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Event Notification Report for May 01, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/30/2020 - 5/1/2020

** EVENT NUMBERS **

Agreement State	Event Number: 53996
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT HOSPITAL Region: 1 City: ATLANTA State: GA County: License #: GA 292-1 Agreement: Y Docket: NRC Notified By: IRENE BENNETT HQ OPS Officer: CATY NOLAN	Notification Date: 04/12/2019 Notification Time: 13:21 [ET] Event Date: 04/03/2019 Event Time: 00:00 [EDT] Last Update Date: 04/30/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): ANNE DeFRANCISCO (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION OF Y-90 THERASPHERES

The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:

On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient.

There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing).

The licensee will follow-up with a formal report.

* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/29/20 AT 1553 EDT * * *

The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis.

The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment.

NMED Item: 190182

Notified R1DO (Schroeder) and NMSS Events Notification (email).

* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/30/20 AT 1323 EDT * * *

The state of Georgia has amended the original report and the update from 4/29/20 as follows:
-the prescribed dose was 122 Gy
-the delivered dose was 78.8 Gy
-the difference is 64.5 percent.

This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database.

Notified R1DO (Schroeder) and NMSS Events Notification (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.

Agreement State	Event Number: 54110
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT HOSPITAL Region: 1 City: ATLANTA State: GA County: License #: GA 292-1 Agreement: Y Docket: NRC Notified By: IRVIN GIBSON HQ OPS Officer: JEFF HERRERA	Notification Date: 06/11/2019 Notification Time: 18:07 [ET] Event Date: 06/11/2019 Event Time: 00:00 [EDT] Last Update Date: 04/30/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): JOHN CHERUBINI (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDER DOSAGE DUE TO AIR BEING TRAPPED IN THE DELIVERY LINE

The following report was received from the Georgia Department of Natural Resources via email:

"A TheraSphere Y-90 patient did not receive the full dose to the target organ that was prescribed. The administered dose differed from the prescribed dose by more than 20 [percent].

"The prescribed activity to be delivered to the patient was 2.15 GBq (58 mCi). The calculated delivered activity to the patient was 1.01 GBq (27.3 mCi). The delivered activity was determined by comparing pre-and post-administration survey meter measurements of the administration equipment, as per standard TheraSphere procedure.

"Radiological Analysis:
Prescribed dose to target volume (liver): 127 Gy
Administered dose to target volume (liver): 59.8 Gy

"Discussion and Outcome:
On May 28, 2019, it was brought to the radiation safety officer's attention that a Y-90 TheraSphere administration had not delivered the full prescribed activity to the patient as intended. Upon further discussion it was noted that the performing physician noticed after connection of the line between the micro-catheter and the delivery vial that multiple air bubbles had become trapped in the line. He then created a closed system manifold using a three-way stopcock and syringes to effectively bleed out air bubbles and flush back as much of the dose as possible to the patient. The closed system prevented any spillage or contamination, and residual dose was retained in the syringes and stopcocks. Despite these actions taken by the physician, a post-administration assay of the waste container showed that the full desired activity had not made it out of the delivery equipment and into the patient. The procedure was a segmentectomy, and [the] patient will be re-evaluated in one month's time to determine if an additional therapeutic administration will be needed.

"Root Cause:
Human error: Air was likely trapped somewhere in the system during the initial setup of the equipment. Operator technique failed to completely purge the lines of this air. Air bubbles in the line were not visible or not noticed prior to the connection of the line. Efforts to eliminate the air and deliver the full dose to the patient were then not successful.

"Corrective Actions and Actions to Prevent Further Occurrences:
The nature of this event and the likely cause has been discussed with all staff involved in these procedures.

"A refresher training session has been scheduled for staff involved in these procedures. This training will be provided by a representative from BTG/TheraSphere starting on June 10, 2019.

"An additional step will be added to the procedure to visually and verbally confirm that there is no detectable air in the line between the micro-catheter and the dose vial prior to connection."

* * * UPDATE FROM IRENE BENNETT TO HOWIE CROUCH (VIA EMAIL) ON 4/30/20 AT 1323 * * *

The NMED report number from the original report was removed. The new NMED report number was not obtained. NRC Event number 54684 was also created for this event and was deleted from the database.

Notified R1DO (Schroeder) and NMSS Event Notification (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.

Agreement State	Event Number: 54676
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL Licensee: INTERNATIONAL PAPER Region: 1 City: MAYSVILLE State: KY County: License #: 401-531-410 Agreement: Y Docket: NRC Notified By: RUSSELL HESTAND HQ OPS Officer: OSSY FONT	Notification Date: 04/22/2020 Notification Time: 14:23 [ET] Event Date: 04/22/2020 Event Time: 10:42 [CDT] Last Update Date: 04/22/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE SYSTEM SWITCH FAILURE

The following was received from the state of Kentucky via fax:

"Kentucky Radiation Health Branch was notified on 4/22/20 by a representative from International Paper of a failure of a magnetic reed switch on their Honeywell gauging system. This switch senses when the mass measurement heads are separated and closes the shutter window on the radioactive source. There are two other means of determining whether the heads are out-of-alignment that also trigger the shutter window to close if indicated. Therefore, these additional layers of protection are adequate to protect against a radiation exposure if the heads are separated. International Paper has returned the system to service with the Honeywell recommendation to replace the switch as soon as the replacement part arrives. Per [the representative] of Honeywell, with the understanding that the failed component will be replaced, the customer can continue to keep the scanner under operation with the basis weight sensor."

Agreement State	Event Number: 54679
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: UNIVERSAL PRESSURE PUMPING, INC. Region: 1 City: CANTON State: PA County: License #: PA-1446 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: HOWIE CROUCH	Notification Date: 04/23/2020 Notification Time: 10:57 [ET] Event Date: 04/05/2020 Event Time: 00:00 [EDT] Last Update Date: 04/23/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON BERTHOLD RADIOACTIVE GAUGE

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

"On April 5, 2020, a technician reported to the [licensee radiation safety officer] RSO that when a shutter handle on a Berthold LB8010 with 20 mCi Cs-137 was moved to the closed position, the radiation survey indicated reduced radiation, but not the expected level. The shutter was opened and closed again, and radiation levels were lower but not at normal closed position levels. The gauge has been removed from service and is secured onsite in Canton, PA, awaiting a shipping container for return to the manufacturer. The gauge will be returned for repair or replacement. No personnel overexposure has occurred.

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

Pennsylvania Report ID No.: PA200008

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 54687
Facility: COOK Region: 3 State: MI Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: RODNEY PICKARD HQ OPS Officer: DONALD NORWOOD	Notification Date: 05/01/2020 Notification Time: 11:53 [ET] Event Date: 05/01/2020 Event Time: 03:54 [EDT] Last Update Date: 05/15/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(i) - Plant S/D Reqd By Ts 50.72(b)(3)(ii)(A) - Degraded Condition	Person (Organization): ANN MARIE STONE (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

Hot Standby

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO REACTOR COOLANT SYSTEM PRESSURE BOUNDARY LEAKAGE

"At 1000 EDT on May 1 2020, Operations commenced a shutdown of DC Cook Unit 2 to comply with LCO 3.4.13, Condition B Reactor Coolant System (RCS) pressure boundary leakage.

"At 0354 EDT on May 1, 2020, Operations detected an estimated 8 gpm Reactor Coolant System leak. The source of the leak could not be identified and Tech Spec 3.4.13, Condition A was entered for unidentified RCS leakage in excess of the 0.8 gpm limit.

"At 0745 EDT on May 1, 2020, Unit 2 entered LCO 3.4.13, Condition B when the 4-hour limit to complete the required actions of Condition A could not be met.

"At 0945 EDT on May 1, 2020, Unit 2 entered LCO 3.4.13, Condition B when the 4-hour limit to complete the required actions of Condition A could not be met.

"At 0945 EDT on May 1, 2020, inspections inside containment identified the leak as pressure boundary leakage from a pressurizer spray line which also requires entry into LCO 3.4.13, Condition B.

"At 1059 EDT on May 1, Unit 2 was tripped from 15 percent power. All systems functioned normally.

"This event is reportable under 10 CFR 50.72(b)(2)(i), the initiation of any nuclear plant shutdown required by the plant's Technical Specifications as a 4-hour report and under 10 CFR 50.72 (b)(3)(ii)(A), degraded condition, as an 8-hour report. The NRC Resident Inspector has been notified."

* * * PARTIAL RETRACTION ON 5/15/2020 AT 1442 EDT FROM BUD HINCKLEY TO THOMAS HERRITY * * *

"The condition identified in EN #54687, pursuant to 10 CFR 50.72 (b)(3)(ii)(a) has been evaluated, and has been determined not to be RCS pressure boundary leakage. As such, the 8-hour report is being retracted, as it is not an event or condition that results in, 'the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.'

"The leakage was subsequently determined to be from the tell-tale nipple of a pressurizer spray valve, not from the pressurizer spray line piping as previously reported. The Reactor Coolant Pressure Boundary (RCPB) is formed by the valve body, plug, seat, body to bonnet extension, and bonnet of the pressurizer spray valve. Therefore, the leakage is not RCPB leakage.

"There is no change to the 4-hour report made under 10 CFR 50.72(b)(2)(i), the initiation of any nuclear plant shutdown required by the plant's Technical Specifications.

"The NRC Resident Inspector was notified of this retraction."

Notified R3DO (Stone).

Power Reactor	Event Number: 54688
Facility: SUMMER Region: 2 State: SC Unit: [1] [] [] RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000 NRC Notified By: GEORGE SHEALY HQ OPS Officer: DONALD NORWOOD	Notification Date: 05/01/2020 Notification Time: 13:16 [ET] Event Date: 05/01/2020 Event Time: 12:53 [EDT] Last Update Date: 05/01/2020
Emergency Class: Unusual Event 10 CFR Section: 50.72(a) (1) (i) - Emergency Declared	Person (Organization): MARK MILLER (R2DO) LAURA DUDES (R2RA) HO NIEH (NRR) JEFFERY GRANT (IRD) CHRIS MILLER (NRR EO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Cold Shutdown

Event Text

NOTIFICATION OF UNUSUAL EVENT DUE TO FIRE IN NON-SAFETY RELATED ELECTRICAL SWITCHGEAR

At approximately 1238 EDT on May 1, 2020, an alarm indicated smoke on a non-safety related electrical switchgear bus in the turbine building. Plant personnel were dispatched to investigate. Smoke and heat were found coming from the bus. At 1253 EDT, a Notification of Unusual Event was declared. At 1308 EDT the fire was declared out and fire watches posted.

Offsite assistance was requested during the event and the Jenkinsville, SC fire department responded to the site. There were no plant personnel injuries or impact to the health and safety of the public.

The cause of this event is unknown at the present time. The electrical bus has been de-energized. The unit is currently in a planned refueling outage.

The licensee notified the NRC Resident Inspector.

Notified DHS SWO, FEMA Operations Center, CISA IOCC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE FROM GEORGE SHEALY TO DONALD NORWOOD AT 1754 EDT * * *

The Notification of Unusual Event was terminated at 1737 EDT on May 1, 2020. The cause of the event is currently being investigated.

The licensee will notify the NRC Resident Inspector.

Notified R2DO (Miller). NRR EO (Miller), IRD MOC (Grant). Additionally, notified DHS SWO, FEMA Operations Center, CISA IOCC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

Power Reactor	Event Number: 54690
Facility: COOPER Region: 4 State: NE Unit: [1] [] [] RX Type: [1] GE-4 NRC Notified By: RANDY KOUBA HQ OPS Officer: DONALD NORWOOD	Notification Date: 05/01/2020 Notification Time: 15:34 [ET] Event Date: 05/01/2020 Event Time: 08:31 [CDT] Last Update Date: 05/01/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel 50.72(b)(3)(v)(D) - Accident Mitigation	Person (Organization): JAMES DRAKE (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

BOTH SECONDARY CONTAINMENT ACCESS DOORS OPEN SIMULTANEOUSLY

"At 0831 CDT, the Main Control Room received a 'Reactor Building 903 ft. Access Both Doors Open' alarm. Investigation found the interlock between the inner and outer doors did not prevent the opening of both doors while personnel were accessing the Reactor Building. The doors were immediately closed. Based on alarm times, both doors were open for less than one second. With both doors open, SR 3.6.4.1.3 was not met and Secondary Containment was declared inoperable. This unplanned Secondary Containment inoperability constitutes a condition reportable under 10 CFR 50.72(b)(3)(v)(c) and (d), 'An event or condition that at the time of discovery could have prevented the fulfillment of the safety function of SSCs that are needed to control the release of radioactive material and mitigate the consequences of an accident.'

"Secondary Containment was declared operable at 0836 CDT after independently verifying at least one Secondary Containment access door was closed.

"The NRC Senior Resident Inspector has been informed."

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