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Event Notification Report for July 02, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/1/2020 - 7/2/2020

** EVENT NUMBERS **


54706 54755 54757 54761

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Agreement State Event Number: 54706
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Ineos Oligomers Chocolate Bayou
Region: 4
City: Alvin   State: TX
County:
License #: G02551
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Kerby Scales
Notification Date: 05/12/2020
Notification Time: 14:02 [ET]
Event Date: 05/10/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/01/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 7/2/2020

EN Revision Text: AGREEMENT STATE REPORT - NUCLEAR GAUGE BROKEN LOCKING MECHANISM

The following was received by the state of Texas via email:

"On May 12, 2020, the Agency [Texas Department of State Health Services] was notified by the licensee that the locking mechanism on a Endress Houser nuclear gauge model number FQG61 had broken off the gauge housing preventing them from locking the shutter in the closed position. The gauge contains a 100 milliCurie (original activity) cesium-137 source. The shutter operates normally. The licensee reported the gauge will not present an exposure risk to any individual. The licensee stated it is in the process of trying to schedule repairs to the gauge. Additional information will be provided as it is received in accordance with SA 300."

Texas Incident Number: 9766

* * * UPDATE ON 7/1/2020 AT 1312 EDT FROM KAREN BLANCHARD TO BRIAN LIN * * *

The following update was received via email:

"On June 30, 2020, the licensee reported that there had been another failure with the gauge. The Radiation Safety Officer [RSO] was investigating to determine what had happened and learned that the rotary element and the source tube attached to it had come partially out of the gauge and when employees tried to put it back in it came apart into pieces. The two employees thought the source was still in the gauge housing and they picked up the pieces. They did not realize that one of the pieces they picked up was the source and it had separated from the source tube. One employee picked it up and gave it to the other employee who put it into his shirt pocket. The RSO contacted a licensed service company who put the source into a lead pig and it is now secured at the licensee's facility. The licensee is continuing to investigate, but initial dose calculations as of July 1, 2020 indicate the dose, especially to the one employee, will exceed reporting requirement of greater than 25 rem TEDE [Total Effective Dose Equivalent]. The licensee will conduct a re-enactment to collect better information for dose reconstruction and calculation. They have been given the information for REAC/TS and have indicated they will pursue contacting them for biodosimetry. Current activity for the Cesium-137 source is 95 milliCuries (was 100 milliCi original activity). More information will be provided as it is obtained in accordance with SA-300."

Notified R4DO (Silva), NMSS Regional/INES Coordinator (Rivera-Capella) and NMSS Event Notifications (email).

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Agreement State Event Number: 54755
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Texas Oncology PA
Region: 4
City: Harlingen   State: TX
County:
License #: L 00154
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian Lin
Notification Date: 06/24/2020
Notification Time: 08:00 [ET]
Event Date: 06/23/2020
Event Time: 09:00 [CDT]
Last Update Date: 06/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - HIGH DOSE RATE TANDEM APPLICATOR BROKEN DURING TREATMENT

The following was received via E-mail from the State of Texas:

"On June 23, 2020, the licensee reported that at approximately 0900 CDT, a Medical Event occurred at its facility. The event involved a patient receiving an High Dose Rate (HDR) cervix treatment with a Nucletron Model microSelectron using a tandem and ring. The device contained a 5.191Curie Iridium-192 source. After the treatment was completed and the device was removed, it was discovered the tandem had broken into two pieces. The licensee stated it is unknown where the source was positioned during the treatment. The licensee reported no warnings or errors from the machine were recorded from either the check source or the treatment cable. The licensee stated the source was in the patient for a total of 564.7 seconds. The source was in the tandem a total of 355.2 seconds of that total time. The licensee stated the physician has been notified, but was not sure if the patient had been notified. The licensee stated they were still investigating what occurred and will provide more specific information as it is discovered. Additional information will be provided as it is received in accordance with SA300."

Texas Incident No.: 9774


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 0902 EDT ON 6/30/2020 * * *

"The break in the tandem occurred about four inches from the end of the tandem. A picture provided by the licensee shows the break at the beginning of the bend in the tandem on the insertion end at the start of the ring. The licensee stated using the location of the guide wire, which they could track, it now appears that the source tracked next to the tandem and that the exposure occurred only to the intended tissue. The manufacture is investigating the event with the licensee. Additional information will be provided as it is received in accordance with SA300."

Notified R4DO (Silva) and NMSS Events Notification E-mail group.

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Agreement State Event Number: 54757
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: University of Oklahoma Health Science Center
Region: 4
City: Oklahoma City   State: OK
County:
License #: OK-03176-01
Agreement: Y
Docket:
NRC Notified By: Kevin Sampson
HQ OPS Officer: Bethany Cecere
Notification Date: 06/24/2020
Notification Time: 16:31 [ET]
Event Date: 06/23/2020
Event Time: 00:00 [CDT]
Last Update Date: 06/24/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SUSPECTED DOSE TO WRONG ORGAN

The following is a summary of email received from the Oklahoma Department of Environmental Quality (OK DEQ):

OK DEQ was just informed that yesterday, June 23, 2020, a medical event may have occurred involving a patient undergoing radiation therapy to the vagina. The treatment plan called for three (3) fractions delivered by a High Dose Rate (HDR) afterloader. After the first fraction was administered, the therapist noted the presence of fecal matter on the applicator. The licensee is assuming that the applicator was placed in the patient's rectum instead of the vagina. The treatment plan estimated a dose of 0.85 Sv to the rectum due to the procedure. The licensee estimates the actual dose delivered, assuming the applicator was in the rectum, to be 1.5 Sv. The licensee is the University of Oklahoma Health Science Center, OK-03176-01. This is a Type A medical broadscope license. OK DEQ will provide more information as it becomes available.


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: 54761
Facility: Fermi
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Jeffrey Myers
HQ OPS Officer: Kerby Scales
Notification Date: 07/02/2020
Notification Time: 02:01 [ET]
Event Date: 07/01/2020
Event Time: 23:05 [EDT]
Last Update Date: 07/02/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
PATRICIA PELKE (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

LOSS OF OFFSITE POWER - AUTO INITIATION OF EMERGENCY DIESEL GENERATOR

"At 2305 EDT on July 1, 2020, while in Mode 5 for Refueling Outage 20 with no core alterations in progress, Fermi 2 experienced a loss of Division 2 offsite power (345 kV) which resulted in a valid automatic initiation of the Division 2 Emergency Diesel Generators (EDG) 13 and 14. EDG 13 and 14 started as expected to supply their associated busses. Division 1 offsite power remains operable and powering the Division 1 Residual Heat Removal (RHR) system in Shutdown Cooling (SDC) mode of operation. Division 1 EDGs 11 and 12 remain operable and available.

"The cause of the loss of Division 2 offsite power is under review and has preliminarily been determined to be caused by Mayfly accumulation in and around the Division 2 (345 kV) switchyard. Actions have been put in place to minimize and deter Mayflies from gathering near plant switchyards.

"All systems responded as expected for the loss of Division 2 offsite power and no loss of SDC occurred. There was no impact to the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified.

"The event is reportable pursuant to 10 CFR 50.72(b)(3)(iv)(A), as a valid specified system actuation."


Page Last Reviewed/Updated Thursday, July 02, 2020
Thursday, July 02, 2020