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Event Notification Report for June 23, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/22/2017 - 06/23/2017

** EVENT NUMBERS **


52804 52807 52818 52820 52821

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Agreement State Event Number: 52804
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ALPHA-OMEGA SERVICES, INC.
Region: 4
City: VINTON State: LA
County:
License #: LA-10025-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/14/2017
Notification Time: 16:29 [ET]
Event Date: 06/13/2017
Event Time: 07:30 [CDT]
Last Update Date: 06/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - INCORRECT SOURCE SHIPMENT

The following report was received from the Louisiana Department of Environmental Quality [LDEQ] via email:

"Event Date and Time: On June 13, 2017, 0730 [CDT] the e-mail was received by LDEQ. The report was for two Elekta Clients under timely renewals who both received Ir-192 sources for HDR [High Dose Rate] units. Neither set of documentation matched the sources it was accompanying. Both sources were manufactured, calibrated and shipped from the A&O [Alpha-Omega Services, Inc.], LA facility on April, 27, 2017.

"Facility #1: A report of an HDR source being shipped to Texas Oncology PA where the source activity was less than the activity ordered and documented from the source received. The source received was actually 8.98 Ci Ir-192, but the shipping documents and source information listed the source as 11.28 Ci Ir-192. The mis-documented source was returned and a new source with the correct activity and documentation was requested. The source was an exchange source as a replacement source for the Texas Oncology PA, dba Texas Cancer Center Sherman [TCCS], Sherman, TX 75090. TX License # L05019, Amendment #23, Expiration date: January 31, 2016. The licensee is under a timely renewal and on Amendment #31. The Source S/N D36G1424.

"Facility #2: The report of an HDR source being shipped to New York Oncology Hematology PC (NYOH), Albany, New York, 12206. NYSDH Radioactive Material License No. 5284, Amendment #6, DH Number 09-1113. The HDR source received was 13.88 Ci of Ir-192 on May 10, 2017. The documentation for the source received was 11.01 Ci of Ir-192. This source is being held for decay and will be put into service June 13, 2017. A&O sent a source with incorrect documentation that is in violation NYOH license for activity received and activity installed in the HDR unit. The Source S/N D36G1425.

"A&O is a source supplier for Elekta HDR units. Elekta's ordering process notifies A&O when sources should be shipped/supplied their licensees.

"Event Location: The shipments originated from Alpha and Omega Services, Vinton, LA 70668 and were delivered to TCCS, Sherman, TX 75090 and NYOH, Albany, New York 12206. Neither facility received the quantity of radioactive material they ordered and were licensed to receive nor was the documentation for the radioactive material correct. The facilities were licensed each to receive an Ir-192 HDR source.

"Event type: Calibrating, shipping and delivery of radioactive material in quantities greater than the licensed activities and under documented quantities. The licenses were correct, but the sources shipped were greater than the facility was licensed to receive and/or the documentation accompanying the RAM Ir-192 sources for each HDR units was incorrect. A&O explained that their reference numbers were mixed up during the manufacturing process.

"The A&O errors were detected by TCCS and NYOH licensees when they were performing their QC/QA on the active sources prior to patient treatment.

"The shipments were intact and not damaged. The sources were secure and in the hands of trained radiation safety personnel. Health and safety to the radiation workers and general public was not the issue. The issue was the reference numbers did not match the calibration activities of each source and wrong activities were shipped.

"Notification: On June 8, 2017, the error, quantities of RAM greater than licensed activity was discovered and reported to A&O. On June 8, 2017, the replacement source was shipped to TCCS. The incident preliminary notification was reported to the LDEQ, Assessment Radiation Section by e-mail on June 13, 2017. Reported to the NRC as LAC 33:XV.340.C. For not reviewing a radioactive material license before transferring radioactive material and LAC 33:XV.328.L.1.C. A permanent label was not affixed to the source or device containing the information on the radionuclide."

LA Event Report ID No.: LA-170009

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Non-Agreement State Event Number: 52807
Rep Org: PROVIDENCE ALASKA MEDICAL CENTER
Licensee: PROVIDENCE ALASKA MEDICAL CENTER
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-17838-01
Agreement: N
Docket:
NRC Notified By: YONGLI NING
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/15/2017
Notification Time: 15:26 [ET]
Event Date: 06/14/2017
Event Time: [YDT]
Last Update Date: 06/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

PATIENT RECEIVED A HIGHER DOSE THAN PRESCRIBED

On 6/14/17 a patient undergoing treatment using Sir-Spheres (Y-90) received a dose of 540 Gray instead of the 110 Gray prescribed. This occurred due to a calibration error. The prescribing physician discussed the error with the patient who was released and returned home. The Radiation Safety Officer (RSO) is investigating the incident. No adverse effect to the patient has been observed to date.

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: 52818
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KENNETH HUNTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/22/2017
Notification Time: 09:32 [ET]
Event Date: 04/27/2017
Event Time: 00:29 [EDT]
Last Update Date: 06/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
REINALDO RODRIGUEZ (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

INVALID SPECIFIED SYSTEM ACTUATION DUE TO FAILED RELAY

"On April 27, 2017 at 0029 EDT, Unit 2 received an invalid partial Group 2 isolation due to a failed relay (2D11-K80) on the auxiliary trip unit. Both of the U1 and U2 Standby Gas Treatment (SGT) trains started and the U2 Group II primary containment and all secondary containment inboard isolation valves closed. Also, the refuel floor isolation dampers closed, the reactor building supply and exhaust fans tripped, and the refueling floor supply and exhaust fans tripped.

"This event is reportable per 10 CFR 50.73(a)(2)(iv)(A) since the containment isolation and auto-start of SGT on both units was not part of a pre-planned sequence and the event resulted in the invalid actuation of general containment isolation valves in more than one system.

"All primary and secondary containment inboard isolation valves and SGT systems functioned successfully. The failed relay was replaced and the systems were restored to normal alignment.

"The licensee will notify the NRC Resident Inspector."

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Power Reactor Event Number: 52820
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KENNETH GRACIA
HQ OPS Officer: VINCE KLCO
Notification Date: 06/22/2017
Notification Time: 20:33 [ET]
Event Date: 06/20/2017
Event Time: 14:44 [EDT]
Last Update Date: 06/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
FRANK ARNER (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

Event Text

SECONDARY CONTAINMENT DECLARED INOPERABLE DUE TO BOTH AIRLOCK DOORS OPEN SIMULTANEOUSLY

"On June 20, 2017, at 1444 hours [EDT], with the reactor at 100% core thermal power and steady state conditions, plant personnel identified that both doors in one of the secondary containment airlocks (Door #58 and Door #85) were open briefly as part of normal passage of personnel.

"The Technical Specification definition of SECONDARY CONTAINMENT INTEGRITY states 'At least one door in each access opening is closed.' Actions were taken to immediately close both doors and restore operability of secondary containment. PNPS [Pilgrim Nuclear Power Station] is providing an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(v)(C), an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material.

"The NRC Resident Inspector has been notified."

The licensee notified the Commonwealth of Massachusetts.

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Power Reactor Event Number: 52821
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: DEBORAH MCBREEN
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/23/2017
Notification Time: 01:00 [ET]
Event Date: 06/22/2017
Event Time: 20:43 [CDT]
Last Update Date: 06/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PATRICIA PELKE (R3DO)

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

Event Text

LOW PRESSURE CORE SPRAY DECLARED INOPERABLE DUE TO LOSS OF COOLING

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) for an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. The Unit 1 Low Pressure Core Spray (LPCS) Pump Injection System was declared inoperable at 2043 [CDT] due to a loss of corner room area cooling and loss of motor cooling. The common diesel generator cooling water pump received an auto trip signal while being secured. The LPCS pump remained in standby during the event. This condition prevents LPCS, a single train safety system, from performing its design function. This is a reportable condition as an 8 hour ENS notification.

"The required action of Technical Specifications (TS) 3.5.1, 'ECCS - Operating,' was entered on June 22, 2017 at 2043 CDT when the condition was identified and the LPCS system was determined to be inoperable. Investigation into the cause of the condition is in progress."

The Low Pressure Core Spray (LPCS) Pump Injection System was declared operable, and the TS LCO was exited at 2112 CDT.

Page Last Reviewed/Updated Friday, June 23, 2017
Friday, June 23, 2017