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Event Notification Report for June 18, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/15/2018 - 6/18/2018

** EVENT NUMBERS **


53447 53448 53449 53450 53459

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Agreement State Event Number: 53447
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: JOHN PETER SMITH HOSPITAL
Region: 4
City: FORT WORTH   State: TX
County:
License #: L02208
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: KENNETH MOTT
Notification Date: 06/07/2018
Notification Time: 12:16 [ET]
Event Date: 01/12/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING CALIBRATION SOURCE

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

"On June 7, 2018, the Agency [Texas Department of State Health Services] received a written report detailing a source had been found leaking in January 2018. The source was a dose calibration reference source. The labeled activity was 198.8 microCuries, Cs137, reference date of 1/1/2012, serial number 1551-38-4, RA number 030880. The leak test was completed twice with results of 9.65 and 12.9 nanoCuries on January 5 and 15, 2018. [Neither] the radiation safety officer nor the medical physicist reported the leak in January. The report was submitted today due to discovery when an inspector found the leak test record during the routine inspection of the facility. The violation was cited in the inspector's report. A second violation was not cited although a record was completed for the leaking source. The source was disposed of at a licensed site on March 20, 2018."

Texas Incident #: 9582

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Agreement State Event Number: 53448
Rep Org: OK DEPT OF ENVIRONMENTAL QUALITY
Licensee: SW REGIONAL MEDICAL CENTER dba CANCER TREATMENT CENTERS
Region: 4
City: TULSA   State: OK
County:
License #: OK-27041-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/07/2018
Notification Time: 16:09 [ET]
Event Date: 06/06/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION

The following was received from the State of Oklahoma by email:

"We [the Oklahoma Department of Environmental Quality] were just informed of a medical event and abnormal occurrence that happened yesterday at Southwestern Regional Medical Center dba Cancer Treatment Centers of America (OK-27041-01) in Tulsa, OK. The incident involved a patient who was supposed to receive a 110.8 Gy dose of Yt-90 SIR Spheres to the right lobe of the liver. A CT [scan] of the patient after the procedure showed that the microspheres had actually been delivered to the left lobe."

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: 53449
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FLORIDA INTERNATIONAL UNIVERSITY
Region: 1
City: MIAMI   State: FL
County:
License #: 3669-1
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: KENNETH MOTT
Notification Date: 06/07/2018
Notification Time: 16:10 [ET]
Event Date: 04/19/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

The following report was received from the State of Florida:

"[The Florida Department of Health / Bureau of Radiation Control] received an email from Florida International University [FIU] reporting a leaking source. On April 19, the RSO [Radiation Safety Officer] opened a cabinet inside CP- 194 and did leak tests on stored sealed sources inside that cabinet. One Ni-63 source (9.4 milliCurie) was contained in a plastic vial with a screw top lid. The RSO removed the plastic vial from the radiation container for one minute to do a swab test, and sent the swab to an approved vendor for analysis. FIU EHS [Environmental Health and Safety] and the RSO were informed that the leak test associated with the Ni-63 source came back with a reading of 0.0119 microCuries (above the max. 0.005 microCurie limit) on May 18th. The RSO removed the radiation container containing the rad source from CP- 194 on May 22nd and moved it to the EHS vault in ACH 4 to await proper disposal. No other contamination was found."

Incident Number: FL18-070

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 53450
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: WESTERN TUMOR MEDICAL GROUP
Region: 4
City: LOS ANGELES   State: CA
County: LOS ANGELES
License #: 7954-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/09/2018
Notification Time: 10:48 [ET]
Event Date: 05/09/2018
Event Time: 00:00 [PDT]
Last Update Date: 08/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION

The following report was received from the State of California by email:

"[The] National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred.

"The potential Medical Event occurred during an HDR [High Dose Rate] brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel.

"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, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification."

* * * RETRACTION FROM THOMAS GEZA TO VINCE KLCO ON 8/14/18 AT 1425 EDT * * *

The following information was received from the State of California via email:

"Calculations have been performed by the Licensee's RSO that demonstrated to [the State of California] that [the dosage] fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose)."

California ID # 060818

Notified the R4DO (Deese) and NMSS Events Notifications via email.

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: 53459
Facility: ARKANSAS NUCLEAR
Region: 4     State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: KEVIN CASEY
HQ OPS Officer: ANDREW WAUGH
Notification Date: 06/16/2018
Notification Time: 15:56 [ET]
Event Date: 06/16/2018
Event Time: 11:21 [CDT]
Last Update Date: 06/16/2018
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):
NICK TAYLOR (R4DO)
BO PHAM (IRD)
MICHAEL F. KING (NRR EO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 2 Startup 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DURING STARTUP

"At 1121 CDT on June 16, 2018, Arkansas Nuclear One, Unit 1 (ANO-1) performed a manual reactor trip due to a Turbine Bypass valve failing open on reactor startup. At the time, ANO-1 was in Mode 2 at approximately 2 percent power.

"The failed Turbine Bypass valve resulted in an overcooling event and the Overcooling Emergency Operating Procedure (EOP) was entered. Main Steam Line Isolation (MSLI) automatic actuation occurred on 2 of the 4 channels of Emergency Feedwater Initiation and Control during the overcooling event in the 'B' Steam Generator. The remaining channels of MSLI were manually actuated by the control room staff from the control room. Overcooling was terminated after the closure of the Main Steam Isolation Valve (MSIV) and reactor coolant parameters were stabilized as directed by the Overcooling EOP. Additionally, Gland Sealing Steam was lost to the main turbine due to the closure of the 'B' Steam Generator MSIV and Loss of Condenser Vacuum Abnormal Operating Procedure was entered.

"This is a 4-hour non-emergency 10 CFR 50.72 (b)(2)(iv)(B) notification due to a Reactor Protection System actuation (scram) and an 8-hour non-emergency 10 CFR 50.72 (b)(3)(iv)(A) notification for safety system actuation."

All control rods fully inserted into the core during the trip. Heat removal is via the Atmospheric Dump Control valves to atmosphere.

The NRC Resident Inspector has been notified. The licensee also notified the State of Arkansas.


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