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Event Notification Report for November 22, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/21/2017 - 11/22/2017

** EVENT NUMBERS **


53071 53072 53081 53083 53084

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Agreement State Event Number: 53071
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120780000
Agreement: Y
Docket:
NRC Notified By: MICHAEL J. RUBADUE
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/14/2017
Notification Time: 16:17 [ET]
Event Date: 11/06/2017
Event Time: [EST]
Last Update Date: 11/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE GREATER THAN 50 REM DELIVERED AT A SITE NOT INTENDED FOR TREATMENT

The following report was received from the Ohio Department of Health via email:

"On Friday, November 10, 2017, ODH [Ohio Department of Health] received notification that a cancer patient may have received a dose greater than 50 rem at a site not intended for treatment. A follow-up call was made on Monday November 13, 2017. The licensee stated they believe the Elekta Flexitron (model 136149A02) remote afterloader software package used an incorrect catheter model during the first treatment fraction. The error was discovered while preparing the second fraction.

"ODH will be sending an inspector to investigate the event this week.

"See licensee initial description below:

"A patient was planned to be treated with HDR [High Dose Rate] brachytherapy for GYN [Gynocology] cancer with three fractions. The HDR treatment was planned with a single curved catheters through a Tandem and Cylinder. A dosimetrist preformed a CT based treatment plan for the first fraction. During planning, the dosimetrist did not digitize the catheter correctly. A physicist checked the HDR plan in a hurry and failed to detect the incorrect reconstructed catheter shape in the planning software. During the treatment delivery, the delivery system translated the incorrectly reconstructed catheter as a linear catheter, resulting in the treatment length from the intended 9.0 cm to 15.7 cm. On the second fraction, a new plan was created based on the CT of the day. The dosimetrist did the digitization correctly this time. During the planning check (a routine process), the physicist noticed the differences between the two plans and discovered the error on the first fraction treatment."

Remote afterloader HDR
Device: ELEKTA
Model Number: 136149A02

Sealed Source Brachytherapy
Source: IR-192
Model Number: 136147

Ohio Event Number: OH170008

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: 53072
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: ST. VINCENTS
Region: 4
City: PORTLAND State: OR
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/14/2017
Notification Time: 17:35 [ET]
Event Date: 11/14/2017
Event Time: [PST]
Last Update Date: 11/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION FOUND DURING SOURCE EXCHANGE

On 11/14/2017, during a source exchange, a radiation technician discovered contamination on an High Dose Rate device located inside a pig container. The device was located inside the vault. The Radiation Safety Officer isolated and roped off the area to prevent unauthorized entry and contacted the vendor: Varian. The vendor is expected to arrive tomorrow to continue the investigation.

Device: Varian HDR 600333
Source: IR-192
Activity: 11 Curies

Oregon Event Report ID: 17-0071

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Power Reactor Event Number: 53081
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: JUSTIN M. WILD
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/21/2017
Notification Time: 11:26 [ET]
Event Date: 11/20/2017
Event Time: 15:48 [EST]
Last Update Date: 11/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
LADONNA SUGGS (R2DO)
FFD GROUP (EMAI)

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

FITNESS-FOR-DUTY REPORT

A non-licensed contract employee had a confirmed positive for illegal drugs during a random fitness-for-duty test.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53083
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MATTHEW MILLER
HQ OPS Officer: DAVID AIRD
Notification Date: 11/21/2017
Notification Time: 14:22 [ET]
Event Date: 10/06/2017
Event Time: 09:10 [CDT]
Last Update Date: 11/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
LAURA KOZAK (R3DO)

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

INVALID SPECIFIED SYSTEM ACTUATION

"On October 6, 2017 at 0910 CDT hours, with Unit 1 in Mode 1 (Power Operation), the 1A Diesel Generator Cooling Water Pump (DGCWP) automatically started. The cause was the misoperation of the 1B/C RHR [Residual Heat Removal] Room Cooler Fan (1VY03C) control switch, which was placed in the start position instead of the intended pull-to-lock position. The start of the 1VY03C fan resulted in the automatic actuation of the 1A DGCWP. This system actuation is reportable in accordance with 10CFR50.73(a)(2)(iv)(A). The invalid actuation was not part of a pre-planned sequence during testing or reactor operation.

"The 1A DGCWP, an emergency service water system that does not normally run and that serves as an ultimate heat sink, responded satisfactorily.

"This call is being made in accordance with 10CFR50.73(a)(1), which states that in the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv), other than an actuation of the reactor protection system when the reactor is critical, the licensee may provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written Licensee Event Report."

The licensee notified the NRC Resident Inspector.

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Part 21 Event Number: 53084
Rep Org: ENGINE SYSTEMS, INC.
Licensee: ENGINE SYSTEMS, INC.
Region: 1
City: ROCKYMOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOM HORNER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/21/2017
Notification Time: 17:07 [ET]
Event Date: 11/20/2017
Event Time: [EST]
Last Update Date: 11/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
LADONNA SUGGS (R2DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART-21 - AUXILIARY FEEDWATER PUMP POWER SUPPLY FAILURE

The following report is an excerpt from a fax from Engine Systems, Inc.:

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on October 17, 2017 upon notification of a potential issue with power supply P/N 2938604 supplied to Vogtle Nuclear Plant. The power supply is installed in a safety-related control panel for the Terry Turbine driven auxiliary feedwater pump. Analysis determined the power supply failure was due to an internal rectifier diode failure which resulted in a short circuit on the power supply output.

"The evaluation was concluded on November 20, 2017 and it was determined that this issue is a reportable defect as defined by 10CFR Part 21. The power supply failure will adversely affect speed control of the turbine driven auxiliary feedwater pump and therefore may prevent safe shutdown of the nuclear reactor.

"This issue applies to all customers that have power supply P/N 2938604 within the date code range 0648 through 0723. ESI has supplied power supplies within the suspect date code range to [Vogtle and Farley]."

Point of Contact: Tom Horner, Quality Manager, 252-977-2720

Page Last Reviewed/Updated Wednesday, November 22, 2017
Wednesday, November 22, 2017