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Event Notification Report for July 02, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/29/2018 - 7/2/2018

** EVENT NUMBERS **


53465 53466 53468 53481

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Agreement State Event Number: 53465
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: TULSA GAMMA RAY, INC.
Region: 4
City: TULSA   State: OK
County:
License #: OK-17178-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/21/2018
Notification Time: 12:07 [ET]
Event Date: 06/20/2018
Event Time: 16:15 [CDT]
Last Update Date: 06/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA CRANK FAILURE

The following was received from the state of Oklahoma via phone call and E-mail:

On June 20, 2018, at approximately 1615 CDT, Tulsa Gamma Ray, Inc. (License # OK-17178-02) had a failure of the industrial radiography camera leaving the source exposed. The radiography camera is a model QSA 880D, source Spec T5, source strength unknown. The crank was a Sentinel SAN 882 Serial Number 15997.

The licensee was authorized to perform a source recoveries, and the Radiation Safety Officer (RSO) successfully recovered the source. The RSO received a dose of 140 mRem as indicated on the RSO's pocket dosimeter. No other exposure information was provide at the time of the report.

The state of Oklahoma will provide more information on this event as it becomes available. A State report number will be provided at that time.

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Agreement State Event Number: 53466
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: CHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS
Region: 4
City: EMERY   State: UT
County:
License #: NONE
Agreement: Y
Docket:
NRC Notified By: SPENCER WICKHAM
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/21/2018
Notification Time: 18:12 [ET]
Event Date: 06/21/2018
Event Time: 13:35 [MDT]
Last Update Date: 06/21/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM SIGNS

The following was received from the state of Utah via E-mail:

On June 21, 2018 at 1335 MDT, Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC), received written notification from the Church of Jesus Christ and Latter-Day Saints that on June 21, 2018 four tritium exit signs were discovered to having been sent to the landfill for disposal. The licensee will continue to investigate the incident and will submit a written report to the DWMRC.

Utah Event Report ID No: UT180004.

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Agreement State Event Number: 53468
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: Atlanta   State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/22/2018
Notification Time: 14:26 [ET]
Event Date: 06/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the State of Georgia via email;

"RMP [Georgia Radioactive Materials Program] received a call regarding an event that occurred at the main Emory Campus. A 57 year old male was treated on June 21, 2018 with 81.1 mCi of Y-90 Therasphere. The treatment site was the right lobe of the liver. Approximately an hour after the treatment the patient was scanned. The scan indicated that approximately 80% of the administered dose went to the left lobe, 10% went to the right lobe and some went to the stomach and some went to the 1st portion of the duodenum. It was determined there was a vessel spasm during the treatment that caused the theraspheres to shunt to the left lobe of the liver."

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.

Georgia Incident Report # 3.

* * * UPDATE FROM IRENE BENNETT TO VINCE KLCO ON 6/2/2018 AT 1426 EDT * * *

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

"[The Georgia Radioactive Materials Program] received Emory's report regarding the Y-90 procedure and verified the backflow to the left lobe was due to shunting. Based on this information, [Georgia has] determined that this is not a medical event. All documentation will be filed in the licensee's file and electronically."

Notified the R1DO (Powell) and the NMSS Events Group via email.

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Power Reactor Event Number: 53481
Facility: PERRY
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: STEPHEN KAPOSTASY
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/01/2018
Notification Time: 08:24 [ET]
Event Date: 07/01/2018
Event Time: 01:00 [EDT]
Last Update Date: 07/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 92 Power Operation 92 Power Operation

Event Text

BLOWN FUSE LEADS TO LOSS OF SAFETY FUNCTION

"On July 1st, 2018 at 0100 [EDT], a portion of the Division 1 Emergency Core Cooling System (ECCS) Loss Of Coolant Accident (LOCA) initiation logic was declared inoperable due to the discovery of a blown fuse. The fuse was replaced at 0215 on July 1st, 2018 and the Division 1 ECCS LOCA initiation logic was declared operable at 0230 on July 1st, 2018.

"The blown fuse caused the loss of a portion of the Division 1 ECCS LOCA initiation logic which would have prevented the initiation of the Emergency Closed Cooling (ECC) A system. ECC A and supported systems were declared inoperable. Low Pressure Core Spray (LPCS) was one of the supported systems that were declared inoperable. LPCS is considered a single train safety system. Inoperability of LPCS is considered an 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.

"The blown fuse also caused the loss of a portion of the Division 1 ECCS LOCA initiation logic which would have prevented the automatic isolation of Nuclear Closed Cooling and Instrument Air to the Containment. The loss of Containment isolation capability is considered an 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 event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D)

"The NRC Senior Resident Inspector has been notified."


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