had the correct planned activity, but when the order was placed with air kerma, the wrong activity was ordered and subsequently implanted to the patient.

"Event date and notification date: Implanted 7/9/15. Identified and reported the medical event 7/13/15.

"Phone Call received from Physicist to NC RAM [North Carolina Radioactive Materials] Branch at 1246 [EDT] on 7/13/15.

"Cause and corrective actions: Incorrect calculations and human error in conversion from air kerma to activity; [The licensee] ordered and implanted [the] wrong activity.

"Notifications: NC RAM Branch notified 7/13/2015

"Indicate if there are any generic implications: Lack of attention to units and procurement procedures for seeds.

"Source/Radioactive Material: Iodine 125 brachytherapy seeds from Theragenics Corporation

"Procedure administered; dose intended and actual dose administered; isotope and activity administered; target organ: Prostate Seed Implant, Intended Dose 144 Gray or 23.48 mCi (71 seeds), Implanted Dose of 31.299 mCi (75 Seeds), ~33% overdose based on activity alone (physicist reported 28%), I-125 seeds and 31.299 mCi administered, prostate was target organ.

"[The] patient and Referring Physician were notified 7/13/15.

"Report identification number: NC150017"

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: 51230
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: STANFORD
Region: 4
City: STANFORD State: CA
County:
License #: 0676
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/14/2015
Notification Time: 15:20 [ET]
Event Date: 06/09/2015
Event Time: [PDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - LOST CD-109 SOURCE

The following report was received from the California Radiation Health Branch via email:

"Stanford University RSO [Radiation Safety Officer] informed RHB [California Radiation Health Branch] that a 0.285 mCi Cd-109 source had been lost."

The licensee has implemented corrective actions to bolster inventory accountability.

California 5010 Number: 062515

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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Agreement State Event Number: 51233
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY HOSPITALS OF CLEVELAND
Region: 3
City: CLEVELAND State: OH
County: CUYAHOGA
License #: OH-0211018007
Agreement: Y
Docket:
NRC Notified By: KARL VAN AHN
HQ OPS Officer: VINCE KLCO
Notification Date: 07/15/2015
Notification Time: 10:50 [ET]
Event Date: 07/14/2015
Event Time: 10:30 [EDT]
Last Update Date: 07/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA ()

Event Text

AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE

The following information was received by the State of Ohio via email:

"On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]."

Ohio Report: OH150007

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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Non-Agreement State Event Number: 51235
Rep Org: UNITED STATES AIR FORCE
Licensee: UNITED STATES AIR FORCE
Region: 3
City: WRIGHT-PATTERNSON AFB State: OH
County:
License #: 42-23539-01AF
Agreement: Y
Docket:
NRC Notified By: RAMACHANDRA BHAT
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/15/2015
Notification Time: 15:52 [ET]
Event Date: 07/15/2015
Event Time: 15:15 [EDT]
Last Update Date: 07/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

LOST Am-241 SOURCES

The following was received via email:

"The Installation Radiation Safety Officer of the Wright- Patterson AFB telephoned at 1515 [EDT] stating that they lost two sources which have 10 microcuries of Am-241 each. IAW 10 CFR 20.2201, [the licensee has] reported the loss of sources to the NRC Operation Center."

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: 51247
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: TODD CASAGRANDE
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/22/2015
Notification Time: 07:08 [ET]
Event Date: 07/22/2015
Event Time: 00:13 [CDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

SEISMIC MONITOR INOPERABLE

"[At] 0013 CDT, [on] 7/22/15, the seismic monitor was found inoperable. The seismic monitor was inoperable such that emergency classification at the ALERT level could not be obtained with site instrumentation.

"The loss of assessment capability is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).

"[The NRC] Senior Resident Inspector has been notified."

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Power Reactor Event Number: 51250
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOHN RIDINGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/22/2015
Notification Time: 12:38 [ET]
Event Date: 07/22/2015
Event Time: 04:45 [CDT]
Last Update Date: 07/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RANDY MUSSER (R2DO)

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

Event Text

HPCI DECLARED INOPERABLE

"During the performance of the Unit 1 quarterly surveillance 1-SR-3.6.1.3.5 (HPCI), HPCI [High Pressure Coolant Injection] System Motor Operated Valve Operability, the inboard steam isolation valve failed to close within the required time. The valve was subsequently declared inoperable and Technical Specification (TS) Limiting Condition for Operation (LCO) 3.6.1.3 (Primary Containment Isolation Valves (PCIVs)) was entered which required the HPCI steam line to be closed and de-activated. To comply with TS LCO 3.6.1.3 Condition A, the outboard steam isolation valve was closed and breaker opened. Due to the steam line being isolated, TS 3.5.1, ECCS Operating, Condition C was entered on July 22, 2015 at 0445 CDT as a result of the inoperable HPCI system. Troubleshooting and repair is in progress and during this inoperability, other systems are available to provide the required safety functions.

"This constitutes an unplanned HPCI system inoperability and requires an 8-hour ENS notification in accordance with 10 CFR 50.72(b)(3)(v)(D), due to the failure of a single train system affecting accident mitigation, and a 60-day written report in accordance with 10 CFR 50.73(a)(2)(v)(D).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 51253
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: WALTER GRUER
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/23/2015
Notification Time: 04:21 [ET]
Event Date: 07/23/2015
Event Time: 01:15 [CDT]
Last Update Date: 07/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
HEATHER GEPFORD (R4DO)
SCOTT MORRIS (NRR)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 0 Cold Shutdown

Event Text

INITIATION OF PLANT SHUTDOWN DUE TO RCS LEAKAGE

"On July 23, 2015 at 0115 [CDT], Callaway Plant initiated a shutdown required by Technical Specifications (TS). At 2139 [CDT] on July 22, 2015, TS 3.4.13 Condition A was entered due to unidentified RCS leakage being in excess of the 1 gpm TS limit. The leak was indicated by an increase in containment radiation readings, increasing sump levels, and decreasing levels in the Volume Control tank (VCT).

"A containment entry identified a steam plume; due to personnel safety the exact location of the leak inside the containment building could not be determined.

"At this time radiation levels inside [the] containment are stable and slightly above normal. There have been no releases from the plant above normal levels.

"The [NRC] Senior Resident Inspector was notified."

Page Last Reviewed/Updated Thursday, July 23, 2015
Thursday, July 23, 2015