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Event Notification Report for April 18, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/17/2018 - 04/18/2018

** EVENT NUMBERS **


53322 53340 53341

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Agreement State Event Number: 53322
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KAISER PERMANENTE MEDICAL CARE PROGRAM OF SOUTHERN CA
Region: 4
City: Los Angeles State: CA
County:
License #: 0372-19
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/10/2018
Notification Time: 20:38 [ET]
Event Date: 03/28/2018
Event Time: [PDT]
Last Update Date: 04/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DOUGLAS BOLLOCK (NMSS)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE DID NOT FULLY RETRACT

The following was received from the State of California via E-mail.

"The Regional RSO, Kaiser Permanente Medical Care Program, contacted LA County Radiation Management (LA County) on April 10, 2018 to report a Medical Event that occurred at the Kaiser Therapy Department on March 28, 2018 located in Los Angeles, CA. The event occurred during a HDR [High-Dose Rate] brachytherapy procedure in which the iridium-192 (Ir-192) source did not fully retract post-treatment and remained in the transfer guide tube about 5 cm from the cylinder-transfer guide tube connector. The source remained in this position between the patient's thighs for approximately 15 minutes resulting in the patient receiving about 300 cGy (300 rad) to the thighs. It was later determined that the source wire was bent near the source which is suspected to be the reason the source did not retract fully.

"A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, especially concerning the delay in removing the source from the immediate vicinity of the patient, the delay in reporting the event to the RSO, as well as to better understand the reason the source wire did not fully retract. "

California 5010 Number: 041018 (5010#)

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: 53340
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: CHRISTOPHER BENNETT
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/17/2018
Notification Time: 12:02 [ET]
Event Date: 04/17/2018
Event Time: 04:16 [CDT]
Last Update Date: 04/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ALAN BLAMEY (R2DO)

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

HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

"At 0416 CDT on April 17, 2018, the High Pressure Coolant Injection System (HPCI) was isolated due to a water side leak from the gland seal condenser. Unit 1 HPCI remains inoperable pending repairs to the gland seal condenser.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(V)(D), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' This is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(V)(D).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified of this event."

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Power Reactor Event Number: 53341
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KRIS STRAUSSER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/17/2018
Notification Time: 16:29 [ET]
Event Date: 04/17/2018
Event Time: 10:30 [EDT]
Last Update Date: 04/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JON LILLIENDAHL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 15 Power Operation 15 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"Unit 1 HPCI [High Pressure Coolant Injection] was declared inoperable due to a Main Pump seal leak that was identified during surveillance testing. Unit 1 HPCI was declared inoperable at 1030 EDT. HPCI was secured and was manually re-aligned to an available status."

At the time of this notification, repairs have been completed and the licensee is making preparations to re-perform the surveillance.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, April 18, 2018
Wednesday, April 18, 2018