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Event Notification Report for August 03, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/2/2018 - 8/3/2018

** EVENT NUMBERS **


53516 53524 53525 53533 53537

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Agreement State Event Number: 53516
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: PROVIDENCE SAINT JOSEPH MEDICAL CENTER
Region: 4
City: BURBANK   State: CA
County: LOS ANGELES
License #: 0059-19
Agreement: Y
Docket:
NRC Notified By: THOMAS GEZA MIKO
HQ OPS Officer: BRIAN LIN
Notification Date: 07/19/2018
Notification Time: 02:04 [ET]
Event Date: 07/17/2018
Event Time: 10:00 [PDT]
Last Update Date: 07/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

The following information was obtained from the state of California via email:

"A cervical patient was receiving her first High Dose Rate (HDR) brachytherapy treatment, using the Varian VariSource iX HDR, on Tuesday, July 17, 2018, starting at 10 am [PDT]. The patient's 3 applicators, for the tandem and right/left ovoids, were attached to the distal ends of the transfer guide tubes specially coded for the GYN treatments (using the Varian Quick Fit connectors), with the tandem as channel 1, ovoid right as channel 2 and ovoid left as channel 3. The guide tubes were attached by the radiation therapist, and checked by two other employees. After the first fraction, the radiation therapist was preparing to disconnect the guide tubes from the applicators and noted that the distal end of the transfer guide tube for channel 1 was hanging approximately vertically along the end of the gurney. The physicist also verified this, and that the Quick Fit connectors for all of the guide tubes were still secured to the applicator and locked in place with their locking rings. However, it appeared that the transfer tube for channel 1 had been severed at its distal end from its Click Fit connector. The patient was re-surveyed to confirm that the source had retracted appropriately, with no radiation detected within the patient. The radiation therapist proceeded to disconnect the guide tubes from the applicators, remove the applicators from the patient, and clean the patient up for discharge home. The licensee is unable to ascertain whether the tube failed before the Ir-192 source deployed to the treatment site or upon return of the source to HDR storage. It is possible that the patient received the planned treatment, with the source in the correct dwell locations. It is also possible that the Ir-192 seed landed on the gurney close to the patient's skin, or that the source extended vertically down from the distal end of the transfer tube, in which case the patient's lower extremities were exposed to a smaller dose of approximately 500 mR. Staff immediately notified Varian of the event, and took the tubing out of service. New tubing is scheduled to arrive on Friday 7/20/2018, and no HDR treatments will occur before then. Staff also immediately notified the patient's physician. RHB will conduct a site visit on Friday 7/20/2018."

California report no.: 5010-071718

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: 53524
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: BURNELL-LAMMONS ENGINEERING, INC
Region: 1
City: GREENVILLE   State: SC
County: GREENVILLE
License #: 548
Agreement: Y
Docket:
NRC Notified By: ANDREW M. ROXBURGH
HQ OPS Officer: BRIAN LIN
Notification Date: 07/26/2018
Notification Time: 07:15 [ET]
Event Date: 07/25/2018
Event Time: 15:30 [EDT]
Last Update Date: 07/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the State of South Carolina via email.

"On July 25, 2018, the Department [South Carolina Department of Health and Environmental Control] was notified by the licensee at approximately 3:30 PM [EDT] that one of its gauges had been run over by a bull dozer at a jobsite. The gauge was a Troxler Model 3430 (S/N 34618) containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be. The sealed source serial number for the Cs-137 source is 77-1459 and the sealed source serial number for the Am-241:Be source is 47-30042. A radiation survey and wipe test of the gauge were performed at the scene. The gauge was safely transported back to the licensee's facility and placed in storage awaiting disposal."

South Carolina Incident #: L548

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Agreement State Event Number: 53525
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CALFRAC WELL SERVICES CORP
Region: 4
City: SAN ANTONIO   State: TX
County:
License #: L06710
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/26/2018
Notification Time: 14:47 [ET]
Event Date: 07/25/2018
Event Time: 00:00 [CDT]
Last Update Date: 07/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

TEXAS AGREEMENT STATE REPORT - DAMAGED GAUGE

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

"On July 26, 2018, the licensee notified the Agency [Texas Department of State Health Services] that on July 25, 2018, while using a crane to perform routine loading of a pipe on which was mounted a Berthold Model LB8010 density gauge, containing a 20 millicurie cesium-137 source, the pipe/gauge fell. The shutter handle was bent and the shutter, which was in the closed position, was not operable due to the damage. The licensee performed surveys to ensure the shutter was in the fully closed position. The licensee is making arrangements for the disposal of the device. There is no risk of exposure to any individual as a result of this event. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident #9601

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Power Reactor Event Number: 53533
Facility: MILLSTONE
Region: 1     State: CT
Unit: [] [] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: NICOLAOS KOSTOPOULOS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 08/02/2018
Notification Time: 13:09 [ET]
Event Date: 08/02/2018
Event Time: 09:00 [EDT]
Last Update Date: 08/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO RELEASE OF POSSIBLE TRITIUM BEARING WATER

The following was received via telephone and email notification from Millstone Power Station:

Millstone Power Station Unit 3, identified that the underground pipe to the Condensate Surge Tank had leaked greater than 100 gallons of water that included trace amounts of tritium to the ground. The effected piping is inside the protected area and has been isolated and drained.

No tritium has been detected in any monitoring wells outside of the Protected Area. There is no threat to employees or the public or impact to drinking water.

The Connecticut Department of Energy and Environmental Protection, and the towns of Waterford and East Lyme were notified at approximately 1300 [EDT] on August 2, 2018.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53537
Facility: FERMI
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: EHAN HAUSER
HQ OPS Officer: VINCE KLCO
Notification Date: 08/03/2018
Notification Time: 14:10 [ET]
Event Date: 08/03/2018
Event Time: 09:40 [EDT]
Last Update Date: 08/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVE ORTH (R3DO)
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

HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"At 0940 EDT on August 3, 2018, the Division 2 Mechanical Draft Cooling Tower (MDCT) fans were declared inoperable due to failure of the over speed fan brake inverter. The brakes prevent fan over speed from a design basis tornado. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. Investigation into why the Division 2 MDCT fan over speed brake inverter failed is in progress. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"The NRC Resident Inspector has been notified."


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Friday, May 03, 2019