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Event Notification Report for May 9, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/08/2017 - 05/09/2017

** EVENT NUMBERS **


52714 52717 52719 52720 52736 52738

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Agreement State Event Number: 52714
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: COMPASS ONCOLOGY
Region: 4
City: PORTLAND State: OR
County:
License #: 91121
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/28/2017
Notification Time: 17:30 [ET]
Event Date: 04/28/2017
Event Time: [PDT]
Last Update Date: 04/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - HIGH DOSERATE AFTERLOADER CHECK SOURCE CABLE FAILURE

The following is an excerpt of a report received from the Oregon Department of Health via email:

Yesterday, April 27, 2017, while treating a patient with a 2 channel plan the licensee received the fault that the 'dummy' cable could not extend to the end of the applicator on the second channel. The licensee's procedure is to go into the HDR vault, check connections and position of the transfer tubes and then retry. The retry failed as well.

Because this was a 2 channel treatment, the patient had received only half of the treatment. The licensee explained what was going on to the patient and gave them the option of ending the treatment that day or waiting while the licensee did some testing and, if all went well, would finish the treatment. The patient opted to wait.

The licensee changed some of the applicators and transfer tubes, tested without failure, then brought the patient back into the vault to finish the treatment without any issues.

After the patient completed treatment and left, the licensee was able to extend the check source cable out of the afterloader and could see right away that the dummy source/end of cable had a bend in it. The licensee inspected the applicator that was used during the fault and thought there was a slight 'burr' in it. Between the bent cable and burr, there might have been snagging, leading to a fault.

The licensee called service (ELEKTA, Inc.) to come change the check source cable, which was done today, April 28, 2017.

After the check source cable change was completed, the licensee ran all combinations of transfer tubes and applicators without any failures. The licensee believed their theory about the burr and snag may have been wrong as that particular combination ran multiple times without any issues. Therefore, the bent cable caused the fault.

There were no adverse or unintended results for the patient, other than waiting 15 minutes while the licensee did some equipment testing. The patient received the prescribed dose. The system is designed so that if the check source/dummy cable cannot extend all the way to the end of the applicator you cannot proceed with the treatment so no possible way in this event to deliver an unintended dose to the patient.

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Agreement State Event Number: 52717
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VERSA INTEGRITY
Region: 4
City: HOUSTON State: TX
County:
License #: L06669
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/29/2017
Notification Time: 19:27 [ET]
Event Date: 04/28/2017
Event Time: [CDT]
Last Update Date: 04/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER TRAINEE BADGE READ GREATER THAN 5 REM

"On April 29, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that on April 28, 2017, one of its radiographer trainees had reported their self-reading dosimeter had gone off-scale. The licensee stopped all work and sent the trainee's OSL [Optically Stimulated Luminescence] dosimeter to be processed. The licensee received a verbal report from the processer on April 29, 2017, and the dose was reported as 5.392 REM. The licensee did not know if the dose was static or dynamic. The licensee stated that the trainee had not operated the exposure device and did not know how the trainee could have received the exposure. The licensee stated there was a chance that the dose was to the badge only. The licensee is conducting a formal investigation into the event. No other individual reported an unusual exposure. The exposure device was a QSA 880D camera containing a 51 Ci Ir-192 source. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9482

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Agreement State Event Number: 52719
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: JANX
Region: 4
City: PARMA State: TX
County:
License #: 21-16560-01
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/30/2017
Notification Time: 22:05 [ET]
Event Date: 04/29/2017
Event Time: [CDT]
Last Update Date: 04/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT

The following information was received from the state of Texas via email:

"On April 30, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that a radiography crew working at a temporary field site was unable to retract a 101 Curie iridium-192 source into a SPEC 150 exposure device (camera). The failure occurred after the radiography crew had moved the camera from one location to another at the same job site. The radiography crew notified the licensee of the event. The licensee sent an individual to the site to retrieve the source. The individual found that the guide tube had disconnected from the front of the camera and the flex in the cable was causing the connector to hang up on the camera inlet port. The recovery individual straightened the cable by pulling on the crank out cables and was able to fully retract the source. The RSO stated no over exposures occurred from this event. The RSO stated he believes sand had gotten into the guide tube to camera connection preventing the guide tube from fully latching on the camera outlet connection. The licensee possesses a license issued by the Nuclear Regulatory Commission and is operating under reciprocity in the State of Texas. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9483

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Agreement State Event Number: 52720
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: LEXMARK INTERNATIONAL INC.
Region: 1
City: LEXINGTON State: KY
County:
License #: 201-072-56
Agreement: Y
Docket:
NRC Notified By: CHRISTOPHER KEFFER
HQ OPS Officer: VINCE KLCO
Notification Date: 05/01/2017
Notification Time: 11:30 [ET]
Event Date: 04/27/2017
Event Time: 15:00 [CDT]
Last Update Date: 05/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING SOURCE

The following information was received from the Commonwealth of Kentucky via facsimile:

"KY RHB [Kentucky Radiation Health Branch] Inspector, Christopher Keffer, was performing a routine health and safety inspection of the licensee when the RSO [Radiation Safety Officer] discovered that a stored device was missing. According to the RSO, the laboratory where the device was stored was cleaned out the week before; it is currently believed that the device has been thrown away and is now in a landfill."

The sealed source identification number is NR-536-D-808-B associated with a Perkins Elmer Clarus Model 500. The source is a Ni-63, 15 microCurie source.

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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Part 21 Event Number: 52736
Rep Org: AMETEK SOLID STATE CONTROLS
Licensee: AMETEK SOLID STATE CONTROLS
Region: 3
City: COLUMBUS State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ETHAN SALSBURY
HQ OPS Officer: JEFF HERRERA
Notification Date: 05/08/2017
Notification Time: 09:52 [ET]
Event Date: 05/08/2017
Event Time: [EDT]
Last Update Date: 05/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
JAMES DWYER (R1DO)
ROBERT ORLIKOWSKI (R3DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - INTERIM NOTIFICATION OF A POTENTIAL DEFECT ON A PRINTED CIRCUIT BOARD

"Ametek Solidstate Controls began a 10 CFR Part 21 evaluation after receiving notification from NextEra Energy Seabrook Station that a 7.5kVA Inverter would prematurely transfer to alternate source at 27A load during commissioning. The X202 Crest factor board (80-9213516-90) was replaced and the unit operated normally.

"Analysis of the failed X202 Crest Factor board identified an SCR on the printed circuit board was turning on prematurely and resulted in a transfer to alternate source or with the absence of the alternate source, to a dead bus. A capacitor was placed across the SCR on the X202 board to protect the SCR from dv/dt turn on. Subsequent testing determined the added capacitor corrected the anomaly.

"In addition to Seabrook, Ametek has recently experienced similar anomalies on two separate occasions. However, these occurrences were discovered during manufacturing and in-house testing phase for new product and were attributed to a SCR failure, excessive noise, and long leads.

"ACTION RECOMMENDED:
Ametek Solidstate Controls recommends installing a 0.22 microfarad capacitor p/n 80-134734-90 across X202 terminals J1-11 to J1-12. This capacitor will have no effect on EMI or seismic qualifications.

"If you wish to acquire the 80-134734-90 capacitor, Ametek Solidstate Controls will work with you to provide spare parts. Please contact Mr. Mark Shreve of our Client Services group at 1-800-222-9079 or 1-614-846-7500 ext. 6332. mark.shreve@ametek.com"

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Power Reactor Event Number: 52738
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN HARKINS
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/08/2017
Notification Time: 13:55 [ET]
Event Date: 05/08/2017
Event Time: 09:25 [EDT]
Last Update Date: 05/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
DON JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

THROUGH-WALL LEAKAGE IDENTIFIED ON REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DURING TESTING

"On May 8th, 2017 at 0925 [EDT], during the performance of LGS [Limerick Generating Station] leakage testing of the reactor pressure vessel and associated piping, a through-wall leak was identified on an instrument line connected to the N16D nozzle.

"The reactor will be maintained shutdown until pipe repairs and testing are complete."

The licensee informed the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, May 09, 2017
Tuesday, May 09, 2017