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Event Notification Report for June 26, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/25/2018 - 6/26/2018

** EVENT NUMBERS **


53458 53471 53472 53476

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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: 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

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Power Reactor Event Number: 53472
Facility: COMANCHE PEAK
Region: 4     State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM BENNETT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/26/2018
Notification Time: 04:26 [ET]
Event Date: 06/26/2018
Event Time: 00:03 [CDT]
Last Update Date: 06/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RYAN ALEXANDER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

MAIN STEAM LINE RADIATION MONITOR DETERMINED TO BE NON-FUNCTIONAL

"At time 0003 [CDT], Main Steamline Radiation Monitor 2-RE-2326 (Main Steam line 2-02) reading spiked and [was] declared non-functional.

"With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in steam generator 2-02 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10CFR50.72(b)(3)(xiii).

"Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity and there is negligible safety significance to the current condition [with respect to the] public health and safety perspective.

"Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP emergency plan in the unlikely event of challenges to the steam generator or fuel cladding. The N16 radiation monitor serves as a backup with alarm function and Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL 2-02.

"Corrective actions are being pursued to restore 2-RE-2326 to functional status.

"The NRC Resident Inspector has been notified."

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53476
Facility: COOPER
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: RANDY KOUBA
HQ OPS Officer: ANDREW WAUGH
Notification Date: 06/26/2018
Notification Time: 23:29 [ET]
Event Date: 06/26/2018
Event Time: 16:30 [CDT]
Last Update Date: 08/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RYAN ALEXANDER (R4DO)
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

CONTROL ROOM EMERGENCY FILTRATION SYSTEM DECLARED INOPERABLE

"On June 26, 2018, at 1630 CDT, the Control Room Emergency Filtration System (CREFS) was declared inoperable when Main Control Room Supply Fan SF-C-1B was discovered to have elevated vibrations that brought into question the ability to meet its mission time.

"CREFS is a single train safety system. Per 10 CFR 50.72(b)(3)(v)(D), an 8 hour report is required due to the fact that at the time of discovery this condition could have prevented the fulfillment of a safety function of an SSC [System Structure or Component] that is required to mitigate the consequences of an accident.

"The licensee has notified the NRC Senior Resident Inspector."

* * * RETRACTION FROM THOMAS FORLAND TO VINCE KLCO ON 8/13/18 AT 1024 EDT * * *

The following retraction was received from Cooper Nuclear Station (CNS) via facsimile and phone call:

"CNS is retracting the 8-hour non-emergency notification made on June 26, 2018 at 1630 CDT (EN# 53476). Subsequent evaluation concluded that overall vibration levels were not at a level that would impact the ability of the Main Control Room Supply Fan SF-C-18 to perform its safety function for its required mission time and the CREFS therefore, was operable.

"The NRC Senior Resident Inspector has been notified."

Notified the R4DO (Deese).


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Friday, May 03, 2019