Event Notification Report for December 15, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/14/2015 - 12/15/2015
Agreement State
Event Number: 51651
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: RADAMERICA
Region: 1
City: BALTIMORE State: MD
County:
License #: MD0505103
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: DONALD NORWOOD
Licensee: RADAMERICA
Region: 1
City: BALTIMORE State: MD
County:
License #: MD0505103
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/13/2016
Notification Time: 16:24 [ET]
Event Date: 12/15/2015
Event Time: 00:00 [EST]
Last Update Date: 01/15/2016
Notification Time: 16:24 [ET]
Event Date: 12/15/2015
Event Time: 00:00 [EST]
Last Update Date: 01/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEDICAL EVENT - BRACHYTHERAPY SOURCE NOT PLACED IN INTENDED TREATMENT LOCATION
This is a preliminary notification by the State of Maryland, Radiological Health Program of a medical event. During both the first and second of four High Dose Rate brachytherapy treatments to one of the patient's lungs occurring on December 15, 2015 and December 21, 2015, the radioactive source was incorrectly placed between 2 and 3 centimeters away from the intended placement location. The radioactive source being used was Iridium 192. The activity level of the radioactive source is unknown at this time.
The placement error was discovered during the third treatment on January 13, 2016. The reason for the placement error involved the use of an incorrect connection between the marker and the catheter.
The State of Maryland, Radiological Health Program will conduct an investigation on January 18, 2016.
* * * UPDATE FROM ALAN JACOBSON TO JOHN SHOEMAKER AT 1249 EST ON 1/15/16 * * *
This updated licensee report was received from the State of Maryland via email:
"On January 12, 2016, while treating the third treatment fraction for an HDR patient with exuberant granulation tissue of the right lung lower lobe bronchus, we [the licensee] found out a discrepancy in our simulation imaging procedure which contributed to a geographic miss of approximately 4 cm. The geographic miss occurred for the patient's 1st and 2nd fractions on 12/15/2015 and 12/21/2015, respectively. The activity of the source was 6.9 Curies on 12/15/2015.
"In this procedure a dummy marker is normally sent into the catheter and radiographed to mark the dwell source position for treatment. It was found that in previous two treatments the dummy marker was not sent all the way through the catheter because it was used with an adapter piece on. The adapter piece was used with dummy markers in the previous microSelectron afterloader but it is not supposed to be used with the Flexitron afterloader system that we have been upgraded to since August 2014.
"The patient was treated correctly on 1/12/2016, however, the Radiation Oncologist is stating that no harm was done to the patient from the geographical miss in last two treatments. Since we reported this case to the State [Maryland Department of the Environment] on Wednesday 1/13/2016, we have found two more patients treated with intrabronchial HDR since the upgrade to Flexitron at this center that may have had a geographic miss. Investigation is still under way for these cases."
Notified the R1DO (Gray) and NMSS Events Notification via email.
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.
This is a preliminary notification by the State of Maryland, Radiological Health Program of a medical event. During both the first and second of four High Dose Rate brachytherapy treatments to one of the patient's lungs occurring on December 15, 2015 and December 21, 2015, the radioactive source was incorrectly placed between 2 and 3 centimeters away from the intended placement location. The radioactive source being used was Iridium 192. The activity level of the radioactive source is unknown at this time.
The placement error was discovered during the third treatment on January 13, 2016. The reason for the placement error involved the use of an incorrect connection between the marker and the catheter.
The State of Maryland, Radiological Health Program will conduct an investigation on January 18, 2016.
* * * UPDATE FROM ALAN JACOBSON TO JOHN SHOEMAKER AT 1249 EST ON 1/15/16 * * *
This updated licensee report was received from the State of Maryland via email:
"On January 12, 2016, while treating the third treatment fraction for an HDR patient with exuberant granulation tissue of the right lung lower lobe bronchus, we [the licensee] found out a discrepancy in our simulation imaging procedure which contributed to a geographic miss of approximately 4 cm. The geographic miss occurred for the patient's 1st and 2nd fractions on 12/15/2015 and 12/21/2015, respectively. The activity of the source was 6.9 Curies on 12/15/2015.
"In this procedure a dummy marker is normally sent into the catheter and radiographed to mark the dwell source position for treatment. It was found that in previous two treatments the dummy marker was not sent all the way through the catheter because it was used with an adapter piece on. The adapter piece was used with dummy markers in the previous microSelectron afterloader but it is not supposed to be used with the Flexitron afterloader system that we have been upgraded to since August 2014.
"The patient was treated correctly on 1/12/2016, however, the Radiation Oncologist is stating that no harm was done to the patient from the geographical miss in last two treatments. Since we reported this case to the State [Maryland Department of the Environment] on Wednesday 1/13/2016, we have found two more patients treated with intrabronchial HDR since the upgrade to Flexitron at this center that may have had a geographic miss. Investigation is still under way for these cases."
Notified the R1DO (Gray) and NMSS Events Notification via email.
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.
Power Reactor
Event Number: 51607
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: THERON ROWBOTHAM
HQ OPS Officer: JEFF ROTTON
Region: 4 State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: THERON ROWBOTHAM
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/15/2015
Notification Time: 10:24 [ET]
Event Date: 12/15/2015
Event Time: 05:44 [CST]
Last Update Date: 12/15/2015
Notification Time: 10:24 [ET]
Event Date: 12/15/2015
Event Time: 05:44 [CST]
Last Update Date: 12/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAY AZUA (R4DO)
RAY AZUA (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 43 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP DUE TO LOSS OF FEED TO ONE STEAM GENERATOR
"This is a 4-hour Non-Emergency 10 CFR 50.72(b)(2)(iv)(B) notification due to a Reactor Protection System (RPS) actuation. Arkansas Nuclear One, Unit 1, was manually tripped from 43 percent power at 0544 CST. The reactor was manually tripped due to operator judgement during control issues with the Integrated Control System (ICS) during a planned downpower for Electro-Hydraulic Control (EHC) system maintenance. CV-2672 B, low load control valve, failed to close. Subsequently, CV-2674 B, low load block valve, began to close and caused a loss of feed to E-24B Steam Generator.
"No additional equipment issues were noted. All control rods fully inserted. Emergency Feedwater (EFW) actuated and was utilized to maintain Steam Generator (SG) levels. This [EFW actuation] meets the 8 hour Non-Emergency Immediate Notification Criteria [(10CFR50.72(b)(3)(iv)(A)]. No Primary safety valves lifted. Main Steam Safety Valves (MSSVs) did lift initially after the trip.
"The NRC Resident [Inspector] has been notified."
Decay heat is being removed via the steam dump valves to the main condenser. Unit 1 is in a normal shutdown electrical lineup. Unit 2 was not affected by the transient on Unit 1. The licensee notified the State of Arkansas.
"This is a 4-hour Non-Emergency 10 CFR 50.72(b)(2)(iv)(B) notification due to a Reactor Protection System (RPS) actuation. Arkansas Nuclear One, Unit 1, was manually tripped from 43 percent power at 0544 CST. The reactor was manually tripped due to operator judgement during control issues with the Integrated Control System (ICS) during a planned downpower for Electro-Hydraulic Control (EHC) system maintenance. CV-2672 B, low load control valve, failed to close. Subsequently, CV-2674 B, low load block valve, began to close and caused a loss of feed to E-24B Steam Generator.
"No additional equipment issues were noted. All control rods fully inserted. Emergency Feedwater (EFW) actuated and was utilized to maintain Steam Generator (SG) levels. This [EFW actuation] meets the 8 hour Non-Emergency Immediate Notification Criteria [(10CFR50.72(b)(3)(iv)(A)]. No Primary safety valves lifted. Main Steam Safety Valves (MSSVs) did lift initially after the trip.
"The NRC Resident [Inspector] has been notified."
Decay heat is being removed via the steam dump valves to the main condenser. Unit 1 is in a normal shutdown electrical lineup. Unit 2 was not affected by the transient on Unit 1. The licensee notified the State of Arkansas.