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Event Notification Report for October 16, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/13/2017 - 10/16/2017

** EVENT NUMBERS **


53001 53014 53015

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Agreement State Event Number: 53001
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: JOHNS HOPKINS OUTPATIENT CENTER
Region: 1
City: BALTIMORE State: MD
County:
License #: MD-07-005-03
Agreement: Y
Docket:
NRC Notified By: ALAN GOLDEY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/06/2017
Notification Time: 13:11 [ET]
Event Date: 10/05/2017
Event Time: [EDT]
Last Update Date: 10/06/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

"On October 5, 2017, Johns Hopkins Outpatient Center, notified the Maryland Radiological Health Program (RHP) that on October 5, 2017, following a prostate seed implant procedure, the licensee discovered that one (1) seed was unaccounted for. The Pd-103 seed has an activity of approximately 1.5 milliCuries. The number of seeds implanted into the patient was 42 out of 47 seeds ordered. Four (4) seeds remained in the applicator. This left one (1) seed unaccounted for. Two physicists counted 42 seeds implanted, verified on two separate C-arm images. All personnel were scanned with a sodium iodide survey meter as they exited the room. All equipment, tables, waste bags, surgical covers, linens, etc. were scanned multiple times. The floor was systematically and methodically scanned, including the patient's Foley bag, with negative results.

"The patient will return tomorrow [October 6, 2017] for a follow-up CT and chest x-ray. Radiation Oncology will re-count the seeds. Theragenics Corporation will also be contacted to determine if only 46 seeds were shipped. These seeds are received precalibrated and presterilized.

"A reactive inspection will be conducted to investigate this event."

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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Power Reactor Event Number: 53014
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: STEWART WETZEL
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 22:46 [ET]
Event Date: 10/13/2017
Event Time: 17:00 [CDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ROSE (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

Event Text

ACCIDENT MITIGATION - HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"On October 13, 2017 at 1700 CDT, Unit 1 High Pressure Coolant Injection (HPCI) was declared Inoperable due to discovery of a leak on a sensing line to 1-PCV-073-0043, Lube Oil Cooler & Gland Seal Condenser Pressure Control Valve. The leak is a steady stream located where the sense line connects to the valve.

"This constitutes an unplanned HPCI System inoperability and requires an 8 hour ENS notification in accordance with 10 CFR 50.72(b)(3)(v)(D), due to the failure of a single train system affecting accident mitigation and a 60 day written report in accordance with 10 CFR 50.73(a)(2)(v)(D)."

The NRC Resident Inspector has been notified by the Licensee.

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Power Reactor Event Number: 53015
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DELBERT ELKINTON
HQ OPS Officer: DAN LIVERMORE
Notification Date: 10/14/2017
Notification Time: 16:37 [ET]
Event Date: 10/13/2017
Event Time: 19:48 [MST]
Last Update Date: 10/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
FFD GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - NON LICENSED SUPERVISOR FAILED RANDOM DRUG TEST

"At approximately 19:48 Mountain Standard Time on October 13, 2017, Palo Verde Nuclear Generating Station (PVNGS) staff confirmed a non-licensed supervisor tested positive for drugs during a random 'Fitness for Duty' test. The person's access authorization was terminated in accordance with station procedures."

The NRC resident inspector has been notified by the licensee.

Page Last Reviewed/Updated Monday, October 16, 2017
Monday, October 16, 2017