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Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

Event Notification Report for June 25, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/22/2018 - 6/25/2018

** EVENT NUMBERS **


53458 53467 53469 53471

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Agreement State Event Number: 53458
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: UNIVERSITY OF UTAH RADIATION SAFETY
Region: 4
City: SALT LAKE CITY   State: UT
County:
License #: UT 1800001
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 06/15/2018
Notification Time: 16:55 [ET]
Event Date: 06/14/2018
Event Time: 00:00 [MDT]
Last Update Date: 08/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The licensee informed the State of Utah they are evaluating a potential medical event. A patient was implanted with 54 Pd-103 seeds in the prostate under ultrasound guidance. Per standard practice, the patient returned for a CT scan to verify the placement of the seeds. The CT scan revealed that 32 of the seeds had been implanted outside of the prostate. In addition, only 51 seeds were located, likely the result of 3 seeds being passed via stool. They believe that several additional seeds are in the rectum and will be passed following an enema."

Utah Event Report ID No.: UT180003


* * * UPDATE ON 8/17/2018 AT 1106 EDT FROM TIM BUTLER TO ANDREW WAUGH * * *

The following update was received from the State of Utah via email:

"The licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 Pd-103 brachytherapy [seeds] (Theragenics, Theraseed) containing a total activity of 4 GBq (108.167 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 12,500 cGy (rad). The prostate gland only received approximately 1,000 cGy (rad). The seeds were implanted on June 14, 2018 under ultrasonic guidance. On June 15, 2018, the patient returned to the facility for a post implant CT scan. The scan showed that the implanted seeds, although in an appropriate pattern, were placed outside the intended target. The Licensee's Radiation Oncology group determined that an additional quality assurance review was warranted. The State performed a reactive inspection during the week of June 15, 2018. The cause was determined to be human error. An unintended dose to the rectum of approximately 18,677 cGy (rad) was received, where no dose was anticipated. Corrective actions included changes to the prostate brachytherapy protocol to incorporate an additional step to ensure the medical physicist and authorized user clearly identifies the prostate gland and the surrounding anatomy. The treatment will be cancelled if the prostate gland and surrounding anatomy cannot be visualized adequately."

Notified R4DO (Deese), INES Coordinator (Milligan), and NMSS Event 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: 53467
Facility: WATTS BAR
Region: 2     State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY PATE
HQ OPS Officer: THOMAS KENDZIA 		Notification Date: 06/22/2018
Notification Time: 12:14 [ET]
Event Date: 06/22/2018
Event Time: 08:41 [EDT]
Last Update Date: 06/22/2018
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):
GERALD MCCOY (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 95 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP

"At 0841 EDT on June 22, 2018, the Watts Bar Unit 2 reactor automatically tripped while operating at 95% power. All control and shutdown bank rods inserted properly in response to the automatic reactor trip. All safety systems including Auxiliary Feedwater actuated as designed. The plant is stable with decay heat removal through Auxiliary Feedwater and Steam Dump Systems.

"The reactor automatically tripped due to a main turbine trip. The turbine trip was caused by main generator electrical trip. An investigation is in progress.

"The automatic actuation of the Reactor Protection System (RPS) is being reported as a four hour report under 10 CFR 50.72 (b)(2)(iv)(B).

"The expected actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72 (b)(3)(iv)(A).

"The NRC Senior Resident Inspector has been notified for this event."

The plant is currently stable at normal operating temperature and pressure. The grid is stable and the plant is in its normal shutdown electrical lineup. Unit 1 was unaffected by the Unit 2 trip.

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Power Reactor Event Number: 53469
Facility: VOGTLE
Region: 2     State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: DANIEL MICKINAC
HQ OPS Officer: VINCE KLCO 		Notification Date: 06/22/2018
Notification Time: 15:12 [ET]
Event Date: 06/22/2018
Event Time: 09:00 [EDT]
Last Update Date: 06/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GERALD MCCOY (R2DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

NON-LICENSED SUPERVISORY CONTRACTOR SUBVERTS FITNESS FOR DUTY TEST

"At 0900 [EDT] on June 22, 2018, a non-licensed supervisory contractor subverted a random Fitness for Duty test. The contractor's site access has been terminated. The NRC Resident Inspector was notified. "

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Power Reactor Event Number: 53471
Facility: DIABLO CANYON
Region: 4     State: CA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATT PLEASANT
HQ OPS Officer: ANDREW WAUGH 		Notification Date: 06/25/2018
Notification Time: 17:58 [ET]
Event Date: 06/25/2018
Event Time: 10:29 [PDT]
Last Update Date: 06/25/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
RYAN ALEXANDER (R4DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

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

At 1029 PDT on June 25, 2018, Pacific Gas and Electric determined a non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified

Page Last Reviewed/Updated Thursday, March 25, 2021

Page Last Reviewed/Updated Thursday, March 25, 2021