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Event Notification Report for October 20, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/19/2017 - 10/20/2017

** EVENT NUMBERS **


52914 52955 53008 53009 53026

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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: 10/19/2017
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

* * * UPDATE AT 1649 EDT ON 10/19/17 FROM JASON MOAK TO S. SANDIN VIA EMAIL * * *

"Update: 10/18/2017

"Licensee reported four (4) medical events utilizing the tandem and ring applicator model within Elekta's Oncentra Brachy Software version 4.5.2. Licensee written report received, 8/23/2017, for the period between 11/8/2016 and 8/15/2017, stated two of the four patients treated using Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit and utilizing the tandem and ring applicator model within Oncentra's Treatment Planning software received a dose less than 20% of the prescribed dose to the treatment site (base of the uterus). All of the treated patients received greater than 50 Rem and 50 percent or more of the dose expected from the administration to unintended tissue (vaginal canal). The written directives called for a prescribed dose of 28 Gy for three patients and 27 Gy for one patient, to be delivered in four (4) separate fractions to the base of the uterus. All four (4) fractions were affected for one patient, three (3) fractions for two patients, and only one (1) fraction for one patient, which received 50 percent or more of the dose expected from the administration.

"Patient / Estimated Dose Delivered to Treatment Site / Percent of Intended Dose from Written Directive / Affected Number of Fractions / Expected Range of Doses to Unintended tissue / Estimated Dose to Unintended Tissue

"Patient A / 18.44 Gy / 65.84 % / 4 / 126 cGy and 175 cGy per treatment fraction / > 28 Gy
"Patient B / 21.78 Gy / 77.7 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy)
"Patient C / 23.39 Gy / 83.55 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy)
"Patient D / 26.84 Gy / 99.41 % / 1 / 126 cGy and 175 cGy per treatment fraction / > 14 Gy for one fraction


"A software error occurs in the Oncentra Treatment Planning Software version 4.5.2, whenever the built-in tandem and ring applicator model is used. The microSelection afterloader step size of a measured source path is 2.5 mm. An override to the default step size of 5 mm (RDStore), from the step size of the measured source path in the planning software occurred. A change in the source position step size, from 2.5 mm to 5 mm was not realized by the licensee for the ring catheter but was implemented for the delivery plan. The dose distribution, prescription point values, and dose volume histogram readouts were all based on a 5 mm spaced tandem and a 2.5 mm spaced ring. When the plans were exported to the treatment unit and delivered, the afterloading brachytherapy unit utilized a source step size of 5 mm for both the tandem and ring applicators, thus a discrepancy between the planned and delivered dose distributions occurred.

"The licensee has suspended use of the tandem and ring applicator model within the software and will define all catheters for the tandem and ring applicator manually until further notice of Elekta's software correction.

"The referring physician and patients have been notified. No adverse health effects were noted for the patients due to the medical events.

"Activity: 12 Ci Licensee Authorization

"Update: (8.85 Ci - 5.195 Ci)

"Date of Incident: 11/8/2016 through 8/15/2017

"List any other actions required of DRH [Mississippi Division of Rad Health]: Licensee notified to send 15-day written report. Elekta Notification, FCA-NU-0004, FCO Reference No. 806-01-BTP-001, was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR. Licensee's written report received August 23, 2017.

"DRH conducted a reactive inspection of the licensee on September 1, 2017, to determine the cause and further clarify the medical events. The medical events were discussed with the licensee's RSO's, medical physicist(s), and the chair of Radiation Oncology on September 1, 2017, and again on October 17, 2017 and October 18, 2017, with the licensee's medical physicist.

"Case Closed: Yes
"Date Closed: 10/19/2017"

Notified R4DO (Vasquez) and NMSS Events Notification via email.

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52955
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: CRAIG VROMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/08/2017
Notification Time: 16:45 [ET]
Event Date: 09/08/2017
Event Time: 11:30 [CDT]
Last Update Date: 10/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANN MARIE STONE (R3DO)

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

HPCI SYSTEM INOPERABLE

"On September 8, 2017 at 1130 hours CDT, Unit Two High Pressure Coolant Injection (HPCI) Minimum Flow Valve MO 2-2301-14 flow indicating switch (FIS 2-2354) failed to meet the Technical Specification Allowable Value during calibration testing. Technical Specification Table 3.3.5.1-1 Allowable Value (3.f) requires greater than or equal to 634 gpm (3.14 inches water column as required by procedure). HPCI was subsequently declared inoperable.

"This event is being reported as a condition that could have prevented fulfillment of a safety function in accordance with 10CFR50.72(b)(3)(v)(D). The HPCI system is a single train system and the loss of HPCI could impact the plant's ability to mitigate the consequences of an accident. The Reactor Core Isolation Cooling (RCIC) system was confirmed operable.

"Note: On September 8, 2017 at 1140 hours CDT, the HPCI Minimum Flow Valve MO 2-2301-14 flow indicating switch (FIS 2- 2354) was successfully recalibrated and HPCI was returned to Operable status.

"The NRC Senior Resident Inspector has been notified."

* * * RETRACTION AT 1216 EDT ON 10/19/17 FROM RYAN DECKER TO DONG PARK * * *

"The purpose of this notification today (10/19/17) is to retract the ENS Report made on September 8, 2017 at 1545 hours CDT (ENS Report #52955).

"Upon further investigation, it was determined that a surveillance procedure contained an overly restrictive statement that directed operators to immediately declare the High Pressure Coolant Injection (HPCI) system inoperable when the HPCI Minimum Flow Valve MO 2-2301-14 flow indicating switch (FIS 2-2354) fails. This statement was in conflict with existing Technical Specification (TS) 3.3.5.1, Condition E, that allows seven days to restore the HPCI FIS (instrument channel only) to an operable status prior to entry into TS 3.3.5.1, Condition H, which requires declaring HPCI inoperable immediately. Hence, during the period of FIS inoperability (i.e., 10 minutes), the HPCI system was not required to be declared inoperable in accordance with Technical Specifications. Therefore, based on this information, ENS Report # 52955 is being retracted.

"Note: On September 8, 2017 at 1140 hours CDT, the HPCI Minimum Flow Valve MO 2-2301-14 flow indicating switch (FIS 2-2354) was successfully recalibrated and HPCI was returned to Operable status.

"The NRC Resident Inspector has been notified."

Notified R3DO (Daley).

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Agreement State Event Number: 53008
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS DEPT OF STATE HEALTH SERVICES
Region: 4
City: AUSTIN State: TX
County: TRAVIS
License #: 05865
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DAN LIVERMORE
Notification Date: 10/11/2017
Notification Time: 11:16 [ET]
Event Date: 10/10/2017
Event Time: 11:35 [CDT]
Last Update Date: 10/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

ALARM SYSTEM BREACH

The following report was received from the Texas Department of State Health Service via email:

"On October 10, 2017, the Agency had an alarm system breach at 1135 CDT. Security called our program stating the alarm to the source room was alarming. I went down to the room to check it out. I checked the door and it was locked, turned off the alarm system by entering the code, and called the security company and provided information to stop law enforcement from responding to the location. The postal service technician was next door and I asked her who opened the door, she said the contractors asked her to open the door and she stated she went to building operations office and got the key and opened the door for the contractors. And she said when the alarm went off, the door was closed and security guard was informed. That is when our program received the call to go down there. An investigator from our program stayed with the contractors and set the alarm when they were finished. A complete investigation will be completed. Investigation ongoing. Update will be provided in accordance with SA300."

Texas Incident#: I-9516

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Agreement State Event Number: 53009
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/11/2017
Notification Time: 13:58 [ET]
Event Date: 08/11/2017
Event Time: [CDT]
Last Update Date: 10/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017.

"DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event."

Wisconsin Event Report: WI170016

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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Fuel Cycle Facility Event Number: 53026
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: NANCY PARR
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/19/2017
Notification Time: 10:03 [ET]
Event Date: 10/18/2017
Event Time: 10:05 [EDT]
Last Update Date: 10/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
SHANE SANDAL (R2DO)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

INDIVIDUAL CONTAMINATED WHILE OFFLOADING URANYL NITRATE

"24 Hour Event Notification based on 10 CFR 70.50(b)(1) for an unplanned contamination event that requires access to the contaminated area to be restricted for more than 24 hours, by imposing additional radiological controls or by prohibiting entry into the area.

"On October 18, 2017 at approximately 1005 EDT, while operators were unloading a LR-230 container of liquid uranyl nitrate, the liquid offload hose became disconnected from the container fitting. The event resulted in a uranyl nitrate exposure to one operator and a release in the offloading area. The estimated quantity of spilled solution was 6-8 gallons.

"The operator used the emergency shower and was cleared by Health Physics and Medical personnel. Operations and Health Physics personnel cleaned up the spill of low-enriched uranyl nitrate. While decontamination efforts are essentially complete, efforts continue to assure there is no smearable contamination.

"This event has been entered into the facility Corrective Action Prevention And Learning system (CAPAL)."

Page Last Reviewed/Updated Friday, October 20, 2017
Friday, October 20, 2017