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Event Notification Report for September 23, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/21/2018 - 9/23/2018

** EVENT NUMBERS **


53602 53603 53617

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Agreement State Event Number: 53602
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: THE POLYCLINIC
Region: 4
City: Seattle   State: WA
County:
License #: WN-M0218-1
Agreement: Y
Docket:
NRC Notified By: RAJ MAHARJAN
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 09/13/2018
Notification Time: 12:11 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - REPORT OF LEAKING MEDICAL SOURCE

The following excerpted information was obtained from the State of Washington via email:

"On 8/31/2018, two [70 microCurie] I-125 seeds were implanted into a patient's breast associated with an RSL [radioactive seed localization] procedure; they were explanted on 9/4/2018. On 9/5/2018, [the State of Washington] was notified by a Nuclear Medicine Technician from Polyclinic-Madison Center (904 Seventh Avenue, Seattle) that I-125 seeds had been returned to them following a pathologic exam at the Polyclinic Histology Laboratory."

"The leaking seeds and surgical clips were placed in a shielded container that housed multiple seeds undergoing decay-in-storage prior to disposal. The three plastic containers that were used (specimen cup, sentinel node container, and breast tissue container) have sealed lids and are presently located in the shielded Biodex storage locker located in Polyclinic's nuclear cardiology Hot Lab at Madison Center. All three containers have internal I-125 contamination from the leaking seed. In an attempt to establish a mechanism of action for the leaking source, the surgeon was interviewed and nothing in the way of an apparent cause was identified. Additionally, the surgical notes did not identify any anomalies."

"Although a breach of source containment occurred for an unknown cause, the radiation exposures received by personnel involved with handling of the leaking seed and the patient that had the seed implanted in breast tissue for four days were assessed as not representing a safety issue for any individual."

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

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Agreement State Event Number: 53603
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: CY-FAIR MEDICAL CENTER
Region: 4
City: HOUSTON   State: TX
County: HARRIS
License #: L06907
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: VINCE KLCO
Notification Date: 09/13/2018
Notification Time: 14:38 [ET]
Event Date: 07/16/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The following information was received by the State of Texas:

"On 09/13/2018, the Agency [Texas Department of State Health Services] was notified by a licensee that an employee received a personnel dosimetry report of 16.0 rem for the second quarter of 2018. The employee had received a report of a 3.3 rem exposure for the previous quarter. The licensee suspects that someone tampered with the dosimeter. The employee works in the nuclear medicine department and always leaves the badge attached to the lab coat on the door to the hot lab. Other employees performing similar work only received minimal exposures. Due to the amount of the reported exposure, the agency will conduct an investigation on site."

Texas Incident: I-9613

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Power Reactor Event Number: 53617
Facility: PEACH BOTTOM
Region: 1     State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: SAMIJ PATEL
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2018
Notification Time: 22:04 [ET]
Event Date: 09/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JONATHAN GREIVES (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

HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE

"On 9/21/18, at 1755 EDT, Peach Bottom Atomic Power Station Unit 3 declared the High Pressure Coolant Injection system [HPCI] inoperable due to an inoperable differential pressure indicating switch [DPIS]. The DPIS is used to isolate the HPCI system when there is a high steam line flow condition. Operations declared the HPCI system inoperable and entered Technical Specification 3.5.1 Condition C for HPCI being inoperable. Technical Specification 3.3.6.1 was also entered for HPCI instrumentation being inoperable. Other standby systems (Reactor Core Isolation Cooling and Low Pressure Emergency Core Cooling Systems) are OPERABLE.

"HPCI is a single train system. Therefore, per NUREG-1022, this condition is being reported pursuant to 10CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of the safety function of a system required to mitigate the consequences of a design event.

"This condition has been entered into the corrective action program (IR 4175355). Investigation of the exact cause of the indication issue is in progress.

"The NRC Resident has been informed of this notification."

* * * UPDATE AT 1317 EDT ON 09/22/2018 FROM CRAIG TAULMAN TO JEFF HERRERA * * *

"On 09/22/18 at 0955 EDT, RCS [Reactor Coolant System] pressure boundary leakage was identified as the cause of the HPCI high steam flow indication issue. Technical Specification 3.4.4 was entered which will require the initiation of a nuclear plant shutdown. This indicates a degradation of a principal safety barrier. Current Unit 3 reactor power is 35%. This condition is being reported pursuant to 10 CFR 50.72(b)(2)(i) and 50.72(b)(3)(ii). This condition is being tracked in the corrective action program (IR 4175355). The NRC Resident has been informed".

Peach Bottom will be notifying State and local agencies regarding the event.

Notified the R1DO (Greives).


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Friday, May 03, 2019