Event Notification Report for February 20, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/19/2019 - 2/20/2019

** EVENT NUMBERS **

53868

53869

53883

Agreement State	Event Number: 53868
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: EASTERN REGIONAL MEDICAL CENTER Region: 1 City: PHILADELPHIA State: PA County: License #: PA-0980 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: JEFF HERRERA	Notification Date: 02/11/2019 Notification Time: 14:15 [ET] Event Date: 02/08/2019 Event Time: 00:00 [EST] Last Update Date: 02/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHRISTOPHER CAHILL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE TO PATIENT LESS THAN PRESCRIBED DOSE

The following report was received from the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection via email:

"The licensee reported that on February 8, 2019, while reviewing a patient treatment plan, it was discovered that the patient had received a dose from a high dose rate remote afterloader containing iridium-192 that was less than the prescribed dose in the written directive. The original treatment plan was prescribed for 7.0 Gy per fraction, however at the beginning of the 3rd fraction it was noticed that the total dose delivered was 4.67 Gy instead of the prescribed 14 Gy they should have received for the same 2 fractions. The physician has informed the patient and will amend the written directive to add additional fractions at different doses to achieve the original prescribed dose to the treatment area. No more information is available at this time from the licensee. We will update this event as soon as more information is provided.

"Cause of the Event: Unknown / Human error.

"ACTIONS: The Department [Pennsylvania Department of Environmental Protection] will perform a reactive inspection. More information will be provided upon receipt."

* * * UPDATE AT 1227 EST ON 02/14/2019 FROM JOHN CHIPPO TO TOM KENDZIA * * *

The following update was received from the Pennsylvania Department of Environmental Protection via email:

"The patient received treatment on January 29, 2019, and February 5, 2019. The patient had not finished her initially scheduled 3rd fraction. The Medical Event was identified on Friday, February 8, 2019. The equipment manufacturer is Varian, model VariSource iX(t), Serial Number 00400. The source activity as of February 11, 2019 was 6.819 Ci. The licensee is still in the process of identifying root cause and corrective action."

Pennsylvania Report: PA190003

Notified the R1DO (Ferdas) and NMSS Events (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.

Fuel Cycle Facility	Event Number: 53869
Facility: LOUISIANA ENERGY SERVICES RX Type: Comments: URANIUM ENRICHMENT FACILITY GAS CENTRIFUGE FACILITY Region: 2 City: EUNICE State: NM County: LEA License #: SNM-2010 Docket: 70-3103 NRC Notified By: RICARDO MEDINA HQ OPS Officer: RICHARD SMITH	Notification Date: 02/12/2019 Notification Time: 13:55 [ET] Event Date: 02/11/2019 Event Time: 15:19 [MST] Last Update Date: 02/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS	Person (Organization): ERIC MICHEL (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

LOSS OR DEGRADATION OF SAFETY ITEMS

"[On February 11, 2019 at 1519 MST,] it was discovered that the calibration certificates for Measuring and Testing Equipment (M&TE) used to perform temperature trip IROFS [Items Relied On For Safety] surveillances, only had 1 set of calibration data. The instruments have an internal temperature sensor and an external input for temperature. Previously, the IROFS surveillances for IROFS 1, 2, 4, 5, 11, 43, C15, and C16 were performed using the external input.

"An external vendor, that performs the calibration for this M&TE, confirmed that the calibration had only been performed on the internal temperature sensor. This issue of how ATC-1 and ATC-2 (Jofra brand dry-block temperature calibrators) were calibrated is not currently an issue, as UUSA [URENCO USA] now only uses the Jofras as a heat source and uses a separately calibrated resistance temperature detector (RTD) and display for IROFS surveillances.

"Further investigation findings showed that a number of UF6 stations had not had their scheduled surveillance with the new method using a separately calibrated RTD. In total, 25 stations had their required annual IROFS surveillances performed with M&TE equipment which used an input that was not properly calibrated.

"The plant is in a safe condition."

The licensee will be contacting Region II.

Power Reactor	Event Number: 53883
Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: JEFF MYERS HQ OPS Officer: JOANNA BRIDGE	Notification Date: 02/19/2019 Notification Time: 15:19 [ET] Event Date: 02/19/2019 Event Time: 12:53 [EST] Last Update Date: 02/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL	Person (Organization): ERIC DUNCAN (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

SECONDARY CONTAINMENT INOPERABLE

"On February 19, 2019, at 1307 EST, with the reactor at 100 percent Core Thermal Power and steady state conditions, plant personnel notified the Main Control Room that both doors in the Secondary Containment Airlock on the Reactor Building Fifth Floor were opened simultaneously for a period of approximately five minutes (i.e., from 1253 to 1258 EST). The failure of this interlock, which is intended to prevent both doors from being opened simultaneously, resulted in the Technical Specification (TS) Surveillance Requirement (SR) 3.6.4.1.3 not being met. The maximum Secondary Containment pressure observed during that time remained within TS limits. There were no radiological releases associated with this event.

"Declaring Secondary Containment inoperable as a result of not meeting TS SR 3.6.4.1.3 is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material.

"The licensee has notified the NRC Resident Inspector."

The repair to the failed interlock is in progress. As a compensatory measure signs are posted on the doors to notify personnel to not access the Reactor Building via those doors.

Page Last Reviewed/Updated Wednesday, March 24, 2021