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Event Notification Report for March 9, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/08/2017 - 03/09/2017

** EVENT NUMBERS **


52580 52584 52599 52600

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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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Agreement State Event Number: 52584
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: HEURESIS CORPORATION
Region: 1
City: NEWTON State: MA
County:
License #: 55-0702
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/01/2017
Notification Time: 12:57 [ET]
Event Date: 02/28/2017
Event Time: 14:30 [EST]
Last Update Date: 03/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - TWO SEALED SOURCES TESTED POSITIVE FOR LEAKAGE

The following information was received via email from the Commonwealth of Massachusetts:

"The licensee reported on February 28, 2017 that licensee learned from its licensed leak test service provider that two 6 milliCurie, Cobalt-57, sealed sources, of 20 sources received in a package from the source manufacturer, Isotope Products Laboratories, tested positive for leakage.

"The leak test result for one of the sealed sources was reported to be at least 0.4 microCuries which is the maximum activity that the instrument used can measure. The leak test result for the other sealed source was reported to be below the reporting requirement of 0.005 microCuries.

"The sealed sources are each Isotope Products Laboratories Model 3901-2 sources. The serial number attributed to the source having leak test result of at least 0.4 microCuries was reported to be P3-682. The serial number attributed to the source having leak test result of below 0.005 microCuries was reported to be P3-689.

"The licensee reported that each of the sources is contained and secured in a separate plastic bags; that there is no facility contamination based on area surveys performed; that the external surfaces of the package received, that had contained the sources, had been wipe tested and that the package was not contaminated; and that the sources were not used pending leak test results.

"The licensee reports that it will notify the source manufacturer, to inquire about proper return of the sources back to the source manufacturer.

"The Agency [Massachusetts Radiation Control Program] considers this event to be open."

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Power Reactor Event Number: 52599
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DARVIN DUTTRY
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/08/2017
Notification Time: 08:49 [ET]
Event Date: 03/08/2017
Event Time: 02:39 [EST]
Last Update Date: 03/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JAMES DWYER (R1DO)

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 N 0 Refueling 0 Refueling

Event Text

LOSS OF SECONDARY CONTAINMENT DUE TO CONTAINMENT FAN TRIP

"On March 08, 2017 at 0239 hours [EST], Secondary Containment Zone 3 (Unit 1 and 2 Reactor Building) differential pressure lowered to 0 [inches] WG due to a trip of the running Zone 3 Secondary Containment fans. The fan trip was caused by a human performance error during a Unit 2 outage related activity. Required differential pressure per SR 3.6.4.1.1 could not be maintained. Zone 3 differential pressure recovered to [greater than] 0.25 [inches] WG at 0255 hours after restart of Zone 3 Secondary Containment fans. All other Zones of Secondary Containment were unaffected by this event.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(C) and per the guidance of NUREG 1022 Rev. 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment System."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 52600
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: SCOTT MEIKLEJOHN
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/08/2017
Notification Time: 20:13 [ET]
Event Date: 03/08/2017
Event Time: 16:27 [CST]
Last Update Date: 03/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JESSE ROLLINS (R4DO)

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

Event Text

BOTH TRAINS OF LOW PRESSURE SAFETY INJECTION INOPERABLE DUE TO MAINTENANCE ERROR

"This is a non-emergency notification from Waterford 3.

"On March 8, 2017 at 1627 [CST] Technical Specification (TS) 3.5.2 action 'c' was entered due to both trains of Low Pressure Safety Injection (LPSI) being inoperable. This TS action requires one train of LPSI be restored within 1 hour or be in at least Hot Standby within the next 6 hours.

"It was identified that LPSI train B was inoperable due to SI-135B, Reactor Coolant Loop 1 Shutdown Cooling Warmup Valve, being found open. At the time of discovery, LPSI train A was inoperable for pre planned maintenance, but available and awaiting operability retest. The station was in compliance with TS 3.5.2 action 'a'. Maintenance workers were scheduled to work Sl-135A Reactor Coolant Loop 2 Shutdown Cooling Warmup Valve, and inadvertently began work on Sl-135B and manually opened the valve which resulted in the LPSI Train B being inoperable.

"Once identified by Operations Control Room staff, the valve [SI-135B] was placed in the closed position and stroke tested to ensure operability. TS 3.5.2 action 'c' was exited at time 1705. The station remained in compliance with TS 3.5.2 action 'a'. "

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 09, 2017
Thursday, March 09, 2017