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Event Notification Report for March 15, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/14/2018 - 03/15/2018

** EVENT NUMBERS **


53249 53250 53260 53261

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Agreement State Event Number: 53249
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: ISORAY MEDICAL, INC.
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ANDREW HALLORAN
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/07/2018
Notification Time: 17:09 [ET]
Event Date: 02/27/2018
Event Time: [PST]
Last Update Date: 03/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
LANCE ENGLISH (ILTA)
NMSS_EVENTS_NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT- LOST AND THEN FOUND SHIPMENT

The following was received from the State of Washington via email:

"A shipment of 55 Cs-131 seeds with a total activity at the time of shipment of 10.7 GBq was lost by [common carrier] during shipment from Richland, WA to New York, NY. [Common carrier] stated to Isoray that the package went missing on 2/27/2018. The package was scanned leaving Spokane, WA but was never scanned in at the hub in Memphis, TN. The package description from the licensee is as follows: Isoray's internal order number is SCP181163. The package was 55 seeds, total apparent activity of 139 mCi, shipped as a Limited Quantity of Radioactive Material/Priority Alert Overnight. The total GBq at time of shipment was 10.7. The seeds were shipped non-sterile per the ordering M.D.'s request, they were contained in six 'Mick' cartridges inside of a stainless steel pig.

"Update on 3/7/2018: The package was found by [the common carrier] and has been returned to the Isoray facility unopened. Isoray has stored the seeds for decay."

Incident Number: WA-18-006

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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Agreement State Event Number: 53250
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: HOUSTON METHODIST
Region: 4
City: HOUSTON State: TX
County:
License #: 00457
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: STEVEN VITTO
Notification Date: 03/07/2018
Notification Time: 17:20 [ET]
Event Date: 03/02/2018
Event Time: [CST]
Last Update Date: 03/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION

The following was received from the State of Texas via email:

"On March 7, 2018 Agency [Texas Department of State Health Services] received notification that a Novoste device jammed with no exposure consequence to the patient. Licensee stated two attempts to complete the therapy procedure had taken place, there was no dose to the patient that would be classified as a medical event. The initial attempt with a beta-rail catheter was not successfully completed. The source train (16, Sr 90) did not move along the beta-rail catheter as expected, the source train was not retracted back into the device robotically. The source train in the Novoste device failed to go into the expected treatment position and stayed in the robotic interventional cardiology device for about 1.5 minutes during the intravascular brachytherapy procedure. The interventional catheter with the indicator source train was removed by the doctor (which he wasn't supposed to do). When the train could not be robotically remove back into the device through the beta rail catheter, the source removal from the patient had to be done manually. The source train was retrieved in 15 seconds and placed back into the Novoste device. The treatment was stopped. The patient was surveyed to confirm no sources in the patient. It was believed the beta catheter developed a kink and could not retract the sources. The second attempt was with a new beta rail catheter and source reset. The treatment continued without any incidents. The source returned to the device without any problems."

Incident # 9552

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Power Reactor Event Number: 53260
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: RICK ROTERS
HQ OPS Officer: OSSY FONT
Notification Date: 03/14/2018
Notification Time: 09:34 [ET]
Event Date: 03/13/2018
Event Time: [EDT]
Last Update Date: 03/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
REBECCA NEASE (R2DO)
FFD GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - NON-LICENSED SUPERVISOR TESTED POSITIVE FFD TEST

A non-licensed contract supervisor had a confirmed positive for illegal drugs during a pre-access drug test. The individual's access has been denied.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 53261
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 03/15/2018
Notification Time: 01:39 [ET]
Event Date: 03/14/2018
Event Time: 17:11 [CDT]
Last Update Date: 03/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JESSE ROLLINS (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF EMERGENCY NOTIFICATION TONE ALERT RADIO SYSTEM

"At approximately 1711 CDT on 14 MAR 2018, Cooper Nuclear Station was notified by the National Weather Service that the Shubert radio transmission tower was not functioning. This affects the tone alert radios used to notify the public in event of an emergency condition. This condition is reportable under I0CFR50.72(b)(3)(xiii). A backup notification method is available and will be utilized for notifications if needed.

"The local telephone company is providing troubleshooting and repair services. A return to service time for the Shubert tower is not currently available.

"The NRC Senior Resident Inspector has been informed."

The issue was identified during periodic maintenance.

The licensee notified all counties within the 10 mile Emergency Planning Zone.

Page Last Reviewed/Updated Thursday, March 15, 2018
Thursday, March 15, 2018