Alert

Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

Event Notification Report for July 28, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/27/2017 - 07/28/2017

** EVENT NUMBERS **

52864

52866

52874

Agreement State	Event Number: 52864
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT Licensee: UNIVERSITY OF KANSAS HOSPITAL AUTHORITY Region: 4 City: KANSAS CITY State: KS County: License #: 18-C801 Agreement: Y Docket: NRC Notified By: JAMES UHLEMEYER HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/19/2017 Notification Time: 17:11 [ET] Event Date: 07/18/2017 Event Time: [CDT] Last Update Date: 07/19/2017
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): THOMAS HIPSCHMAN (R4DO) NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

KANSAS AGREEMENT STATE REPORT - MEDICAL EVENT

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

"A medical event occurred during a Yttrium-90 TheraSphere treatment of a patient's liver cancer. The patient received approximately 24 percent of the dose prescribed in the written directive. There was no harm to the patient other than the inconvenience of rescheduling the treatment to receive the remainder of the dose.

"[The licensee is] investigating the event and will submit a report within the required 15 days. With this procedure the vial containing the TheraSpheres cannot be viewed due to being inside a lead pig. Therefore, a digital radiation dosimeter is placed near the delivery device. As the dose is delivered to the patient, the readings drop to or near zero. In this case, the technologists and the physician stated the dosimeter was reading 0.0 at the end of the procedure.

"[The licensee's] immediate corrective action will be for radiation safety staff to verify the instrument readings when the physician feels the entire dose has been delivered."

The prescribed dose or quantity was not provided by the State.

Kansas NMED Item Number KS170006

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.

Non-Agreement State	Event Number: 52866
Rep Org: DEPT OF NAVY RADIATION SAFETY CMTE Licensee: DEPT OF NAVY RADIATION SAFETY CMTE Region: 1 City: Arlington State: VA County: License #: 45-23645-0INA Agreement: Y Docket: NRC Notified By: JERRY SANDERS HQ OPS Officer: DAN LIVERMORE	Notification Date: 07/20/2017 Notification Time: 15:40 [ET] Event Date: 07/19/2017 Event Time: 17:30 [EDT] Last Update Date: 07/20/2017
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X	Person (Organization): ANNE DeFRANCISCO (R1DO) NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

LOSS OF HELICOPTER INTEGRATED BLADE INSPECTION SYSTEM WITH 500 MICROCURIE STRONTIUM 90 SOURCE

"At 1730 on 19 July 2017, HM-15 aircraft 13 had the Main Rotor Fairing, commonly referred to as the 'beanie', depart in flight. The 'beanie' cover is constructed of fiberglass, is circular in shape and 5 feet in diameter, weighing approximately 20 pounds. In addition to the beanie, we discovered that one of the In-flight Blade Inspection System (IBIS) Indicators also departed the aircraft. Loss of this IBIS Indicator is of concern because it contains strontium-90 which is radioactive material. Loss of this IBIS Indicator was not discovered until the aircraft shutdown on its line at Naval Station Norfolk.

"Location lost: Approximately 100 miles west of Norfolk, VA over the Roanoke River near Lake Gaston. The location is just north of the Virginia / North Carolina border over the Roanoke River approximately 3 miles east of the Kerr Lake Power Plant."

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

Power Reactor	Event Number: 52874
Facility: LIMERICK Region: 1 State: PA Unit: [ ] [2] [ ] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: JEFF WEAVER HQ OPS Officer: VINCE KLCO	Notification Date: 07/27/2017 Notification Time: 18:54 [ET] Event Date: 07/27/2017 Event Time: 13:15 [EDT] Last Update Date: 07/27/2017
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): DAN SCHROEDER (R1DO)

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

Event Text

HIGH PRESSURE CORE INJECTION SYSTEM DECLARED INOPERABLE

"[Unit 2] HPCI was declared inoperable due to improper valve alignment stemming from an incorrect sequence directed from a work order. [Unit 2] HPCI was inoperable for 20 minutes and was manually re-aligned to an operable status."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, March 24, 2021