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Event Notification Report for November 24, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/22/2017 - 11/24/2017

** EVENT NUMBERS **


53071 53072 53073 53075 53076 53085 53089

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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: 11/22/2017
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 [HDR] device located inside a pig container. The device was located inside the vault. The Radiation Safety Officer [RSO] 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

* * * UPDATE AT1655 EST ON 11/22/2017 FROM DARYL LEON TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

"The radiation technician who found the contamination is the Varian field service engineer (FSE) who performed the HDR source exchange. The decayed Ir-192 source was removed from the HDR and placed into a transport container. The new container with the new Ir-192 source was surveyed and a contamination wipe performed with all readings within normal range for a new source. The new source wire was wiped and no contamination found and it was loaded into the HDR. A dose rate survey was performed around the afterloader and the new transport container to confirm the source transfer was successful. However, the measurement inside the empty container indicated a dose rate of 35 microSv/hr (background in the vault given at 0.1 microSv/hr). The Varian RSO was called at this time (11:30 AM PT). The FSE placed the lid onto the new transport container and the dose rate dropped to 2.4 microSv/hr. Per company procedure, the new Ir-192 source was unloaded from the HDR and placed back into the new transport container and a confirmation survey and wipe performed on the HDR to ensure no contamination was transferred into the machine. The FSE then performed a contamination wipe on the new source wire and found the count rate at 6.35 cps with a background of 0.62 cps. This was a second indication of contamination. The FSE was instructed by the Varian RSO to leave the room and secure it. The FSE was surveyed by the facility AMP [Authorized Medical Physicist] upon exit to ensure no spread of contamination. The Varian RSO then contacted Oregon Radiation Protection Services [RPS] to report the event as well as the source manufacturer, Alpha-Omega Services, Inc. (AOS) to plan a response.

"The Varian RSO and AOS RSO came to the Oregon site on November 15th. Oregon RPS also responded and observed the procedure by the Varian RSO to clear any contamination from the HDR vault. No contamination was found outside the new transport container. The new transport container was prepared and shipped by the AOS RSO for return to their licensed facility in Louisiana, the Louisiana Agreement State agency was notified by Oregon RPS of the event. Oregon RPS requested a copy of the AOS investigation report stating what radionuclide is identified in this contamination event and potential source of the contamination. The Varian FSE indicated that similar contamination events, 'four (including this one) since 2013 where a hot particle has been found' in the container of AOS shipments containing HDR sealed sources of Ir-192."

Notified the D4DO (Hay) and NMSS (via e-mail).

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Agreement State Event Number: 53073
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEISINGER HEALTH SYSTEM
Region: 1
City: DANVILLE State: PA
County:
License #: PA170016
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/15/2017
Notification Time: 13:25 [ET]
Event Date: 11/15/2017
Event Time: [EST]
Last Update Date: 11/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - INCORRECT WRITTEN DIRECTIVE FOR LIVER PATIENT

The following report was received from the Pennsylvania Bureau of Radiation Protection via facsimile:

"The event involved a patient who was scheduled to be treated with 16 mCi of Y-90 SirSpheres to the left lobe of the liver. The written directive (WD), however, was incorrectly written for the right lobe of the liver. The authorized user (AU) did in fact deliver the correct dose to the correct lobe and the discrepancy was only noticed after the procedure was complete. No harm is expected as the patient received the intended dose to the correct location. The cause of the event was noted as human error resulting from:

(1) Failure of the AU to indicate the correct treatment site on the WD.
(2) Failure of the AU to forward documentation of the pre-therapy information to the RSO (or designee) prior to the therapy.
(3) Failure of clinical staff to identify the discrepancy on the WD during the patient time out just before implantation of the microspheres.

"Corrective actions include: Before drawing up the dose/activity in Nuclear Medicine (and preferably before the dose/activity is ordered from the manufacturer), the AU must forward pre-therapy documentation (WD, pre-post therapy worksheet, etc.) to the RSO (or designee) to ensure documentation is correct/appropriate.

"The Department [Pennsylvania Bureau of Radiation Protection] will perform a reactive inspection. The licensee will update their procedure to include additional checks for the written directive."

Event Report ID No: PA 170016

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: 53075
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: 33-51220-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/16/2017
Notification Time: 15:43 [ET]
Event Date: 11/15/2017
Event Time: [CST]
Last Update Date: 11/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE FAILED TO RETRACT

The following information was received via E-mail:

"Desert NDT, LLC dba Shawcor (Shawcor) reported that a 3.15 TBq (85 Ci) Ir-192 sealed source (SPEC model G-60, serial #YJ2608) had disconnected from a drive cable connected to a SPEC model SPEC-150 radiography exposure device (serial #786) at a temporary job site in Watford City, ND on 11/15/2017.

"Upon completion of an exposure, the radiography crew performed a radiation survey while approaching the exposure device. At approximately 35 feet from the device, they noticed an elevated reading of approximately 20 mR/hr. At this point, the crew determined the source had not retracted into the safe, shielded position. The crew moved away from the device, secured the area, maintained a 2 mR/hr barrier and contacted the Branch Manager. The Branch Manager, who is trained in source retrieval, responded to the site. He successfully recovered the source following Shawcor established procedures. The Branch Manager inspected the exposure device and associated equipment. He determined no damage had occurred to the exposure device, guide tube, and/or crank assembly, rather the drive cable was not properly connected to the source pigtail.

"At no time during the event did the radiography crew member's pocket dosimeters go off-scale. In response to the initial notification, the North Dakota Department of Health requested the licensee send the exposure device and associated equipment involved in the event to the manufacturer for further evaluation."

North Dakota Item Number: ND170001

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Agreement State Event Number: 53076
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LTI SMART GLASS
Region: 1
City: PITTSFIELD State: MA
County:
License #: G0350
Agreement: Y
Docket:
NRC Notified By: ZARA REJAEE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/16/2017
Notification Time: 15:42 [ET]
Event Date: 05/01/2017
Event Time: [EST]
Last Update Date: 11/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING POLONIUM-210 SEALED SOURCE

The following information was received via E-mail:

"On November 16, 2017, the Massachusetts Radiation Control Program determined that one NRD, LLC, Model P-2021-8201, S/N A2KQ898, static control device, containing a 10 milliCurie, polonium-210 sealed source, could not be located by the licensee (Current decayed activity is approximately 600 microCurie with an original assay date of 5/5/2016).

"When questioned by the Program, the licensee stated that it noticed that the device has been missing since sometime in May of 2017. The licensee believes that they transferred the device from their Lenox, MA facility to their Pittsfield, MA facility and it is somewhere within their Pittsfield facility. However, the licensee stated that it's very unlikely they will find the device due to the facility size and complexity.

"The Program notified the licensee of its responsibility for providing a written report within 30 days of their telephone report in accordance with the requirements of 105 CMR 120.281(B).

"Root cause and corrective action are not known at this time and the Program intends to perform a special inspection.

"This event remains open."

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: 53085
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JULIUS FLETCHER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/22/2017
Notification Time: 10:28 [ET]
Event Date: 11/22/2017
Event Time: 09:37 [EST]
Last Update Date: 11/22/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
LADONNA SUGGS (R2DO)
LAURA DUDES (R2 D)
KATHRYN BROCK (NRR)
WILLIAM GOTT (IRD)
CHRIS MILLER (NRR)

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

ST. LUCIE UNIT 2 UNUSUAL EVENT DUE TO A SMOKE DETECTOR ALARM RECEIVED INSIDE CONTAINMENT

"St. Lucie Unit 2 declared an Unusual Event due to a smoke detector alarm received in the Unit 2 Containment Building that was unable to be confirmed within 15 minutes. A Containment entry is currently being planned to determine the validity of the alarm.

"State and local officials have been notified by the licensee."

The NRC Resident Inspector has been notified.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE ON 11/22/17 AT 1143 EST FROM JULIUS FLETCHER TO JEFF HERRERA * * *

"Personnel entered Containment to determine conditions and found no evidence of smoke, fire or damage to equipment. Event terminated at 1127 EST 11/22/17."

The NRC Resident Inspector has been notified.

Notified R2DO (Suggs), R2 DRA (Dudes), NRR (Brock), IRD (Gott), and NRR EO (Miller), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

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Power Reactor Event Number: 53089
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: CHAS ZACHER
HQ OPS Officer: DAN LIVERMORE
Notification Date: 11/23/2017
Notification Time: 02:54 [ET]
Event Date: 11/22/2017
Event Time: 20:43 [CST]
Last Update Date: 11/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
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

LPCI INOPERABILITY DUE TO OVERVOLTAGE RELAY ACTUATION

"On November 22, 2017, at 2043 [CST], Unit I MCC [Motor Control Center] 18/19-5 overvoltage relay target was found actuated and would not reset. MCC 18/19-5 was powered from the normal feed, Bus 19. Bus 19 voltages were verified to be normal. The overvoltage relay actuation would result in MCC 18/19-5 being de-energized in the event of a DBA LOCA [Design Basis Accident Loss of Coolant Accident] in which the 1/2 Emergency Diesel Generator fails to energize Bus 18, therefore rendering both divisions of the Low Pressure Cooling Injection (LPCI) mode of Residual Heat Removal (RHR) system inoperable. Technical Specification 3.5.1 Condition E was entered, requiring restoration of LPCI in 72 hours.

"The overvoltage target was subsequently able to be reset at 2114 [CST], restoring the LPCI function of RHR. Technical Specification 3.5.1 Condition E was exited at that time.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, November 24, 2017
Friday, November 24, 2017