| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/09/2017 - 08/10/2017 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 52880 | Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: FORT SANDERS REGIONAL MEDICAL CENTER
Region: 1
City: KNOXVILLE State: TN
County:
License #: R-47003
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: JEFF HERRERA | Notification Date: 08/01/2017
Notification Time: 10:28 [ET]
Event Date: 07/25/2017
Event Time: [EDT]
Last Update Date: 08/01/2017 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
| Event Text AGREEMENT STATE REPORT - MISADMINISTRATION DUE TO PROBLEM WITH A DELIVERY CATHETER
The following report was received from the Tennessee Department of Environmental Conservation Division of Radiological Health via email:
"[A] Yttrium-90 TheraSpheres patient procedure misadministration [occurred] due to [a] 'kinked' delivery catheter. [Approximately] 60 Gray [was] administered of [the] prescribed 120 Gray. [Two] manufacturer representatives were in attendance throughout procedure, 'proctoring' the physician. According to both proctors, the case was performed per manufacturer instructions, but unfortunately, the kinked catheter prohibited the complete dose from being administered."
Tennessee Radiological Event No. TN-17-147
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. |
| Agreement State | Event Number: 52882 | Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ELEKTA, INC.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1153-1
Agreement: Y
Docket:
NRC Notified By: GREG REESE
HQ OPS Officer: BETHANY CECERE | Notification Date: 08/02/2017
Notification Time: 14:51 [ET]
Event Date: 07/26/2017
Event Time: [EDT]
Last Update Date: 08/02/2017 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JON LILLIENDAHL (R1DO)
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (EMAI)
|
| This material event contains a "Category 3 " level of radioactive material. | Event Text LOST IRIDIUM SOURCES IN TRANSIT
The following is excerpted from a report emailed from the Georgia Radioactive Materials Program:
On 7/26/17, two Ir-192 Elekta sources (each approximately 11.2 Ci) were shipped from Alpha-Omega Services in Vinton, LA, via a common carrier with two different destination points. They made it to the common carrier's warehouse in Memphis, TN, but then were "lost." An investigation for both cases has been opened with the common carrier and the common carrier point of contact has been notified via email.
The packages were expected on 7/28/17 at their respective destinations. Serial number 31016 to UPMC Altoona in Altoona, PA and serial number 10729 to Arrowhead Radiation & Oncology Imaging Center in Glendale, AZ.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| Agreement State | Event Number: 52883 | Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ATEK ENGINEERING CONSULTANTS, LLC
Region: 4
City: CHANDLER State: AZ
County:
License #: AZ 07-662
Agreement: Y
Docket:
NRC Notified By: BRIAN D. GORETZKI
HQ OPS Officer: STEVE SANDIN | Notification Date: 08/02/2017
Notification Time: 18:53 [ET]
Event Date: 08/02/2017
Event Time: 15:00 [MST]
Last Update Date: 08/02/2017 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
| Event Text AGREEMENT STATE REPORT - FAILED NUCLEAR MOISTURE/DENSITY GAUGE HANDLE LOCKING MECHANISM
The following information was received from the State of Arizona via email:
"During a routine inspection, the Arizona Radiation Regulatory Agency discovered that the handle locking mechanism of a CPN MC-3 Portaprobe (Serial # M39068944) containing 370MBq (10mCi) of Cesium-137 and 1.85 GBq (50mCi) of Americium-241/Beryllium, failed to function as intended. While testing the locking mechanism, the inspector was able to lower the Cs-137 source out of its housing, exposing the source, while the handle and trigger were in the locked position. The licensee was notified and the gauge was immediately placed out of service. The utilization log for the gauge was checked and it was determined that the gauge had not been in use for the previous 6 months. None of the users had reported issues with the gauge prior to that time. The licensee committed to having the gauge serviced as soon as possible.
"The Agency [Arizona Radiation Regulatory Agency] is continuing to investigate the event.
"The [Arizona] Governor's office and U.S. NRC are being notified of this event.
"[Arizona] First Notice: 17-011" |
| Power Reactor | Event Number: 52894 | Facility: SURRY
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ALAN BIALOWAS
HQ OPS Officer: DONG HWA PARK | Notification Date: 08/09/2017
Notification Time: 17:35 [ET]
Event Date: 08/09/2017
Event Time: 16:06 [EDT]
Last Update Date: 08/09/2017 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
| Person (Organization):
FRANK EHRHARDT (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 32 | Power Operation | 0 | Hot Shutdown | Event Text TECHNICAL SPECIFICATION REQUIRED SHUTDOWN FOR REACTOR COOLANT SYSTEM LEAKAGE
"On 8/9/17, a Unit 1 containment entry was made in order to investigate increased Reactor Coolant System (RCS) unidentified leakage. The team noted a through-wall leak from the tubing/socket weld area of 'C' Hot Leg Sample Valve. The sample valve and RCS pressure boundary were declared inoperable, and a 6-hour action statement to place Unit 1 in Hot Shutdown was entered at 1338 [EDT] hours as required by Technical Specification 3.1.C.3.
"At 1606 [EDT] hours on 8/9/17, Unit 1 shutdown was commenced, and at 1637 [EDT], Unit 1 was at Hot Shutdown. This report is being submitted pursuant to 10CFR50.72(b)(2)(i) as a result of power reduction required by Technical Specifications. Further, this report is being submitted pursuant to 10CFR50.72(b)(3)(ii)(A) for any event or condition that results in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded.
"The NRC Resident [Inspector] has been notified of this event and is on site.
"There was no radiation release associated with this event, nor were there any personnel injuries or contamination events." | |