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Event Notification Report for December 1, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/30/2017 - 12/01/2017

** EVENT NUMBERS **


53086 53087 53088 53098 53099 53101

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Agreement State Event Number: 53086
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: FAIRVIEW HOSPITAL
Region: 3
City: CLEVELAND State: OH
County:
License #: 02120180101
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2017
Notification Time: 13:40 [ET]
Event Date: 11/20/2017
Event Time: [EST]
Last Update Date: 11/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL UNDERDOSE

The following information was received via e-mail:

"ODH [Ohio Department of Health] was notified of a potential medical event by Fairview Hospital. The licensee performed a permanent prostate seed implant using I-125 according to the treatment plan. When the post implant dosimetry was performed, the D90 coverage was calculated to be 73% of the prescribed dose. After an initial investigation by the licensee, it was determined the under dose was caused by an 18% increase in prostate size compared to the pre-plan, which was prescribed 6 weeks prior to treatment.

"At the time of reporting, the licensee had informed the referring physician but they did not inform the patient. The licensee believes that once the inflammation subsides the D90 coverage will be within the prescribe treatment plan.

"NMED will be updated once ODH receives additional information from the licensee and conducts an investigation of the event."

Ohio Event: OH170009

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: 53087
Rep Org: COLORADO DEPT OF HEALTH
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: CO 902-01
Agreement: Y
Docket:
NRC Notified By: SHIYA WANG
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2017
Notification Time: 14:37 [ET]
Event Date: 11/22/2017
Event Time: [CST]
Last Update Date: 11/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following report was received via e-mail:

"A crew with [Shawcor] experienced a malfunction on the evening of November 21, 2017, with the INC IR-100 exposure device they were using when performing radiographic operations at Ward Petroleum (10404 E. 146th, Thornton, CO).

"Exposure Device: INC IR-100 (s/n 6839)
"Source: INC (s/n T0799) 65 curies

"After completing a radiographic exposure, the crew attempted to crank the source back into the exposure device; however, they were still able to crank the source out even after the button on the exposure device popped up to indicate the source was fully retracted and locked in place. After an attempt to crank the source out and back into the exposure device, the button was still popping up prematurely. Realizing there was a problem with the locking mechanism, the crew ensured their 2 mR/hr boundary was properly established and immediately contacted the Site RSO/Branch Manager. The crew maintained visual surveillance of the area until [the RSO], along with [the Assistant Site RSO], arrived at the jobsite.

"When [the RSO and Assistant Site RSO] arrived at the jobsite, they also ensured the 2 mR/hr boundary was properly established and began to assess the situation. There was no visible damage to any associated equipment (guide tube, crank assembly, etc.). They attempted several times to crank the source out and back into the fully shielded position; each time the button popped up prematurely even though the source was not locked into the exposure device. While holding down the button on the exposure device, [the RSO] was able to crank the source back in and upon releasing the button, the source locked in place. Surveys were completed to ensure the source was fully shielded.

"At no time during the incident did any crew member's dosimeter go off-scale and there was no threat of overexposure at any time to our company's employees, nor un-monitored workers. All personnel involved were wearing and utilizing proper radiation detection equipment, including OSL [Optically Stimulated Luminescent] badges, pocket dosimeters, alarming rate meters, and they were properly utilizing survey meters.

"The INC exposure device will be sent back to the manufacturer for maintenance and repair, if necessary."

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Agreement State Event Number: 53088
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH AND SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: DARYL LEON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2017
Notification Time: 15:22 [ET]
Event Date: 11/17/2017
Event Time: [PST]
Last Update Date: 11/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

Eye plaque brachytherapy was being performed using I-125 seeds with a prescribed dose of 85 Gray. After the dose, the Iso-dose curve was noted to be different from the brachytherapy plan i.e. the dose was deeper than expected. Investigation revealed that a new model plaque was used which differed from the previous model. This resulted in an underdose with 65 Gray actually administered.

Oregon Report: 17-0073

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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Power Reactor Event Number: 53098
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVID HOPPE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/30/2017
Notification Time: 16:02 [ET]
Event Date: 11/30/2017
Event Time: 10:26 [EST]
Last Update Date: 11/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MEL GRAY (R1DO)

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

Event Text

SECONDARY CONTAINMENT DIFFERENTIAL PRESSURE BRIEFLY INDICATED OUTSIDE OF TECH SPEC LIMIT

"On November 30, 2017 at 1026 EST, the Susquehanna Control Room received indication that a loss of Secondary Containment Zone 2 differential pressure had occurred. Control Room operators noted a differential pressure of 0.0 inch WC [water column] for several seconds, followed by a high DP of 0.5 inch WC. System DP was restored to normal in 3 minutes. The cause of the pressure swings is under investigation.

"Zone 2 differential pressures being less than 0.25 inch WC constitutes a loss of Secondary Containment based on not meeting requirements of SR 3.6.4.1.1.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022, Rev. 3, Section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53099
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM PRZEKOP
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/30/2017
Notification Time: 17:17 [ET]
Event Date: 11/30/2017
Event Time: 16:57 [EST]
Last Update Date: 11/30/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MEL GRAY (R1DO)
JEFFERY GRANT (IRD)
CHRIS MILLER (NRR)
DAN DORMAN (R1A)
BRIAN HOLIAN (NRR)

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

Event Text

UNUSUAL EVENT DECLARED DUE TO EARTHQUAKE

An Unusual Event was declared at 1657 EST due to an earthquake detected onsite. The Unusual Event was declared under EAL HU1.1. There is no release in progress due to this event. There are no protective actions recommended at this time.

The Licensee will notify the NRC Resident Inspector.

Note: See also EN #53101 for Hope Creek Unusual Event.

* * * UPDATE FROM JOSHUA MYERS TO DONALD NORWOOD AT 1742 EST ON 11/30/2017 * * *

"An earthquake was felt onsite at time 1645 EST. Multiple phone calls were made to the Control Room confirming the earthquake. It was verified there was an earthquake felt in Delaware with a magnitude of 4.4. Neither seismic monitor at Salem Unit 1, Salem Unit 2, and Hope Creek actuated. There is no indication of any damage to any systems or plant structures. Plant walk-downs have been initiated in accordance with plant operating procedures for a seismic event. No injuries have been reported to the Control Room."

The licensee will notify the NRC Resident Inspector and State and local government agencies.

Notified R1DO (Gray), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), and DHS Nuclear SSA (email).


* * * UPDATE FROM THOMAS CLARK TO DAVID AIRD AT 2137 EST ON 11/30/2017 * * *

The licensee terminated the Unusual Event at 2125 EST on 11/30/2017 following plant walkdowns that revealed no damage to plant structures, systems, or components.

The NRC Resident Inspector has been notified.

Notified R1DO (Gray), IRD (Grant), and NRR EO (Miller), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), and DHS Nuclear SSA (email).

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Power Reactor Event Number: 53101
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: N/A
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/30/2017
Notification Time: 17:17 [ET]
Event Date: 11/30/2017
Event Time: 16:57 [EST]
Last Update Date: 12/01/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MEL GRAY (R1DO)
JEFFERY GRANT (IRD)
CHRIS MILLER (NRR)
DAN DOORMAN (R1RA)
BRIAN HOLIAN (NRR)

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

UNUSUAL EVENT DECLARED DUE TO EARTHQUAKE

An Unusual Event was declared at 1657 EST due to an earthquake detected onsite. The Unusual Event was declared under EAL HU1.1. There is no release in progress due to this event. There are no protective actions recommended at this time.

The Licensee will notify the NRC Resident Inspector.

Note: See also EN #53099 for Salem Unusual Event.

* * * UPDATE FROM JOSHUA MYERS TO DONALD NORWOOD AT 1742 EST ON 11/30/2017 * * *

"An earthquake was felt onsite at time 1645 EST. Multiple phone calls were made to the Control Room confirming the earthquake. It was verified there was an earthquake felt in Delaware with a magnitude of 4.4. Neither seismic monitor at Salem Unit 1, Salem Unit 2, and Hope Creek actuated. There is no indication of any damage to any systems or plant structures. Plant walk-downs have been initiated in accordance with plant operating procedures for a seismic event. No injuries have been reported to the Control Room."

The licensee will notify the NRC Resident Inspector and State and local government agencies.

Notified R1DO (Gray), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), and DHS Nuclear SSA (email).


* * * UPDATE FROM THOMAS CLARK TO DAVID AIRD AT 2137 EST ON 11/30/2017 * * *

The licensee terminated the Unusual Event at 2125 EST on 11/30/2017 following plant walkdowns that revealed no damage to plant structures, systems, or components.

The NRC Resident Inspector has been notified.

Notified R1DO (Gray), IRD (Grant), and NRR EO (Miller), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), and DHS Nuclear SSA (email).

Page Last Reviewed/Updated Friday, December 01, 2017
Friday, December 01, 2017