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Event Notification Report for June 26, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/23/2017 - 06/26/2017

** EVENT NUMBERS **


52793 52807 52809 52811 52821 52825 52826

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Agreement State Event Number: 52793
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: MAINE MEDICAL CENTER
Region: 1
City: PORTLAND State: ME
County:
License #: ME 05611 #27
Agreement: Y
Docket:
NRC Notified By: THOMAS HILLMAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/08/2017
Notification Time: 12:41 [ET]
Event Date: 06/07/2017
Event Time: 11:40 [EDT]
Last Update Date: 06/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE TO PATIENT WAS LESS THAN PRESCRIBED DOSE

The following information was received from the State of Maine via email:

"The following is a brief description of the event that occurred today in the [Maine Medical Center] (MMC) Cath Lab during an intravascular Brachytherapy (IVB) case.

"The source train was deployed to treat the 1st dwell position of the cardiac stent. Following delivery of the prescribed dose to the 1st dwell position the source train became stuck during return to the afterloader and could not be freed. This required complete removal of the catheter with the source train and placement of it in the bailout box.

"As a result, only 1 dwell position was treated causing the delivered dose to vary by more than 20 percent of the prescribed dose.

"The prescribed dose was 1840 REM. MMC does not have the exact delivered dose estimate, but it is approximately 50 percent of the prescribed [dose] because they had planned on 2 dwell positions.

"MMC will follow this up with a full written report as required by SMRRRP G.3045.D. The Licensee will be providing a full report to the State within 15 days as required."

Maine Event Report: ME 17-003

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.

* * * UPDATE FROM THOMAS HILLMAN TO VINCE KLCO ON 6/23/17 AT 1500 EDT * * *

The following update excerpted information received from the State of Maine via email:

"A brief description of the event: During an IVB procedure the patient was intended to receive two dwells of radiation to cover a treatment area longer than the source train. After the first dwell position the source train become stuck in the catheter and did not properly retract to the after loader, when it was determined that the source was stuck (10-15 seconds), the catheter was pulled from the patient. The catheter, after loader, and source were placed in the bail-out-box. Only one of the two dwell positions was delivered. A survey of the room, the patient (was conducted to insure that source was removed from the patient), and the source was properly secured. The manufacturer, chief physicist, radiation safety and state radiation safety control were contacted.

"Why the event occurred: The reported complaint of failed hydraulic return of the Jacketed Radiation Source Train (JRST) to the Transfer Device (TD) was confirmed. The delivery catheter (DC) source lumen was found not passable by the JRST as a result of a deformation at 7.3 cm distal to the strain relief. The JSRT stopped location would have been outside the patient. The precise cause of the DC deformation is not known. The location and nature of the deformation suggest compression by a device or handling during intervention. Based upon available case information, the most likely scenario is compression of the catheter during a challenging advancement into a commonly tortuous vessel - the left internal mammary artery (LIMA). From published case reports in the literature, although successful in the majority of patients, percutaneous coronary revascularization of the left internal mammary artery using the transfemoral approach is usually a technically challenging procedure. Technical difficulties involved in LIMA intervention from the femoral approach stems from the acute angle between the proximal subclavian artery and the proximal left internal mammary artery. Thus, guide catheter support is often poor. In addition, the relatively long length and tortuosity of the LIMA (graft) make guidewire manipulation and balloon delivery difficult. These technical considerations magnify the difficulty of intervention. For these reasons, it is not unusual or unexpected that operators will experience difficulty advancing devices through the tortuous LIMA -including the distal mono-rail tip design Novoste B-rail delivery catheter. The potential for deformation of the catheter during advancement and navigability challenges in that artery is recognized. The Beta-Cath System User's Manual explicitly advises that the JRST may not navigate Internal Mammary (IM) guide catheters designed specifically for accessing left internal mammary arteries. Despite these challenges, the skilled operators in this case were able to successfully place the delivery catheter and deliver the JRST. In this case it is suspected that the DC source lumen deformation was very slight, not affecting movement during the sending of the JRST since the pressure is highest in the send lumen nearer to the device. However, the return hydraulic pressure is much lower behind the JSRT on return movement as it approaches the transfer device and was apparently not sufficient to overcome resistance of the dimensional interference. This hypothesis is consistent with the results of the method used to improve the source lumen for eventual hydraulic return of the JSRT.

"The effect, if any, on the individual(s) who received the administration: There was no effect on the patient. The patient is not excluded from receiving the additional course of intravascular brachytherapy, if restenosis and symptoms should occur.

"What action, if any, have been taken or at planned to prevent recurrence: Based on this event, no corrective actions are felt to be necessary.

"Certification that the licensee notified the individual and if not, why not: No notification was made to the patient. This decision was based on the Cardiologist's determination that the area of stenosis within the stent was covered by the 1st dwell position and the area did receive the prescribed dose of 18.4 Gy."

Notified the R1DO (Arner), NMSS Events Notification

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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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Agreement State Event Number: 52809
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: KENVIRONS, INC.
Region: 1
City: FRANKFORT State: KY
County:
License #: 401-079-20
Agreement: Y
Docket:
NRC Notified By: CURT PENDERGRASS
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/16/2017
Notification Time: 09:01 [ET]
Event Date: 06/14/2017
Event Time: [CDT]
Last Update Date: 06/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF CONTROL OF LICENSED MATERIAL

The following was received from the Commonwealth of Kentucky:

"Sometime in February 2009 during the decommissioning of the licensee's laboratory, the electron capture detector (ECD) contained in a Varian model 3700 gas chromatograph went missing. The ECD was an Amersham model NBC containing 8 mCi of Ni-63, S/N A404, assay date 2/14/1992. The licensee discovered the device was missing during a routine inspection by the KY Radiation Health Branch. This event is actively being investigated by the licensee."

KY Event Report ID No: KY170005

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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Fuel Cycle Facility Event Number: 52811
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: PHILLIP OLLIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/16/2017
Notification Time: 18:20 [ET]
Event Date: 06/16/2017
Event Time: 17:00 [EDT]
Last Update Date: 06/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
OMAR LOPEZ (R2DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

UNANALYZED CONDITION IDENTIFIED

"At 1700 EDT on June 16, 2017 it was determined that an unanalyzed condition was identified that failed to meet performance criteria. This report is conservatively being made in accordance with 10CFR70 Appendix A (b)(1).

"In the powder process, a non-radioactive additive is added to a can of uranium in a hood. A previous process hazard analysis (PHA) determined that a criticality in the associated HEPA filters was not credible during this step. A recent update to a criticality analysis identified a potential condition where small amounts of uranium could build up in the HEPA filter over decades. The ISA [Integrated Safety Analysis] team met and decided that current safety controls will need to be implemented as IROFS [items relied on for safety] to assure that performance criteria are met. The operation is currently shut down and no unsafe condition existed.

"Safety Significance of Events: At no time was an unsafe condition present.

"Safety Equipment Status: The operation was shutdown.

"Status of Corrective Actions: Additional corrective actions, extent of condition, and extent of cause are being investigated."

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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.


* * * UPDATE FROM RICHARD IMMKE TO DONALD NORWOOD AT 1518 EDT ON 6/23/2017 * * *

"Update to previous ENS notification at 0100 EDT on 6/23/17. The last statement was revised to say the Low Pressure Core Spray System remains Inoperable."

"The Low Pressure Core Spray (LPCS) Injection System remains inoperable."

The licensee notified the NRC Resident Inspector.

Notified R3DO (Pelke).

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Power Reactor Event Number: 52825
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: TIMOTHY GATES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/23/2017
Notification Time: 23:58 [ET]
Event Date: 06/23/2017
Event Time: 20:18 [CDT]
Last Update Date: 06/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM ON MAIN GENERATOR TRIP

"While performing a scheduled generator voltage regulator test, River Bend Station experienced an automatic scram when the main generator tripped. It is unknown at this time why the main generator tripped.

"There were no equipment issues that materially impacted post scram operator response.

"The intention at this time is to go to cold shutdown while the cause of the trip is investigated."

All rods inserted during the scram. Reactor water level is being maintained via normal feedwater with decay heat being removed via turbine bypass valves to the main condenser. The electrical grid is stable and supplying plant loads via the normal shutdown electrical lineup.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 52826
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: VINCE KLCO
Notification Date: 06/24/2017
Notification Time: 15:42 [ET]
Event Date: 06/24/2017
Event Time: 10:28 [EDT]
Last Update Date: 06/24/2017
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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF SECONDARY CONTAINMENT

"On June 24, 2017 at 1028 [EDT], a loss of secondary containment occurred due to trip of 2V217A Zone III Filtered Exhaust Fan causing a reduction in D/P [differential pressure] to less than the required 0.25 WC [water column].

"2V217B Zone III Filtered Exhaust Fan started on low flow in AUTO as designed and secondary containment D/P was restored to greater than 0.25 WC by 1029 hours.

"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 notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, June 26, 2017
Monday, June 26, 2017