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Event Notification Report for June 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/24/2019 - 6/25/2019

** EVENT NUMBERS **


54119 54120 54130

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Agreement State Event Number: 54119
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CHARTER STEEL
Region: 3
City: CUYAHOGA HEIGHTS   State: OH
County:
License #: 31200180001
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: OSSY FONT
Notification Date: 06/14/2019
Notification Time: 16:57 [ET]
Event Date: 06/07/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM HARTMAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was received via email from the Ohio Bureau of Environmental Health and Radiation Protection (Ohio):

"A stuck shutter was reported on a Berthold LB300MLT fixed gauge with a 5 mCi Cs-137 source. The stuck shutter was discovered on 6/7/19 and immediately taken out of service. The gauge was repaired on 6/14/19.

"Ohio was notified on 6/14/19. The licensee reported that the cause was the source wire interfering with the shutter movement."

Item Number: OH190007

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Agreement State Event Number: 54120
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WEST PENN ALLEGHENY HEALTH SYSTEM INC.
Region: 1
City: PITTSBURGH   State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: CATY NOLAN
Notification Date: 06/17/2019
Notification Time: 11:08 [ET]
Event Date: 06/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following was received by email from the Commonwealth of Pennsylvania:

"On Friday, June 14, 2019, the licensee experienced an equipment failure event during a brachytherapy treatment where the source failed to retract from the patient at the end of the treatment time. The catheter was immediately manually removed from the patient and placed in the emergency container and locked up. No harm is expected to the patient and no overexposures occurred. The HDR [High Dose Rate] unit, an Elekta Flexitron Model 136149A02, contained an iridium-192 source less than 12 Curies. The vendor, Best Vascular, was immediately notified and will be on site today, June 17, 2019, to retrieve the source and repair the device.

"The DEP [PA Department of Environmental Protection] will update this event as soon as more information is provided.

"The DEP will perform a reactive inspection. More information will be provided as received."

PA Event Report ID No: PA-190014

* * * UPDATE FROM JOHN CHIPPO TO OSSY FONT ON 6/19/19 AT 1002 (EDT) * * *

The following information was received from the DEP via fax:

"On Monday, June 17, 2019, a service engineer from Best Vascular was able to drive the sources into the catheter and retract them into the device several times without incident. The licensee now believes the CVBT [CardioVascular BrachyTherapy] catheter was not fully seated into the device, causing a small leak and a subsequent pressure differential which does not allow the source to fully retract into the device."

The cause of the event is believed to be operator error. The DEP will perform a reactive inspection.

Notified R1DO (Greives) and NMSS Events Notification 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.

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Power Reactor Event Number: 54130
Facility: FITZPATRICK
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: JOHN WALKOWIAK
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/24/2019
Notification Time: 21:18 [ET]
Event Date: 06/24/2019
Event Time: 18:15 [EDT]
Last Update Date: 06/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DONNA JANDA (R1DO)
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

POTENTIAL UNANALYZED CONDITION DUE TO UNPROTECTED CONTROL CIRCUITS RUNNING THROUGH MUTILPLE FIRE AREAS

"During a review of industry Operating Experience it was identified that there were unprotected DC control circuits for non safety-related DC motors which are routed from the Battery Charger Rooms to other separate fire areas. Circuit Breakers used to protect the motor power conductors appear to be inadequate to protect the control conductors. The concern is that under fire safe shutdown conditions, it is postulated that a fire in one area can cause short circuits potentially resulting in secondary fires or cable fires in other fire areas where the cables are routed. The secondary fires or cable failures are outside the assumptions of the 10 CFR 50 Appendix R Safe Shutdown Analysis.

"This condition is reportable as an 8-hour ENS report in accordance with 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition. Requirements of the Technical Requirements Manual (TRM) for the affected fire areas will be implemented."

The licensee has notified the NRC resident inspector.


Page Last Reviewed/Updated Tuesday, June 25, 2019
Tuesday, June 25, 2019