Event Notification Report for January 02, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/29/2023 - 01/02/2024
EVENT NUMBERS56906 56908 56910
Agreement State
Event Number: 56906
Rep Org: Louisiana DEQ
Licensee: St. Tammany Parish Hospital
Region: 4
City: Covington State: LA
County: St. Tammany Parish
License #: LA-0569-L01, Amendment #64
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Bethany Cecere
Notification Date: 12/22/2023
Notification Time: 10:56 [ET]
Event Date: 12/14/2023
Event Time: 00:00 [CST]
Last Update Date: 12/26/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - SAFETY EQUIPMENT FAILURE LEAD TO UNDERDOSE
The following information was provided by the Louisiana Department of Environmental Quality (DEQ) via email:
"On December 14, 2023, the licensee was performing a Y-90 procedure. A tubing failure resulted in an incomplete dosing of the patient. All of the unadministered radiopharmaceutical was contained within the administrating device's tubing. There was no spill involved.
"No effect on the individual was determined. Of the prescribed dose of 105 Gy, only 50.5 Gy was administered. The remainder of the prescribed dose is scheduled to be administered on January 2, 2024.
"A representative from TheraSphere was in attendance during the procedure and witnessed the tube failure. The TheraSphere representative alerted their colleagues at Boston Scientific.
"Improvements needed to prevent recurrence: More thorough inspection of device tubing prior to administration."
LA Event Report ID No.: LA20230013
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: 56908
Rep Org: California Radiation Control Prgm
Licensee: University of California, San Fran.
Region: 4
City: San Franciso State: CA
County:
License #: CA-RML 1725-38
Agreement: Y
Docket:
NRC Notified By: Kamani Hewadikaram
HQ OPS Officer: Ernest West
Notification Date: 12/22/2023
Notification Time: 20:11 [ET]
Event Date: 12/22/2023
Event Time: 00:00 [PST]
Last Update Date: 12/26/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE - CONTAMINATED PACKAGE
The following information was provided by the California Department of Public Health, Radiation Health Branch (RHB) via email:
"On 12/22/2023, the [University of California, San Francisco] notified RHB that a shipment of F-18 radioactive materials received from SOFIE CO FKA ZEVACOR PHARMA [license number: CA-RML 7131-43] was contaminated. The licensee reported that their contamination wipe tests ranged from 65,000 counts per minute (cpm) to over 100,000 cpm per 300-centimeter squared wipe area using a wipe counter with an efficiency of 25 percent. This amount exceeds the non-fixed radioactive contamination limits specified in Department of Transportation regulations 49 CFR 173.443 of 240 cpm per cm squared for beta and gamma emitters and is reportable under 10 CFR 20.1906(d)(1). RHB is in contact with SOFIE and will be investigating this matter further."
Power Reactor
Event Number: 56910
Facility: Watts Bar
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Tony Pate
HQ OPS Officer: Adam Koziol
Notification Date: 12/28/2023
Notification Time: 18:55 [ET]
Event Date: 12/28/2023
Event Time: 11:29 [EST]
Last Update Date: 12/28/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
| 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
UNANALYZED CONDITION
The following information was provided by the licensee via email:
"Plant alignment caused an unanalyzed condition regarding unit 1 and unit 2 Appendix R procedures.
"[Watts Bar Nuclear] (WBN) unit 1 and unit 2 Appendix R procedures require manual operator action times including [volume control tank] (VCT) isolation. They are calculated with an assumed hydrogen cover gas constant at 20 psig. This is to preclude hydrogen ingestion into the charging pumps with an operator action time of 70 minutes. Due to recent lower hydrogen concentration in the [reactor coolant system] (RCS), [unit 2] VCT hydrogen regulator set point was increased to 28 psig. This increased pressure set point invalidated the initial assumptions made in the Appendix R calculations for manual operator action times.
"WBN unit 1 VCT hydrogen regulator was also verified high out of band at 22 psig.
"WBN has restored unit 1 and unit 2 VCT hydrogen regulators to the required specification.
"The NRC Resident Inspector has been notified of this condition."