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Event Notification Report for November 18, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/15/2019 - 11/18/2019

** EVENT NUMBERS **


54376 54377 54390 54391

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Agreement State Event Number: 54376
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HEALTH NETWORK
Region: 1
City: ALLENTOWN   State: PA
County:
License #: PA-0232
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 11/07/2019
Notification Time: 14:08 [ET]
Event Date: 11/05/2019
Event Time: 00:00 [EST]
Last Update Date: 11/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CHERUBINI (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The Department [Pennsylvania Department of Environmental Protection] received notification from a licensee on November 6, 2019 that on October 8, 2019 they performed a prostate seed implant on a patient including seventy (70) stranded I-125 seeds that were implanted into the prostate treatment volume. They were Best Medical, Model 2301, Lot 48917, at 0.350 mCi per seed and 24.5 mCi total activity. The patient had an appointment on November 5, 2019 for a 30-day post-plan analysis. The CT from November 5, 2019 noted 2 seeds that were outside the prostate volume in the peri-prostatic fat. The post-plan analysis showed that 68 of 70 seeds are within the treatment volume and 94.4 percent of the treatment volume is covered by the prescription dose, which are within appropriate specifications for a prostate seed implant. The two seeds in question are considered discontiguous from the treatment volume. The licensee believes when the needle was retracted, the strand of seeds drug back with the needle and was deposited inferior from their intended location. An analysis was performed by the licensee and no adverse effects to the patient are expected. Both the patient and referring physician were notified. The Department will update this event as soon as more information is provided."

Pennsylvania Event Report ID No: PA190026

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: 54377
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: SONORA   State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/07/2019
Notification Time: 14:55 [ET]
Event Date: 11/06/2019
Event Time: 00:00 [CST]
Last Update Date: 11/07/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

TEXAS AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE

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

"On November 7, 2019, the licensee's radiation safety officer (RSO) notified the Agency [Texas Department of State Health Services] that at approximately 2000 CST on November 6, 2019, one of their industrial radiography crews had been unable to retract a 113 Curie iridium-192 source (model 702, SN: TT2307) into a QSA 880 Delta exposure device (SN: D7727) at a temporary job site in Sonora, Texas. The RSO stated the drive cable had broken at the ball stop. Source retrieval was performed by authorized employees. The initial radiographers' and another of the licensee employee's self-reading pocket dosimeters read 13 and 14 mR. The two authorized source retrievers' self-reading pocket dosimeters had readings of approximately 300 mR. All dosimetry badges are being sent for immediate processing. There were no other persons in the area so there was no risk of exposure to any member of the public. The RSO and staff will examine the crank assembly and drive cable when it gets to their location on November 8, 2019. The RSO also plans to send the crank assembly/drive cable for evaluation by a third party service/repair company. The exposure device was tested multiple times using a different set of cranks following the retrieval and it operated properly. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No: 9723

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Power Reactor Event Number: 54390
Facility: WATTS BAR
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JUSTIN GALLAGHER
HQ OPS Officer: MICHAEL BLOODGOOD
Notification Date: 11/16/2019
Notification Time: 03:02 [ET]
Event Date: 11/15/2019
Event Time: 22:34 [EST]
Last Update Date: 11/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RANDY MUSSER (R2DO)
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

TEMPORARY LOSS OF CONTROL ROOM ENVELOPE BOUNDARY

"At 2234 Eastern Standard Time (EST) on November 15, 2019, a Main Control Room (MCR) alarm was received for low control room positive pressure.

"At 2236 EST, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10 Control Room Emergency Ventilation System (CREVS) was declared not met for both trains. Watts Bar Unit 1 and Unit 2 entered Condition B.

"At 2236 EST on November 15, 2019, the alarm cleared, CREVS was declared operable and LCO 3.7.10 Condition B was exited for both units.

"This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 54391
Facility: WATTS BAR
Region: 2     State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JUSTIN GALLAGHER
HQ OPS Officer: MICHAEL BLOODGOOD
Notification Date: 11/16/2019
Notification Time: 03:02 [ET]
Event Date: 11/15/2019
Event Time: 23:53 [EST]
Last Update Date: 11/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RANDY MUSSER (R2DO)
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

TEMPORARY LOSS OF CONTROL ROOM ENVELOPE BOUNDARY

"At 2353 EST on November 15, 2019, a Main Control Room (MCR) alarm was received for low control room positive pressure.

"At 2355 EST, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10 Control Room Emergency Ventilation System (CREVS) was declared not met for both trains. Watts Bar Unit 1 and Unit 2 entered Condition B.

"At 2355 EST on November 15, 2019, the alarm cleared, CREVS was declared operable and LCO 3.7.10 Condition B was exited for both units.

"This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

See similar EN #54390. The licensee has taken compensatory measures while investigating the cause.


Page Last Reviewed/Updated Monday, November 18, 2019
Monday, November 18, 2019