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Event Notification Report for August 29, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/28/2017 - 08/29/2017

** EVENT NUMBERS **


52816 52914 52916 52917 52922 52932 52934 52935

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Agreement State Event Number: 52816
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: JORDAN VALLEY MEDICAL CENTER, LP
Region: 4
City: WEST JORDAN State: UT
County:
License #: UT 1800231
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/21/2017
Notification Time: 13:51 [ET]
Event Date: 06/19/2017
Event Time: [MDT]
Last Update Date: 08/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED TO SITE ADJACENT TO INTENDED TARGET

The following State of Utah report was received by email:

"The licensee delivered a 500 cGy fraction of HDR [High Dose Rate] brachytherapy to a site adjacent to the intended target. This treatment was a supplemental boost to external beam radiotherapy, and the mistreated volume was included in the target volume of the external beam plan."

The State of Utah was notified of the event on June 21, 2017 by electronic mail opened at 1125 MDT.

Utah Event Report ID No: will be provided in follow up report.

* * * UPDATE at 1212 EDT ON 8/28/17 FROM SPENCER WICKHAM TO MARK ABRAMOVITZ * * *

The following information was received via e-mail:

"The licensee name needs to be changed from 'University of Utah, Radiological Health Department' to 'Jordan Valley Medical Center, LP'."

Notified the R4DO (Gaddy) and NMSS Events Notification via e-mail.

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: 52914
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Region: 4
City: JACKSON State: MS
County:
License #: MS-MBL-01
Agreement: Y
Docket:
NRC Notified By: JAYSON MOAK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/18/2017
Notification Time: 17:43 [ET]
Event Date: 08/18/2017
Event Time: [CDT]
Last Update Date: 08/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PART 21 MATERIALS (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following report was received via e-mail:

"The licensee's RSO reported a possible medical event for four separate patients, involving a Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit. This was noticed during review by the medical physicist. The licensee notified Elekta for confirmation of the software error. The RSO confirmed on 8/18/2017, that two (2) patients were under dosed by more than 20% and the other two (2) patients were being reviewed by the medical physicist.

"An Elekta Notification was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR."

Source: 12 Ci, Ir-192, Elekta Model 105.002
Mississippi Report: MS-170002

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: 52916
Rep Org: NIST
Licensee: NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY
Region: 1
City: GAITHERSBURG State: MD
County:
License #: SNM-362
Agreement: Y
Docket:
NRC Notified By: MANUEL MEJIAS
HQ OPS Officer: STEVEN VITTO
Notification Date: 08/19/2017
Notification Time: 12:07 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [EDT]
Last Update Date: 08/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
TYRONE NAQUIN (PM)

Event Text

UNPLANNED CONTAMINATION EVENT - BROKEN FLAME-SEALED GLASS AMPOULE

"The purpose of this communication is to provide additional details surrounding the circumstances that led to the identification of unplanned contamination in one of the laboratories designated as a restricted area under the US NRC license SNM-362. As indicated verbally during the initial report at 1207 EDT, and required by 10 CFR 30.50(b)(1), this event is described as having a broken flame-sealed glass ampoule that resulted in contamination of the lead-shielding storage area on top of the countertop and other surfaces within room C11 in building 245 of the NIST Gaithersburg, MD campus. This was discovered at approximately 1400 EDT on 8/18/2017.

"The ampoule contained a well-characterized solution of Am-241 with an activity of approximately 47 MBq (most restrictive ALI [Annual Limit on Intake] is 0.006 uCi) and is registered in our database as being in a solution of nitric acid.

"The initial report requirements of 10 CFR 30.50(b)(1) (i) through (iii) are satisfied by the phone notification and supplemented by this communication and attachments. Additional information regarding corrective actions taken and planned, as well as evaluations and/or assessments, will be provided to our Project Manager and Region I in the near future and the required written report will be provided within the required 30 days.

"After reporting event #52916, at the direction of the Radiation Safety Officer and with the support of the NIST Senior Management, multiple efforts will continue to evaluate the extent of the condition and a Stop Work Order will be issued effective today for all other laboratories at NIST Gaithersburg that store similar ampoules until the extent of condition is evaluated and/or mitigated.

"Extensive surveys of the area and air monitoring have confirmed that the contamination is isolated to portions of room C11."

Access has been restricted to room C11.

The licensee notified NRC R1 (Ullrich) and NRC HQ PM (Naquin) regarding this event.

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Non-Agreement State Event Number: 52917
Rep Org: WASHINGTON UNIVERSITY
Licensee: WASHINGTON UNIVERSITY
Region: 3
City: St. Louis State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: SUSAN LANGHORST
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/19/2017
Notification Time: 16:14 [ET]
Event Date: 08/18/2017
Event Time: 14:00 [CDT]
Last Update Date: 08/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER LOBE

"A medical event occurred on 8/18/2017 when Y-90 TheraSpheres meant for treatment of the patient's left liver lobe were administered to the patient's right liver lobe. The patient treatment plan was for radioembolization of the left lobe of the liver on 8/18/17 and radioembolization of the right liver lobe approximately one month later. The interventional radiologist (IR) and radiation oncologist authorized user (AU) signed off on planning activity for the left lobe via the left hepatic artery on 8/2/17 and 8/3/17, respectively. The AU completed the 8/18/17 written directive to deliver 124 Gy to the left lobe via the left hepatic artery (LHA). The IR placed the catheter for treatment in the right hepatic artery which supplies the right liver lobe. The AU, medical physicist and radiation technologist came to the procedure room. A time out procedure was done asking all parties to confirm 124 Gy to the left lobe via the LHA. The IR gave a verbal affirmation of this plan. The IR discovered the error when reviewing patient notes following the procedure. He immediately notified the AU who then notified the Radiation Safety Officer (RSO). The AU estimated dose to the right lobe to be 63 Gy. The RSO continues investigating the event. The patient and the referring physician were notified of the medical event."

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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Part 21 Event Number: 52922
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ELEKTA, INC
Region: 1
City: ATLANTA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GREG REESE
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/24/2017
Notification Time: 06:53 [ET]
Event Date: 08/08/2017
Event Time: [EDT]
Last Update Date: 08/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
SILAS KENNEDY (R1DO)
BILLY DICKSON (R3DO)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PART 21 MATERIALS (EMAI)

Event Text

PART 21 REPORT - ONCENTRA BRACHY SOFTWARE ERROR

The following is excerpted from a report received from the Georgia Department of Natural Resources:

On August 8th, a patient was undergoing a gynecological treatment using a ring applicator with the microSelectron HDR utilizing Oncentra Brachy Software version 4.5.2. On the 2nd of a 4 fraction treatment of ring and tandem, a mistreatment occurred due to inconsistent step size when treating the ring source path. A source step size of 2.5 mm was planned. What was reported in the case explorer was a 5 mm step size. This plan was sent to the TCS [Treatment Control System] and delivered at a 5 mm steps size.

It was intended to treat specific areas, but the delivered areas were 2.5 mm - 60 mm different than intended.

This was confirmed using gafchromic film on a QA plan after treatment was completed.

This event was reported by the State of Mississippi - see related EN 52914.

Elekta identified that this issue occurs when using Applicator Models with a measured source path in combination with a specific afterloader configuration, as follows:

Oncentra Brachy - Version 4.5, 4.5.1, 4.5.2, Applicator Modeling with a measured source path, RDStore default step size 5.0 mm, 10.0 mm
Afterloader - microSelectron HDR/PDR V2, V3/Digital
Applicators - Ring Applicator Sets, Ring CT/MR Applicator sets, Interstitial CT/MR Rings, Vienna CT/MR Rings, Advanced Gynecological Applicator - Venezia with Lunar-shaped ovoids

In Elekta bulletin [IFSN 806-01-BTP-001] the Ring applicator will be used to represent all applicable applicators. Where ring is mentioned also lunar-shaped ovoids apply (Advanced Gynecological Applicator). Where 5.0 mm is used as a default step size this could also be 10.0 mm.

Oncentra Brachy incorrectly handles the placement of the ring applicator models with the measured source path in combination with the microSelectron treatment unit, for which the default step size differs from 2.5 mm.

Three other facilities previously reported this issue and the manufacturer had started working on a bug fix and field notification. All other cases found the issue during QA, so no patients were involved. Veenendaal has put a stop to the delivery of the Applicator Modeling until the Oncentra Brachy v 4.5.3 is released.

An Important Field Safety Notification was sent to all customers concerning the use of ring source paths with applicator modeling on 8/11/17 (IFSN 806-01-BTP-001 attached).

An Oncentra Brachy patch is in process to fix this safety issue.

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Power Reactor Event Number: 52932
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: HANK KIRKLAND
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/28/2017
Notification Time: 10:55 [ET]
Event Date: 08/28/2017
Event Time: 08:37 [EDT]
Last Update Date: 08/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

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

Event Text

AUTOMATIC REACTOR TRIP ON TURBINE TRIP

"On 8/28/2017 at 0837 [EDT], VC Summer Nuclear Station automatically tripped due to a turbine trip. The turbine trip was caused by the Main Generator Differential Lockout due to a fault on the center phase lightning arrester on the Main Transformer (XTF-001).

"There were no complications with the trip. All control rods fully inserted. Balance of Plant (BOP) buses automatically transferred to their alternate power source XTF 31/32. All Emergency Feedwater pumps started as required. All systems responded as required. The plant is stable in Mode 3. Station personnel are investigating the cause of the fault on the main transformer lightning arrester.

"This event is reportable per 10 CFR 50. 72(b)(2)(iv)(B) and 10 CFR 50. 72(b)(3)(iv)(A).

"The NRC Resident Inspector has been notified."

The unit is currently stable in Mode 3 with decay heat removal via the Main Steam to the Main Condenser.

The licensee will inform both State and local authorities.

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Power Reactor Event Number: 52934
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID VAN DER KAMP
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/28/2017
Notification Time: 14:47 [ET]
Event Date: 04/25/2016
Event Time: 21:17 [CDT]
Last Update Date: 08/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BILL COOK (R1DO)
EUGENE GUTHRIE (R2DO)
JAMNES CAMERON (R3DO)
VINCENT GADDY (R4DO)
PART 21/50.55 REACTO (EMAI)

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

PART 21 REPORT - RELAY FAILURE DUE TO OPEN COIL

"Pursuant to 10 CFR 21, this is a non-emergency notification by Nebraska Public Power District (NPPD) concerning a defect in an Allen-Bradley 700DC-P220Z2 relay received at Cooper Nuclear Station.

"On August 28, 2017, NPPD completed a 10 CFR 21 evaluation of a condition that was identified on April 25, 2016, associated with an Allen-Bradley 700DC-P220Z2 relay delivered by NuTherm. The evaluation was performed to determine the applications where the relays were approved for installation, where they were installed in the plant, and determine if the failure of the relays could result in a Substantial Safety Hazard as defined in 10 CFR 21.

"A model 700DC-P220Z2 relay failed after 133 hours of service. An independent laboratory determined the relay contained a wound wire fault at the beginning of the spool near the spool edge. The wire that faulted was connected to the right coil terminal. The fault was at a stress point where the wire came out of the insulating material channel and started onto the spool. Continuity testing indicated that the wire was open between the fault area and the terminal, within the potting material. The relay failure was a case of component infant mortality. It appeared the fault was caused by a manufacturing flaw that likely occurred due to a tensioning issue at the start of the coil wire winding process.

"This deviation presents a Substantial Safety Hazard as defined in 10 CFR 21, as this relay model was approved for use in safety related applications. The relay that failed was installed in the starter for the HPCI auxiliary lube oil pump and caused the HPCI system to be inoperable. This was reported to the NRC in ENS Notification 51882 at 0154 EDT on April 26, 2016 as a loss of safety function, but was not characterized as a 10 CFR Part 21 issue at that time. The relay model was approved for use in numerous HPCI starters and the Recirculation Pump discharge valves."

The licensee notified the NRC Resident Inspector.

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Part 21 Event Number: 52935
Rep Org: FISHER CONTROLS INTERNATIONAL, LLC
Licensee: FISHER CONTROLS INTERNATIONAL, LLC
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE BAITINGER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/28/2017
Notification Time: 17:45 [ET]
Event Date: 08/28/2017
Event Time: [CDT]
Last Update Date: 08/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JAMNES CAMERON (R3DO)
BILL COOK (R1DO)
EUGENE GUTHRIE (R2DO)
VINCENT GADDY (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 REPORT - FLOW SCANNER 6.6 CODE ERROR

The following information was received via e-mail:

"Fisher Information Notice: FIN 2017-04: Erroneous Rotary Seating Torque Calculation in FlowScanner Software

"This Fisher Information Notice (FIN) applies only to the equipment identified in Appendix A, which lists serial numbers and order numbers that were delivered to customers. Specifically, it applies to FlowScanner 6.6 (build 6.6.000.29) and 6.6 SP1 (build 6.6.000.67). Appendix B of this document includes a decision tree to help customers further determine if this FIN applies to any work performed.

"The purpose of this FIN is to alert affected customers that, as of 29 June 2017, Fisher Controls International LLC (Fisher) became aware of a situation which may affect the performance of the aforementioned equipment. Fisher is informing affected customers of this circumstance in accordance with Section 21.21 (b) of 10 CFR 21.

"In the process of updating a customer's older FlowScanner software version to 6.6.000.67 (SP1), the customer performed additional software acceptance validation and discovered a discrepancy between the two software versions when calculating Seating Torque values for Rotary Valve assemblies with Lever Arm linkage type. An equation in 6.6.000.67 is the cause for the discrepancy. This equation was incorrectly written in code with a lack of an additional set of parentheses to order the execution of mathematical functions correctly. In code writing, this is considered a typographical error.

"When FlowScanner 6.6 was in development, there was a need to incorporate a new actuator design into the FlowScanner torque calculations. Because of the design of this actuator, the torque equations and configuration database in FlowScanner required modification. This code was modified on 7 November 2012. FlowScanner 6.6 (build 6.6.000.29) and 6.6 SP1 (build 6.6.000.67) were released subsequent this date and contained the erroneous calculation. Shipments of software were stopped on 30 July 2017 and no shipments took place between 29 June 2017 and 30 July 2017. This code was not transferred to the QUIKLOOK FS software utilized on the QUIKLOOK 3-FS diagnostic system. Thus, this error does not extend into QUIKLOOK FS software.

"The equation has been corrected and full-installation CDs will be ready for distribution to affected customers by 1 December 2017. In addition, a Corrective Action Request (CAR 2017-009) has been initiated by Fisher to prevent reoccurrence of this issue. Additionally, Software Error Notice SEN17-01 was created and released to affected customers on 2 August 2017.

"Fisher requests that the recipient of this FlN review it and take appropriate action in accordance with 10 CFR 21. If there are any technical questions or concerns, please contact:

Guy Scaggs
Quality Manager
Emerson Automation Solutions
Fisher Lifecycle Services
757 Old Clemson Rd
Columbia, SC 29229
Phone: (803) 462-6203
Guy.Scaggs@Emerson.com

"Appendix A - List of Affected Equipment

Table 1: FlowScanner 6000 Safety Related Orders with V6.6 Supplied

FISHER CONTROLS INTERNATIONAL - Marshalltown
EXELON POWERLABS LLC - COATESVILLE
FLORIDA POWER AND LIGHT CO - SEABROOK STATION
NEXTERA ENERGY - DUANE ARNOLD

Table 2: Stand Alone Software Orders- Safety Related V6.6

DOMINION NUCLEAR CONNECTICUT INC. - Millstone Power Station
OMAHA PUBLIC POWER DISTRICT - Fort Calhoun Nuclear Station
FISHER CONTROLS INTERNATIONAL LLC - Fisher Controls International LLC
SOUTHERN CO - Southern Company
NEXTERA ENERGY POINT BEACH LLC - Point Beach Nuclear Plant

"Appendix B - Decision Tree for Applicability

How to determine if this FIN applies to you: Are you using FlowScanner 6.6 or 6.6 SP1?

If 'YES', do you use FlowScanner 6.6 or 6.6 SP1 to complete a 'Dynamic Scan' test on rotary valves with lever arm linkages? Such as any TAG configured with 'LEVER ARM' in the 'Linkage Type' field for example Fisher Types 1052, 2052, and 1061

If 'YES', do you manually select the significant points for Seating Torque and Break Out Torque from the 'Dynamic Scan' test?

If 'YES', do you use the Seating Torque result value provided by FlowScanner for any qualification, validation, or acceptance activities?

If you answered 'NO' to ALL of these questions, this software error does not affect your usage of the FlowScanner 6.6 or 6.6 SP1 software.

If you answered 'YES' to ANY of the questions, further evaluation of the affected Seating Torque test results may be necessary. A workaround has been issued to affected customers."

Page Last Reviewed/Updated Tuesday, August 29, 2017
Tuesday, August 29, 2017