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Event Notification Report for March 8, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/07/2017 - 03/08/2017

** EVENT NUMBERS **


52578 52580 52597

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Non-Agreement State Event Number: 52578
Rep Org: BAYER CROP SCIENCES
Licensee: BAYER CROP SCIENCES
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-03830-01
Agreement: N
Docket:
NRC Notified By: STEVE SCHERICH
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2017
Notification Time: 16:04 [ET]
Event Date: 02/27/2017
Event Time: 14:05 [CST]
Last Update Date: 02/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MARK JEFFERS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

SOURCE HOLDER STUCK OPEN

Licensee reported that they were in the process of removing a Kay-Ray Model # 7062B source holder from an installed position. The device serial number is #24093 with a Cs-137 10 mCi source. They believed the source holder to be closed during the removal operation. While in the process of removing the source holder from its installed location, they received unexpected radiation levels on their survey meter and laid the source holder on the room floor with the source pointing in the down direction. They then used some lead shielding to cover the source device and moved it to a storage location. The current radiation levels in the vicinity of the source holder are normal background. The licensee plans on reviewing the radiation dose information when personal dosimetry is processed at the end of the quarter (March 15, 2017). The licensee also plans on contacting Berthold Technologies for disposal of the device.

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Agreement State Event Number: 52580
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2017
Notification Time: 14:37 [ET]
Event Date: 02/24/2017
Event Time: [EST]
Last Update Date: 02/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO HIGH DOSE

The following information was supplied via email from the State of North Carolina:

"On 2/27/2017 the North Carolina Radiation Protection Section (RPS) received the following notification from Duke University Medical Center, License number 0247-4.

"A possible Medical Event occurred at Duke University Medical Center on February 24, 2017 involving Y-90 microspheres during a liver embolization procedure. Duke personnel reported to North Carolina Radiation Protection Section (RPS) on February 27, 2017 of the event meeting the reporting requirements for a Medical Event as dictated in NRC Licensing Guidance, Rev. 9 under:

"Medical Event [ME] Reporting: The licensee shall commit to report any event, except for an event that results from intervention of a patient or human research subject, in which: the total dose or activity administered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more, except when stasis or emergent patient conditions are documented and resulted in a total dose or activity administered that was less than that prescribed;

"At this time, the details provided by Duke University Medical Center for this ME are as follows: Delivered dose was 94 percent higher than the prescribed dose in the Written Directive to the treatment site. The apparent cause appears to be an error in reading the prescribed radioactivity (in GBq) before converting to the administered activity (in mCi), indicating operator error that occurred in the radio pharmacy at Duke University Medical Center.

"RPS has dispatched an investigator to perform a reactive inspection at Duke University Medical Center. This investigation is ongoing and RPS will have additional information to complete this report."

The State on North Carolina does not know if the patient has been notified of the received dose being higher than the prescribed dose.

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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Power Reactor Event Number: 52597
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JONATHAN REDNER
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/07/2017
Notification Time: 14:39 [ET]
Event Date: 03/07/2017
Event Time: 08:30 [EST]
Last Update Date: 03/07/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BINOY DESAI (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

BREACH IN AUXILIARY BUILDING SECONDARY CONTAINMENT

"At 0830 [EST] on March 7, 2017, operators discovered that on March 3, 2017 at 2046 a door was blocked open creating a breach of the auxiliary building secondary containment enclosure (ABSCE) boundary that exceeded the allowed ABSCE breach margin. As a result, both Unit 1 and Unit 2 entered Technical Specification Limiting Condition of Operation (LCO) 3.7.12 Condition B for two trains of Auxiliary Building Gas Treatment System (ABGTS) inoperable due to an inoperable ABSCE boundary in MODE 1, 2, 3, or 4. The condition has been corrected and ABGTS was restored to operable as of 0949 March 7, 2017.

"In MODES 1, 2, 3, and 4, the analysis of the loss of coolant accident (LOCA) assumes that radioactive materials leaked from the Emergency Core Cooling System are filtered and adsorbed by the ABGTS. For the fuel handling accident, the analysis assumes that the ABSCE boundary is capable of being established to ensure releases from the auxiliary and containment buildings are consistent with the dose consequence analysis.

"The event is reportable in accordance with 10 CFR 50.72(b)(3)(v) as an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to: (C) control the release of radioactive material and (D) mitigate the consequences of an accident.

"No actual LOCA or fuel handling accident occurred while both trains of ABGTS were inoperable. The condition had no impact on the health and safety of the public.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, March 08, 2017
Wednesday, March 08, 2017