Event Notification Report for August 13, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/12/2015 - 08/13/2015
Power Reactor
Event Number: 51318
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN VAN FLEET
HQ OPS Officer: JEFF HERRERA
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN VAN FLEET
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/13/2015
Notification Time: 16:52 [ET]
Event Date: 08/13/2015
Event Time: 09:38 [CDT]
Last Update Date: 08/13/2015
Notification Time: 16:52 [ET]
Event Date: 08/13/2015
Event Time: 09:38 [CDT]
Last Update Date: 08/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
ROBERT ORLIKOWSKI (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 | N | 0 | Startup | 0 | Startup |
FITNESS-FOR-DUTY REPORT INVOLVING A LICENSED EMPLOYEE
"A licensed, non-supervisory employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated."
The licensee notified the NRC Resident Inspector as well as the NRC Region 3 Office Safeguards Inspector.
"A licensed, non-supervisory employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated."
The licensee notified the NRC Resident Inspector as well as the NRC Region 3 Office Safeguards Inspector.
Agreement State
Event Number: 51320
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: AVID RADIOPHARMACEUTICALS PHILADELPHIA PA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0023
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JEFF HERRERA
Licensee: AVID RADIOPHARMACEUTICALS PHILADELPHIA PA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0023
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/14/2015
Notification Time: 17:14 [ET]
Event Date: 08/13/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/14/2015
Notification Time: 17:14 [ET]
Event Date: 08/13/2015
Event Time: 00:00 [EDT]
Last Update Date: 08/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE - EXTERNAL RADIATION LEVELS ON SHIPPING PACKAGE ABOVE LIMITS
The following report was received from the Pennsylvania Department of Environmental Protection via facsimile:
"NOTIFICATIONS: On August 13, 2015, Avid Radiopharmaceuticals (a PA licensee) informed the Department [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] of a shipment of fluorine-18 (F-18) from IBA Molecular Inc. (a New Jersey radiopharmaceutical licensee) with a maximum surface reading of 210 mR/hr. The event is immediately reportable per 10 CFR 20.1906 and 10 CFR 71.47.
"EVENT DESCRIPTION: The licensee informed the Department that upon inspection of the package, the following was determined:
1. The area along the gap between the lid and the body of the shipping package gave the highest dose rates (180-230 mR/hr).
2. The licensee opened the package to [examine] the interior for any damage, but instead determined that the lid of the secondary shield was not present.
3. The licensee removed the 'Biodex pig' containing the F-18 activity in a vial to determine damage or contamination. It was observed that the screw top of the 'pig' was not secured properly (the thread of the lid and the body did not align), therefore there was a gap in the shielding.
"The licensee determined that there was no observable damage to the activity, vial and an absence of removable contamination from the surface of the shipper. The F-18 is in the custody of the licensee.
"CAUSE OF THE EVENT: Possible human error.
"ACTIONS: The Department notified New Jersey's Department of Environmental Protection Radiation Control Program. Pennsylvania will follow-up during the next routine inspection of Avid."
Event Report ID No: PA150023
The following report was received from the Pennsylvania Department of Environmental Protection via facsimile:
"NOTIFICATIONS: On August 13, 2015, Avid Radiopharmaceuticals (a PA licensee) informed the Department [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] of a shipment of fluorine-18 (F-18) from IBA Molecular Inc. (a New Jersey radiopharmaceutical licensee) with a maximum surface reading of 210 mR/hr. The event is immediately reportable per 10 CFR 20.1906 and 10 CFR 71.47.
"EVENT DESCRIPTION: The licensee informed the Department that upon inspection of the package, the following was determined:
1. The area along the gap between the lid and the body of the shipping package gave the highest dose rates (180-230 mR/hr).
2. The licensee opened the package to [examine] the interior for any damage, but instead determined that the lid of the secondary shield was not present.
3. The licensee removed the 'Biodex pig' containing the F-18 activity in a vial to determine damage or contamination. It was observed that the screw top of the 'pig' was not secured properly (the thread of the lid and the body did not align), therefore there was a gap in the shielding.
"The licensee determined that there was no observable damage to the activity, vial and an absence of removable contamination from the surface of the shipper. The F-18 is in the custody of the licensee.
"CAUSE OF THE EVENT: Possible human error.
"ACTIONS: The Department notified New Jersey's Department of Environmental Protection Radiation Control Program. Pennsylvania will follow-up during the next routine inspection of Avid."
Event Report ID No: PA150023
Agreement State
Event Number: 51991
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NY-75-2909-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: NY-75-2909-01
Agreement: Y
Docket:
NRC Notified By: JOSE LORENZO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2016
Notification Time: 14:32 [ET]
Event Date: 08/13/2015
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2016
Notification Time: 14:32 [ET]
Event Date: 08/13/2015
Event Time: 00:00 [EDT]
Last Update Date: 06/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following report was received via e-mail:
"Mount Sinai Medical Center (MSMC) reported that a patient only received 62 percent of their prescribed Y-90 microsphere (BTG International / Nordion model TheraSpheres) dose during treatment performed on 8/13/2015. The patient was prescribed to receive 1.81 GBq (48.92 mCi) of Y-90 microspheres for an exposure of 15,000 cGy (rad) to the liver. Access to the liver was gained through the femoral artery, with catheterization performed using a reverse curve catheter and coaxial micro-catheter. Following completion of the treatment procedure, radiation surveys using a Rados detector revealed 0 mR/hour. The microsphere delivery kit was then taken to the hot laboratory for further radiation surveys. At that time MSMC discovered a residual activity of approximately 33.7 percent of the microspheres in the vial. The cause was determined to be a procedure problem. Corrective actions included procedure modifications."
NMED: 150485
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 report was received via e-mail:
"Mount Sinai Medical Center (MSMC) reported that a patient only received 62 percent of their prescribed Y-90 microsphere (BTG International / Nordion model TheraSpheres) dose during treatment performed on 8/13/2015. The patient was prescribed to receive 1.81 GBq (48.92 mCi) of Y-90 microspheres for an exposure of 15,000 cGy (rad) to the liver. Access to the liver was gained through the femoral artery, with catheterization performed using a reverse curve catheter and coaxial micro-catheter. Following completion of the treatment procedure, radiation surveys using a Rados detector revealed 0 mR/hour. The microsphere delivery kit was then taken to the hot laboratory for further radiation surveys. At that time MSMC discovered a residual activity of approximately 33.7 percent of the microspheres in the vial. The cause was determined to be a procedure problem. Corrective actions included procedure modifications."
NMED: 150485
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.