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Event Notification Report for February 6, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/05/2018 - 02/06/2018

** EVENT NUMBERS **


53121 53186 53187

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Part 21 Event Number: 53121
Rep Org: SOR MEASUREMENT AND CONTROL
Licensee: SOR MEASUREMENT AND CONTROL
Region: 4
City: LENEXA State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MELANIE DIRKS
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/15/2017
Notification Time: 18:02 [ET]
Event Date: 10/18/2017
Event Time: [CST]
Last Update Date: 02/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
RICK DEESE (R4DO)
PART 21/50.55 REACTO (EMAI)
ART BURRITT (R1DO)
BINOY DESAI (R2DO)
ANN MARIE STONE (R3DO)

Event Text

PART 21 - DEVIATION IN ORIGINAL QUALIFICATION TESTING OF SOR SAFETY RELATED SWITCHES

The following is a excerpt from a report received via email:

"On October 18, 2017 a deviation in the original qualification testing of SOR safety-related switches was discovered by a NRC vendor inspection conducted from October 16-20, 2017. SOR continues to evaluate those items cited by NON 99900824/2017-201-01 Items 1 through 3 and other effects on safety related components identified by SOR.

"The qualification test report was written in 1992. Due to the age of the report, SOR continues to retrieve records and consult contracted sources. The evaluation is expected to be completed as soon as possible or by February 27, 2018.

"If you have any questions regarding this matter, please contact:
Mike Bequette,
Vice President of Engineering
Email: mbequette@sorinc.com
Tel 913-956-3040"

* * * UPDATE ON 2/5/2018 AT 1719 EST FROM MELANIE DIRKS TO DAVID AIRD * * *

The following is an excerpt from a report received via email:

"SOR has identified the following reportable deviations:

"The Test Report did not account for all [Measuring and Test Equipment] uncertainties. The following are affected:
-Qualified Life
-LOCA [Loss of Coolant Accident] profile
-HELB1 [High Energy Line Break] profile
-HELB2 profile

"During qualification testing, observed repeatability in excess of 1 percent of span was not adequately addressed for some models. The following will be affected:
-Vacuum switches (post LOCA only)
-Temperature switches

"The Test Report presents data that is intended to provide a means to calculate reductions in qualified life depending on the conditions of the end use. However, there is a risk that this information could be overlooked by the end user. Following are the potential contributing factors to qualified life:
-Temperature rise due to electrical load on switch element
-Temperature rise on direct mount temperature switches due to elevated process temperature

"SOR has conducted or is conducting the following corrective actions:
-Provided details in this report regarding the NQ models strings and non-standard models potentially affected
-Identified the contact list of customers potentially affected by this deviation within this notification
-Notifying the utilities as indicated with a copy of this notification attached targeting completion by February 8, 2018
-Revise and update test report 9058-102 to revision 3 targeting completion and availability by February 28, 2018"

Notified R1DO (Powell), R2DO (Heisserer), R3DO (Duncan), R4DO (Deese), and Part 21 Group (via email).

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Agreement State Event Number: 53186
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: PACIFIC AURORA, LLC
Region: 4
City: Aurora State: NE
County:
License #: GL0704
Agreement: Y
Docket:
NRC Notified By: MALISA MCCOWN
HQ OPS Officer: BETHANY CECERE
Notification Date: 01/26/2018
Notification Time: 15:11 [ET]
Event Date: 01/10/2018
Event Time: [CST]
Last Update Date: 01/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via email:

"On January 12, 2018, GL0704 Pacific Aurora, LLC (formerly Aurora Coop West) contacted [the Nebraska Department of Health and Human Services (NEDHHS)] regarding their overdue Annual Invoice and Current Inventory. The Environmental Manager [EM] noted that Aurora Coop West was bought by Pacific Ethanol on December 16, 2017 and has combined into one entity: Pacific Aurora, LLC. The EM indicated he was unable to locate several of the tritium exit signs on the inventory but would attempt location for one additional week. NEDHHS Office of Radiological Health received written notification on January 25, 2018 of one lost/missing tritium exit sign. The EM assumes the sign may have been moved during a renovation. Should the sign be located, the EM has indicated they will contact [NEDHHS].

"Device Name: Radioluminescent Sign
Manufacturer: Safety Light Corp.
Model Number: SLX60
Serial Number: 418040
Radionuclide: H-3
Activity: 11.5 Ci."

NEDHHS Item Number: NE180002

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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Non-Agreement State Event Number: 53187
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BAPTIST MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-11128-02
Agreement: N
Docket:
NRC Notified By: AMY ETTLING
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/29/2018
Notification Time: 17:20 [ET]
Event Date: 01/29/2018
Event Time: 09:30 [CST]
Last Update Date: 01/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

A patient received SAVI (Strut-Adjusted Volume Implant) High Dose Rate Treatments on January 26, 2018 and January 29, 2018. After the treatment, it was noted that the dwell time on one catheter appeared unusual. The treatment from January 26 was then reviewed and it was discovered that the catheters were labeled incorrectly during the initial treatment planning process. The physician was notified to review the delivered dose. Another physicist was contacted and remotely viewed the delivered treatment of the January 29 treatment as well as the treatment plan from January 26. This physicist came to the same conclusion that the catheters had been mislabeled on the January 26 CT scan.

The skin received a greater dose than intended for one delivered fraction. 1cc received 848cGy, intended 256cGy and 0.1cc received 1500cGy, intended 282cGy. A decision was made by the physician to cancel all further radiation treatments using the SAVI device and the catheter was removed. The patient was notified of the event, as well as the referring physicians.

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.

Page Last Reviewed/Updated Tuesday, February 06, 2018
Tuesday, February 06, 2018