Event Notification Report for June 19, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/18/2015 - 06/19/2015
Agreement State
Event Number: 51176
Rep Org: WASHINGTON STATE DEPT OF HEALTH
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City: SEATTLE State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: DANIEL MILLS
Licensee: UNIVERSITY OF WASHINGTON
Region: 4
City: SEATTLE State: WA
County:
License #: WN-C001-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: DANIEL MILLS
Notification Date: 06/23/2015
Notification Time: 19:53 [ET]
Event Date: 06/19/2015
Event Time: 00:00 [PDT]
Last Update Date: 06/23/2015
Notification Time: 19:53 [ET]
Event Date: 06/19/2015
Event Time: 00:00 [PDT]
Last Update Date: 06/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDER DOSE
The following was received from the State of Washington via email:
"This appears to be a medical event. Eleven Y-90 TheraSphere infusions were performed on eight patients. Five of the infusions involved the use of a smaller catheter, and for all five of these infusions the full dosage was not administered. This was determined when the nuclear medicine physician - who was the authorized user for all of the infusions - determined the percentage of dose delivered to the patient was less than 80 percent of the prescribed dose. The percentage of dose delivered calculation was performed in accordance with the procedure provided in the package insert. Waste for all five infusions was imaged using PET/CT and it was determined that a large amount of radioactive material was present at a hub in the catheter. The radiation safety officer was informed, who informed the hospital health physicist. The referring interventional radiology physicians were notified that the percentage of dose delivered was less than 80 percent, and that further investigations were underway. For these five infusions, the difference in prescribed dose and delivered dose for the organ (liver) exceeded 0.5 Sv; and the total dosage delivered differed from the prescribed dosage by 20 percent or more. The licensee is investigating this matter further and will provide a written report to the Washington State Department of Health within 15 days as required."
WA Item # WA150003
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.
The following was received from the State of Washington via email:
"This appears to be a medical event. Eleven Y-90 TheraSphere infusions were performed on eight patients. Five of the infusions involved the use of a smaller catheter, and for all five of these infusions the full dosage was not administered. This was determined when the nuclear medicine physician - who was the authorized user for all of the infusions - determined the percentage of dose delivered to the patient was less than 80 percent of the prescribed dose. The percentage of dose delivered calculation was performed in accordance with the procedure provided in the package insert. Waste for all five infusions was imaged using PET/CT and it was determined that a large amount of radioactive material was present at a hub in the catheter. The radiation safety officer was informed, who informed the hospital health physicist. The referring interventional radiology physicians were notified that the percentage of dose delivered was less than 80 percent, and that further investigations were underway. For these five infusions, the difference in prescribed dose and delivered dose for the organ (liver) exceeded 0.5 Sv; and the total dosage delivered differed from the prescribed dosage by 20 percent or more. The licensee is investigating this matter further and will provide a written report to the Washington State Department of Health within 15 days as required."
WA Item # WA150003
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.
Power Reactor
Event Number: 51165
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JAMES COX
HQ OPS Officer: JEFF HERRERA
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: JAMES COX
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/19/2015
Notification Time: 10:03 [ET]
Event Date: 06/19/2015
Event Time: 01:53 [CDT]
Last Update Date: 06/19/2015
Notification Time: 10:03 [ET]
Event Date: 06/19/2015
Event Time: 01:53 [CDT]
Last Update Date: 06/19/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
PATTY PELKE (R3DO)
PATTY PELKE (R3DO)
| 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 |
SECONDARY CONTAINMENT INTERLOCK DOORS OPEN SIMULTANEOUSLY
"On June 19, 2015, at 0153 CDT, two Secondary Containment interlock doors (1/2 EDG [Emergency Diesel Generator] room door and the Unit 1 reactor building door) were open simultaneously. The doors were immediately closed and secondary containment pressure remained negative.
"This condition represents a failure to meet surveillance requirement 3.6.4.1.2 given two doors in a single access opening were open simultaneously. As a result entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to secondary containment being inoperable.
"This event is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC Resident Inspector has been notified.
"The door has been posted to notify to restrict access.
"The State of Illinois Emergency Management has been notified."
"On June 19, 2015, at 0153 CDT, two Secondary Containment interlock doors (1/2 EDG [Emergency Diesel Generator] room door and the Unit 1 reactor building door) were open simultaneously. The doors were immediately closed and secondary containment pressure remained negative.
"This condition represents a failure to meet surveillance requirement 3.6.4.1.2 given two doors in a single access opening were open simultaneously. As a result entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to secondary containment being inoperable.
"This event is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC Resident Inspector has been notified.
"The door has been posted to notify to restrict access.
"The State of Illinois Emergency Management has been notified."
Non-Agreement State
Event Number: 51189
Rep Org: MALLINCKRODT PHARMACEUTICALS
Licensee: MALLINCKRODT PHARMACEUTICALS
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: MANUEL DIAZ
HQ OPS Officer: STEVE SANDIN
Licensee: MALLINCKRODT PHARMACEUTICALS
Region: 3
City: MARYLAND HEIGHTS State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: MANUEL DIAZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/29/2015
Notification Time: 14:45 [ET]
Event Date: 06/19/2015
Event Time: 00:00 [CDT]
Last Update Date: 06/29/2015
Notification Time: 14:45 [ET]
Event Date: 06/19/2015
Event Time: 00:00 [CDT]
Last Update Date: 06/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
LAURA KOZAK (R3DO)
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
LAURA KOZAK (R3DO)
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
LOST SHIPMENT OF I-123
On 06/8/15, a shipment of I-123, 1.4 mCi, used for diagnostic imaging, was shipped from the Mallinckrodt Maryland Heights, MO facility for overnight delivery via highway carrier to a company located in Baltimore, MD. The material was not received in Maryland as scheduled. The shipper, carrier and customer performed searches. The shipper concluded that the material was missing as of 6/19/15.
The half-life of I-123 is 13.3 hours.
The licensee will submit a written report within the 30 day requirement.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
On 06/8/15, a shipment of I-123, 1.4 mCi, used for diagnostic imaging, was shipped from the Mallinckrodt Maryland Heights, MO facility for overnight delivery via highway carrier to a company located in Baltimore, MD. The material was not received in Maryland as scheduled. The shipper, carrier and customer performed searches. The shipper concluded that the material was missing as of 6/19/15.
The half-life of I-123 is 13.3 hours.
The licensee will submit a written report within the 30 day requirement.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf