Event Notification Report for May 27, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/26/2016 - 05/27/2016
EVENT NUMBERS
51977519735196351964
Agreement State
Event Number: 51977
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GLATFELTER PAPER
Region: 3
City: CHILLICOTHE State: OH
County:
License #: 31201720002
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Licensee: GLATFELTER PAPER
Region: 3
City: CHILLICOTHE State: OH
County:
License #: 31201720002
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/03/2016
Notification Time: 15:34 [ET]
Event Date: 05/27/2016
Event Time: 00:00 [EDT]
Last Update Date: 06/03/2016
Notification Time: 15:34 [ET]
Event Date: 05/27/2016
Event Time: 00:00 [EDT]
Last Update Date: 06/03/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was received by the State of Ohio via email:
"Shutter stuck in open (normal operating) position on Berthold Model LB300L Fixed Gauge, containing approximately 20 microCi Co-60. Service provider has been contacted to repair. Gauge is not accessible to personnel and continues to operate in process line."
Berthold Gauge Serial Number: 623/3-04-04
Ohio Item Number: OH160004
The following information was received by the State of Ohio via email:
"Shutter stuck in open (normal operating) position on Berthold Model LB300L Fixed Gauge, containing approximately 20 microCi Co-60. Service provider has been contacted to repair. Gauge is not accessible to personnel and continues to operate in process line."
Berthold Gauge Serial Number: 623/3-04-04
Ohio Item Number: OH160004
Agreement State
Event Number: 51973
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNARDINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: JOHN G. FASSELL
HQ OPS Officer: DONG HWA PARK
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNARDINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: JOHN G. FASSELL
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/02/2016
Notification Time: 20:22 [ET]
Event Date: 05/27/2016
Event Time: 00:00 [PDT]
Last Update Date: 06/02/2016
Notification Time: 20:22 [ET]
Event Date: 05/27/2016
Event Time: 00:00 [PDT]
Last Update Date: 06/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE
The following was received from the State of California via email:
"The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office that they believe a medical event occurred on Friday, May 28, 2016.
"A patient was admitted to the hospital for treatment of carcinoma. The treatment plan involved [10 CFR] 35.400 use of Cs-137 sealed sources for brachytherapy with a tandem and ovoid applicator. The patient's written directive called for 3,460 cGy to target area A (left side tandem), but only approximately 1,500 cGy was delivered. The lower rectum and vaginal areas received more than expected dose, but is believed to be within tolerance. Critical organs of bladder and mid-rectum also received less than expected incidental exposure.
"The cause of the under dose was human error. The applicator tube used to place the source into the tandem had become crimped by the lead pig during transport to the patients room. During application by the resident physician and medical physicist, the resistance felt during the application process lead them to believe the source was fully deployed to the end of the tube.
"The chief physicist notified the RSO on Tuesday, May 31, 2016 at 1630 pm, of his dose calculations, in which the hospital began medical event notifications."
5010 Number: 060216
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.
The following was received from the State of California via email:
"The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office that they believe a medical event occurred on Friday, May 28, 2016.
"A patient was admitted to the hospital for treatment of carcinoma. The treatment plan involved [10 CFR] 35.400 use of Cs-137 sealed sources for brachytherapy with a tandem and ovoid applicator. The patient's written directive called for 3,460 cGy to target area A (left side tandem), but only approximately 1,500 cGy was delivered. The lower rectum and vaginal areas received more than expected dose, but is believed to be within tolerance. Critical organs of bladder and mid-rectum also received less than expected incidental exposure.
"The cause of the under dose was human error. The applicator tube used to place the source into the tandem had become crimped by the lead pig during transport to the patients room. During application by the resident physician and medical physicist, the resistance felt during the application process lead them to believe the source was fully deployed to the end of the tube.
"The chief physicist notified the RSO on Tuesday, May 31, 2016 at 1630 pm, of his dose calculations, in which the hospital began medical event notifications."
5010 Number: 060216
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.
Non-Agreement State
Event Number: 51963
Rep Org: JANX INTEGRITY GROUP
Licensee: JANX INTEGRITY GROUP
Region: 1
City: KANAWHA HEAD State: WV
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: STEVE FLICKINGER
HQ OPS Officer: HOWIE CROUCH
Licensee: JANX INTEGRITY GROUP
Region: 1
City: KANAWHA HEAD State: WV
County:
License #: 21-16560-01
Agreement: N
Docket:
NRC Notified By: STEVE FLICKINGER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/27/2016
Notification Time: 16:56 [ET]
Event Date: 05/27/2016
Event Time: 00:00 [EDT]
Last Update Date: 05/27/2016
Notification Time: 16:56 [ET]
Event Date: 05/27/2016
Event Time: 00:00 [EDT]
Last Update Date: 05/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RADIOGRAPHY CAMERA SOURCE UNABLE TO BE RETRACTED
Radiographers were performing an exposure when the guide tube disconnect failed and the guide tube disconnected from the camera. This prevents the source from being fully retracted into the camera. The division manager, trained in source retrieval, was able to get the source into the camera and into its shielded position. No overexposures occurred. The quick disconnect was replaced and tested and the camera was returned to service.
The camera was a SPEC-150 using a 62 Ci Ir-192 source.
Radiographers were performing an exposure when the guide tube disconnect failed and the guide tube disconnected from the camera. This prevents the source from being fully retracted into the camera. The division manager, trained in source retrieval, was able to get the source into the camera and into its shielded position. No overexposures occurred. The quick disconnect was replaced and tested and the camera was returned to service.
The camera was a SPEC-150 using a 62 Ci Ir-192 source.
Power Reactor
Event Number: 51964
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM HERZOG
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM HERZOG
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/27/2016
Notification Time: 23:17 [ET]
Event Date: 05/27/2016
Event Time: 20:46 [CDT]
Last Update Date: 05/27/2016
Notification Time: 23:17 [ET]
Event Date: 05/27/2016
Event Time: 20:46 [CDT]
Last Update Date: 05/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG WERNER (R4DO)
GREG WERNER (R4DO)
| 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 |
OFFSITE NOTIFICATION DUE TO AN INADVERTENT ACTUATION OF ONE EMERGENCY SIREN
"A South Texas Project offsite emergency notification siren was inadvertently going off. The Matagorda County Sheriff's Office notified Site Security that a siren had actuated. At the time of the inadvertent siren actuation the area was experiencing lightning and rain. Suspect lightning caused the inadvertent siren actuation. Station Personnel are addressing the issue with the siren.
"The Matagorda County Sheriff's Office was the only offsite agency that was contacted during the event."
The licensee has notified the NRC Resident Inspector.
"A South Texas Project offsite emergency notification siren was inadvertently going off. The Matagorda County Sheriff's Office notified Site Security that a siren had actuated. At the time of the inadvertent siren actuation the area was experiencing lightning and rain. Suspect lightning caused the inadvertent siren actuation. Station Personnel are addressing the issue with the siren.
"The Matagorda County Sheriff's Office was the only offsite agency that was contacted during the event."
The licensee has notified the NRC Resident Inspector.