| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
8/16/2018 - 8/17/2018 ** EVENT NUMBERS ** |
| 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. |
| Agreement State | Event Number: 53539 | Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: KETTERING MEDICAL CENTER
Region: 3
City: KETTERING State: OH
County: MONTGOMERY
License #: 02120580021
Agreement: Y
Docket:
NRC Notified By: MICHAEL J RUBADUE
HQ OPS Officer: BRIAN LIN | Notification Date: 08/08/2018
Notification Time: 16:46 [ET]
Event Date: 08/02/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/08/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)
DAN COLLINS (EMAIL) | Event Text AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE
The following information was received via E-mail:
"The licensee reported to the [Ohio] Department [of Health] on 8/3/2018 that a potential medical event had occurred due to a delay in a surgical procedure. The delay was caused by the insurance company rescinding approval to remove a breast tumor until three medical opinions were obtained. The licensee implanted a 472 microCi I-125 seed [radioactive seed localization] (RSL) in the tumor on 5/29/2018 after receiving approval from the insurance company. The surgery was scheduled for 6/4/2018. The expected dose to the patient was 12.65 Rem to the tissue and 1.52 Rem EDE [Effective Dose Equivalent]. The surgery was delayed until approval from the insurance company was obtained, and was performed on 8/2/2018. The delay resulted in a tissue dose of 99.45 Rem and EDE of 11.93 Rem.
"A follow-up will be conducted with the routine inspection in September."
Ohio State Report: OH180006
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. |
| Agreement State | Event Number: 53541 | Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: BIONOMICS
Region: 1
City: OAK RIDGE State: TN
County:
License #: TN-R-73021-E25
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: OSSY FONT | Notification Date: 08/09/2018
Notification Time: 16:25 [ET]
Event Date: 08/08/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/14/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | | This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - UNCONTROLLED SOURCE FOUND
The following was received via email from the State of Tennessee
"Bionomics in Oak Ridge, Tennessee was contracted by a metal recycler in Arkansas to pick up some radioactive material that was rejected by a metals processor. Bionomics made the pickup on August 1st. Upon opening the shipment on August 8th they discovered an orphaned radium source. Current survey information indicates that a contact reading on the device is 22 mRem/hr. The information printed on the device is as follows:
"Manufacturer: MINE SAFETY APPLIANCES COMPANY
Model: BILLION-AIRE ANALYZER
Model #: 706P
Serial #: 52328
Isotope: Ra-226 (150 microCi) (JULY 1966) [Calculated 147 microCi (August 2018)]
"A follow-up report will be submitted within 30 days."
* * * UPDATE FROM ANDREW HOLCOMB TO VINCE KLCO ON 8/14/18 AT 1211 EDT * * *
The following information was received from the State of Tennessee via email:
"Bionomics in Oak Ridge, TN was contracted by Tenenbaum Recycling Group (TRG) in Harrison, Arkansas, to pick up some radioactive scrap metals. Bionomics made the pick up on August 1st. Prior to leaving the site, the technician discovered a radium source within the pile of scrap metal scheduled for pick-up. On August 8th, Arkansas was notified by Bionomics and in turn notified the State of TN that a radium device had been picked up and was currently in Oak Ridge, TN at the Bionomics facility. Current survey information indicates that a contact reading on the device is 22 mRem/hr. The information printed on the device is as follows:
"Manufacturer: MINE SAFETY APPLIANCES COMPANY
Model: BILLION-AIRE ANALYZER
Model #: 706P
Serial #: 52328
Isotope: Ra-226 (150 microCi)
"A follow-up report will be submitted within 30 days."
Tennessee Event Report ID NO.: TN-18-140
Notified the R1DO (Young) and NMSS Events Notifications via email.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| Agreement State | Event Number: 53542 | Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: FREEPORT State: TX
County:
License #: LICEN-RAM-L00451
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: DONALD NORWOOD | Notification Date: 08/09/2018
Notification Time: 16:38 [ET]
Event Date: 08/08/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - LEVEL GAUGE STUCK SHUTTER
The following information was received via E-mail:
"On August 9, 2018, the Agency [Texas Department of State Health Services] received a notice from the radiation safety officer that a line level gauge was stuck in the open normal operating position. The gauge was found to be stuck during a blow-down operation yesterday afternoon. The gauge is a Ronan SA1-F37 with a Cesium-137 100 milliCurie source (serial number M5513). The gauge is to be serviced by the manufacturer's technician next week.
"The RSO was contacting the licensing section to request an amendment to the permit to operate the gauge in the stuck open position.
"The gauge is fixed at least 20 feet above ground level on a vessel and should not cause any effects to personnel. No exposures were reported upon discovery and the gauge does not present an exposure risk to any individual. The RSO will report the repair or disposal once the gauge is serviced/inspected. The investigation into this event is on-going. Updates to be provided in accordance with SA300."
Texas Incident #: I-9605 |
| Power Reactor | Event Number: 53548 | Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROB KLINDWORTH
HQ OPS Officer: RICHARD SMITH | Notification Date: 08/12/2018
Notification Time: 02:58 [ET]
Event Date: 08/12/2018
Event Time: 01:58 [EDT]
Last Update Date: 08/16/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
| Person (Organization):
CHRISTOPHER CAHILL (R1DO) | | 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 TECHNICAL SPECIFICATION REQUIRED SHUTDOWN - LOSS OF 480 VOLTAGE EMERGENCY BUS
"On 8-12-18 at 0158 EDT, Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. This resulted in a Loss of Safety Function due to the 2-2 Emergency Diesel Generator [EDG] being Inoperable coincident with the Residual Heat Release Valve (2SVS-HCV104). A Technical Specification shutdown is required per LCO 3.0.3."
The Licensee also stated they were in an unanalyzed condition due to the EDG and Residual Heat Release Valve being inoperable at the same time.
The Licensee is shutting down to Mode 5 (Cold Shutdown).
The Licensee is notifying the Resident Inspector.
The Licensee will be making a Press Release about the unplanned shutdown.
* * * UPDATE ON 08/16/2018 AT 1424 EDT FROM BLASE BARTKO TO KEN MOTT * * *
"On 8-12-18 at 0158 [EDT] Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. Per operational guidance, this was determined to be a Loss of Safety Function due to the Unit 2 Emergency Diesel Generator (EDG) being INOPERABLE coincident with the Residual Heat Release Valve (2SVS-HCV104) 10 CFR 50.72(b)(3)(v)(B) and (D). This was also reported as an Unanalyzed Condition 10 CFR 50.72(b)(3)(ii)(b).
"No Press Release was performed for this event.
"The NRC Resident Inspector was notified.
"At 0410 [EDT] a Technical Specification Shutdown was commenced 10 CFR 50.72(b)(2)(i).
"At 2011 [EDT] the 480 Volt 2P Emergency Bus was restored and energized.
"Further evaluation of the event has determined that this event was not an Unanalyzed Condition and did not result in a Loss of Safety Function. The classifications of Unanalyzed Condition and Loss of Safety Function are being retracted.
"The accuracy of the existing guidance relative to Safety Function has been entered in the Corrective Action Program and interim actions have been taken to provide accurate guidance."
Notified R1DO (Young) via email. |
| Power Reactor | Event Number: 53551 | Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN CONROY
HQ OPS Officer: KENNETH MOTT | Notification Date: 08/16/2018
Notification Time: 12:08 [ET]
Event Date: 08/16/2018
Event Time: 08:40 [CDT]
Last Update Date: 08/16/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
KARLA STOEDTER (R3DO)
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 LICENSED EMPLOYEE
"In accordance with 10 CFR 26.719(b)(2)(ii), this notification reports a licensed Operations employee had a confirmed positive for alcohol during a random fitness for duty test. The individual was not in the protected area and not performing licensed duties at the time of discovery. The employee's access to the plant has been suspended.
"The NRC Resident Inspector has been notified." |
| Power Reactor | Event Number: 53552 | Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ERIC MASCHUCK
HQ OPS Officer: ANDREW WAUGH | Notification Date: 08/17/2018
Notification Time: 08:17 [ET]
Event Date: 08/16/2018
Event Time: 15:19 [EDT]
Last Update Date: 01/08/2019 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
MATT YOUNG (R1DO)
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 | Event Text FITNESS-FOR-DUTY TEST POSITIVE FOR NON-LICENSED EMPLOYEE
At 1519 EDT on August 16, 2018, Exelon determined a non-licensed employee had a confirmed positive for a controlled substance during a random Fitness-for-Duty test. The employee's unescorted access to the plant has been terminated.
The NRC Resident Inspector has been notified.
* * * UPDATE FROM MICHAEL FITZWATER TO DONALD NORWOOD AT 1310 EST ON 1/8/2019 * * *
The following is a correction to the reason for the Fitness-for-Duty test:
At 1519 EDT on August 16, 2018, Exelon determined a non-licensed employee had a confirmed positive for a controlled substance during a follow-up Fitness-for-Duty test. The employee's unescorted access to the plant has been terminated.
The NRC Resident Inspector has been notified of this correction.
Notified R1DO (Bower) and FFD E-mail group. | |