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Event Notification Report for May 01, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/30/2018 - 5/1/2018

** EVENT NUMBERS **


53350 53351 53357 53359 53360 53371 53374

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Non-Agreement State Event Number: 53350
Rep Org: RAPID CITY REGIONAL HOSPITAL
Licensee: RAPID CITY REGIONAL HOSPITAL
Region: 4
City: RAPID CITY   State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: JAMES MCKEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/20/2018
Notification Time: 12:05 [ET]
Event Date: 03/08/2018
Event Time: 00:00 [MDT]
Last Update Date: 04/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PATIENT RECEIVED DOSE LESS THAN PRESCRIBED DOSE

The following was received from the licensee via email:

"On March 8, 2018 and March 12, 2018, the patient was treated with the incorrect setup. On March 15, 2018, the patient was treated with the correct setup. Following the third treatment, both physicists were in the HDR [High Dose Rate] vault. The patient's setup was still on the treatment table, the physicist who had delivered the first two treatments noticed the accuform in the setup. At this time the patient had already left the facility. His next treatment was scheduled for March 19, 2018. This was discussed with the physician and the decision was made to perform a CT without the accuform, prior to the next treatment. The plan was recreated, using the same dwell weights and positions as the original plan. At this point we discovered that the patient had been under-dosed by more than 50 percent. Physics notified the NRC and the prescribing physician.

"As a result of the misadministration discovered March 19, 2018, a root cause analysis was performed. The direct cause of the incident was the failure to properly recreate the initial patient setup. The exclusion of the accuform caused the patient's head to be in the wrong position, leaving a gap between the treatment device and the patient's skin.

"Contributing factors include the lack of a specific policy regarding custom immobilization in HDR procedures, this was only the second brachytherapy patient using custom immobilization, the pictures from the simulation did not completely show the accuform, and it is generally a therapist, not a physicist, who reproduces the daily setup using custom immobilization.

"Items identified during root cause analysis: 1. At the time of treatment, there was not a policy specifically written for skin brachytherapy 2. The accuform was not used in the patient setup 3. The pictures from the simulation did not completely show the custom setup. 4. At the time of the incident there was not a verification system in place, to track the items needed for each custom setup.

"Corrective actions: 1. A policy was created and provided to [NRC R4 (Simmons)] on April 4, 2018. 2. Our new policy ensures that a therapist will be present at the first treatment, and any time a physicist is treating the patient for the first time. 3. In the CT simulation, any custom immobilization used in brachytherapy will be photographed with and without the patient. This will ensure that each piece of the custom device can be clearly visualized. Our IT department will be installing a computer monitor, keyboard and mouse in the HDR treatment vault. This will allow the verification of the setup notes and photographs in the treatment room. 4. Physics is working with our IT department and Elekta to implement a bar code scanning system to track custom setup devices."

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: 53351
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VALERO REFINING COMPANY TEXAS
Region: 4
City: TEXAS CITY   State: TX
County:
License #: L02578
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/20/2018
Notification Time: 15:42 [ET]
Event Date: 04/19/2018
Event Time: 17:00 [CDT]
Last Update Date: 04/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGES

The following information was obtained by the State of Texas via email:

"On April 20, 2018, a consultant for the company called to inform the Agency [State of Texas] that a fire had damaged part of the refinery. The fire happened yesterday, April 19, 2018 around 1700 CDT. The radiation safety officer has been informed and the two are preparing an assessment of the damage. There are 19 gauges in the location of the fire. The fire was located in the allocation unit where phrase fractions are allocated into different hydrocarbon groups for refinement. All but two gauges have been assessed for damage. The two remaining gauges are 1 milliCurie or less in activity and cannot be checked at this time due to safety issues. Once the area is released for entry the gauges will be checked for damage. An update will be provided with gauge identification and correct activity. Updates will be provided in accordance with SA-300 guidelines."

Texas Incident No.: I-9562

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Non-Agreement State Event Number: 53357
Rep Org: STERIS ISOMEDIX PUERTO RICO, INC.
Licensee: STERIS ISOMEDIX PUERTO RICO, INC.
Region: 1
City: VEGA ALTA   State: PR
County:
License #: 52-24994-01
Agreement: N
Docket:
NRC Notified By: DAVID JACKSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/22/2018
Notification Time: 11:42 [ET]
Event Date: 04/21/2018
Event Time: 14:37 [AST]
Last Update Date: 04/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
36.83(a)(4) - FAILED CABLE/DRIVE
Person (Organization):
JON LILLIENDAHL (R1DO)
WILLIAM GOTT (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

FAILURE OF SOURCE RACK DRIVE MECHANISM

The following is a synopsis of information received via E-mail:

On 4/21/2018 at 1437 AST, the irradiator faulted with a 'Source Pass Cylinder Fault.' Source rack No. 1 moved to safe position in the pool but rack No. 2 remained in the raised position. The Maintenance Manager was notified of the situation. After evaluating the problem with the rack, he found that the air from the source rack No. 2 hoist cylinder was not being released through SVP36 and SVP36A. The Operators loosened a pipe fitting and let air slowly bleed from the rack hoist cylinder. This brought rack No. 2 into a fully lowered position at 1446 AST.

The Maintenance Manager contacted the corporate, Radiation Safety Manager and the plant manager and informed them of the situation.

The Maintenance Manager removed SVP36 and SVP36A valves and took them to the maintenance shop. There was no debris or water found in the valves. Both valves were replaced.

The Maintenance Manager contacted the Plant Manager and the corporate RSM to inform them that the rack problem was caused by the valves not releasing and that valves had been replaced.

The Maintenance Manager restarted the irradiator and after one cycle stopped the irradiator to test the valves. The source racks lowered into the pool as designed.

Corrective Actions:
1. The solenoid valve vendor will be contacted Monday morning and backup-replacement valves for SVP35, SVP35A, SVP36 and SVP36A will be ordered.
2. Annual replacement of SVP35, SVP35A, SVP36 and SVP36A will be added as an annual PM task.

Further investigation into the source valve failure will continue and conclusions will be included in the written report to Region 1 within 30 days.

The irradiator is now operating as designed. No personnel were exposed, nor was there the possibility of exposure, to the source.

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Agreement State Event Number: 53359
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CARDINAL HEALTH
Region: 1
City: JACKSONVILLE   State: FL
County:
License #: 3453-6
Agreement: Y
Docket:
NRC Notified By: RENO FABII
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/23/2018
Notification Time: 10:34 [ET]
Event Date: 04/23/2018
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a 'Less than Cat 3' level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN TECHNICIUM-99

The following is a synopsis of information received via E-mail:

St. Vincent Medical Center in Fernandina Beach, Florida (License Number: 0014-8) received five (5) doses of Technicium-99 on the morning of April 16, 2018 from Cardinal Health in Jacksonville, Florida. Portions of the dose were used on patients. Later that day, the remainder of the unused doses were placed in a 'lock box' which was located outside the building. The doses were to be picked up and returned to Cardinal Health. This morning, April 23, 2018, the driver from Cardinal Health went to retrieve the doses and found the lock box had been broken into and the Tc-99 doses had been removed. The Fernandina Police were notified (report #2018-00007035).

The activity of the Tc-99 is estimated to be 30 to 40 mCi.

Florida Incident Number: FL18-053

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: 53360
Rep Org: U.S. ARMY
Licensee: U.S. ARMY
Region: 1
City: FORT CAMPELL   State: KY
County:
License #: 01-00126-22
Agreement: Y
Docket:
NRC Notified By: HAROLD W. DEASON
HQ OPS Officer: OSSY FONT
Notification Date: 04/23/2018
Notification Time: 13:38 [ET]
Event Date: 04/06/2018
Event Time: 21:50 [CDT]
Last Update Date: 04/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
JON LILLIENDAHL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a 'Less than Cat 3' level of radioactive material.

Event Text

LOST SOURCES AT CRASH SITE

A helicopter went down carrying two Americium sources totaling 11 microCuries. The crash site was searched but the sources were not located. The sources were declared lost, possibly buried at the crash site. The crash site is located within a firing range and personnel are not expected to be exposed. A written report will be submitted to the NRC.


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: 53371
Facility: BRAIDWOOD
Region: 3     State: IL
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM KELLER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/30/2018
Notification Time: 14:53 [ET]
Event Date: 04/30/2018
Event Time: 11:24 [CDT]
Last Update Date: 04/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BILLY DICKSON (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 48 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP FOLLOWING TURBINE TRIP

"At 1124 CDT, Braidwood Unit 1 experienced an automatic Reactor Trip. The cause of the Reactor Trip was a Turbine Trip with reactor power greater than P-8. The turbine trip was actuated as a result of a Turbine Motoring Generator Trip. The cause of the generator trip is unknown at this time and is under investigation.

"After the Reactor Trip occurred, the 1A Auxiliary Feedwater pump was manually started to provide feedwater flow to all four steam generators. The 1A Auxiliary Feedwater pump was subsequently secured and placed in standby when the Startup Feedwater pump was placed in service.

"Train A Main Control Room Ventilation Filtration system shifted to Makeup Mode due to a spurious actuation signal.

"No secondary relief valves lifted and no secondary steam was released as a result of the Reactor Trip. The Main Steam dump valves are in service to the Main Condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature. AC power is being provided by Offsite Power with the Diesel Generators in standby and all safety systems available. There is no impact to Unit 2.

"This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for a RPS actuation, 4-hr notification, and per 10 CFR 50.72(b)(3)(iv)(A) for a manual actuation of the Auxiliary Feedwater system, 8-hr notification."

The licensee notified the NRC Resident Inspector and Illinois Emergency Management Agency.

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Power Reactor Event Number: 53374
Facility: GRAND GULF
Region: 4     State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: BRANDON STARNES
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/01/2018
Notification Time: 20:42 [ET]
Event Date: 05/01/2018
Event Time: 15:51 [CDT]
Last Update Date: 05/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
RAY AZUA (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

PLANT RECEIVED DIVISION ONE REACTOR PRESSURE VESSEL LEVEL 1 SIGNAL

"At 1551 hrs [CDT] on 5/1/2018, with the plant in Mode 5, a division one Reactor Pressure Vessel (RPV) Level 1 signal was received; however there was no actual change in RPV level. RPV Level remained at High Water Level supporting refuel operations. This caused an actuation of division one Load Shed and Sequencing system that shed and then re-energized the 15 bus. Division one diesel generator started from standby. Residual Heat Removal pump 'A', which was in shutdown cooling mode, was lost during the bus shed, and was re-sequenced upon re-energization of the 15 bus. Upon restoration of shutdown cooling, the RHR pump discharged into the RPV. RCS temperature increased approximately 5 degrees Fahrenheit as a result of the loss of shutdown cooling. The cause of the actuation signal is under investigation. In accordance with NUREG 1022, Event Reporting Guidelines, this event is conservatively reported under 10 CFR 50.72(b)(2)(iv)(A) as an event that results in emergency core cooling system discharge into the RCS as a result of a valid signal, under 10 CFR 50.72(b)(3)(iv)(B)(8) as an event that results in the actuation of emergency ac electrical power systems, and under 10 CFR 50.72(b)(3)(v)(B) as an event or condition that at the time of discovery could have prevented the fulfillment of a safety function (remove residual heat)."

The licensee notified the NRC Resident Inspector.


Page Last Reviewed/Updated Monday, June 18, 2018
Monday, June 18, 2018