Event Notification Report for September 23, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/22/2015 - 09/23/2015
EVENT NUMBERS
51421514335142451418
Power Reactor
Event Number: 51421
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JEFF SIMPSON
HQ OPS Officer: JEFF ROTTON
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JEFF SIMPSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/24/2015
Notification Time: 05:52 [ET]
Event Date: 09/23/2015
Event Time: 21:00 [CDT]
Last Update Date: 09/24/2015
Notification Time: 05:52 [ET]
Event Date: 09/23/2015
Event Time: 21:00 [CDT]
Last Update Date: 09/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILLY DICKSON (R3DO)
BILLY DICKSON (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH PRESSURE COOLANT INJECTION INOPERABLE DUE TO MGU FAILURE
"During surveillance testing of the U2 HPCI [High Pressure Coolant Injection] system, the HPCI motor gear unit [MGU] was positioned from 100 percent to 75 percent demand to satisfy operability testing. The motor gear unit did not respond as system demand was returned to 100 percent. This indicated a failure of the MGU which requires declaration of inoperability of the HPCI System. This is a 14 day LCO. HPCI is a single train system and reportable under SAF 1.8 'Event or condition that could have prevented fulfillment of a safety function.'"
The licensee will be notifying the NRC Resident Inspector.
"During surveillance testing of the U2 HPCI [High Pressure Coolant Injection] system, the HPCI motor gear unit [MGU] was positioned from 100 percent to 75 percent demand to satisfy operability testing. The motor gear unit did not respond as system demand was returned to 100 percent. This indicated a failure of the MGU which requires declaration of inoperability of the HPCI System. This is a 14 day LCO. HPCI is a single train system and reportable under SAF 1.8 'Event or condition that could have prevented fulfillment of a safety function.'"
The licensee will be notifying the NRC Resident Inspector.
Agreement State
Event Number: 51433
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: UNIVERSITY OF NEW MEXICO MEDICAL CENTER
Region: 4
City: ALBUQUERQUE State: NM
County:
License #: BM 233-94
Agreement: Y
Docket:
NRC Notified By: CARL SULLIVAN
HQ OPS Officer: HOWIE CROUCH
Licensee: UNIVERSITY OF NEW MEXICO MEDICAL CENTER
Region: 4
City: ALBUQUERQUE State: NM
County:
License #: BM 233-94
Agreement: Y
Docket:
NRC Notified By: CARL SULLIVAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/29/2015
Notification Time: 16:49 [ET]
Event Date: 09/23/2015
Event Time: 00:00 [MDT]
Last Update Date: 09/29/2015
Notification Time: 16:49 [ET]
Event Date: 09/23/2015
Event Time: 00:00 [MDT]
Last Update Date: 09/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
NEW MEXICO AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 SIRSPHERES
On 9/23/15, a patient underwent Y-90 SirSphere treatment on their liver. Post-treatment scans indicated the patient had SirSpheres present in their stomach and liver. The calculated dose to the patient's stomach was 54 Rem.
The state of New Mexico will be sending an inspector to investigate the cause of the event.
New Mexico Report No.: NM150004
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.
On 9/23/15, a patient underwent Y-90 SirSphere treatment on their liver. Post-treatment scans indicated the patient had SirSpheres present in their stomach and liver. The calculated dose to the patient's stomach was 54 Rem.
The state of New Mexico will be sending an inspector to investigate the cause of the event.
New Mexico Report No.: NM150004
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: 51424
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ODH PUBLIC HEALTH LEAD INVESTIGATION PROGRAM
Region: 3
City: CHILLICOTHE State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF ROTTON
Licensee: ODH PUBLIC HEALTH LEAD INVESTIGATION PROGRAM
Region: 3
City: CHILLICOTHE State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/25/2015
Notification Time: 09:14 [ET]
Event Date: 09/23/2015
Event Time: 00:00 [EDT]
Last Update Date: 09/25/2015
Notification Time: 09:14 [ET]
Event Date: 09/23/2015
Event Time: 00:00 [EDT]
Last Update Date: 09/25/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
CANADA (FAX)
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)
CANADA (FAX)
AGREEMENT STATE REPORT - STOLEN GENERAL LICENSED MATERIAL
The following information was provided by the State of Ohio via email:
"Sometime between 2330 EDT pm on 9/22/15 and 0430 EDT on 9/23/15, a vehicle maintained by a staff member of the ODH [Ohio Department of Health] Public Health Lead Investigation Program was broken into at their residence in Chillicothe, Ohio. A NITON X-Ray Fluorescence (XRF) lead-based analyzer (SN 92956) containing a Cadmium-109 radioactive source with a maximum activity of 50 mCi [was stolen]. The XRF device was in a locked pelican case in the locked trunk of the vehicle. The theft was reported to local law enforcement and to the Ohio State Highway Patrol. The device has not been recovered as of the date of this report (9/25/15)."
OH Reference Number: 2015-014
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
The following information was provided by the State of Ohio via email:
"Sometime between 2330 EDT pm on 9/22/15 and 0430 EDT on 9/23/15, a vehicle maintained by a staff member of the ODH [Ohio Department of Health] Public Health Lead Investigation Program was broken into at their residence in Chillicothe, Ohio. A NITON X-Ray Fluorescence (XRF) lead-based analyzer (SN 92956) containing a Cadmium-109 radioactive source with a maximum activity of 50 mCi [was stolen]. The XRF device was in a locked pelican case in the locked trunk of the vehicle. The theft was reported to local law enforcement and to the Ohio State Highway Patrol. The device has not been recovered as of the date of this report (9/25/15)."
OH Reference Number: 2015-014
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
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 51418
Rep Org: UNIV OF VT MEDICAL CENTER
Licensee: UNIV OF VT MEDICAL CENTER
Region: 1
City: BURLINGTON State: VT
County:
License #: 44-10187-03
Agreement: N
Docket:
NRC Notified By: MARLEEN MOORE
HQ OPS Officer: DANIEL MILLS
Licensee: UNIV OF VT MEDICAL CENTER
Region: 1
City: BURLINGTON State: VT
County:
License #: 44-10187-03
Agreement: N
Docket:
NRC Notified By: MARLEEN MOORE
HQ OPS Officer: DANIEL MILLS
Notification Date: 09/23/2015
Notification Time: 12:09 [ET]
Event Date: 09/23/2015
Event Time: 10:00 [EDT]
Last Update Date: 09/29/2015
Notification Time: 12:09 [ET]
Event Date: 09/23/2015
Event Time: 10:00 [EDT]
Last Update Date: 09/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MEDICAL UNDERDOSE DURING SIRSPHERE ADMINISTRATION
"SirSphere administration to [the patient] on Wednesday Sept 23, 2015.
"[The patient] was prescribed, with appropriate written directives, 0.27 GBq and 0.29 GBq to segments in the posterior and anterior right lobe of the liver. Paperwork for determination of the activities and volumes are available.
"The SirSpheres were received on Sept 22, 2015, calibrated for 1800 [EDT] on Sept 23, 2015. The two doses were prepared between 0900 and 0930 AM on Wed Sept 23, 2015. The procedure used is attached as are the worksheets for verification of activity. No unusual behavior was observed (e.g. clumping or unusual settling of the spheres).
"The posterior right lobe treatment was given first. The system was set up with D5W for the agitating solution and contrast in a three way set up for the contrast flush. The interventional radiologist administered in the method that has been used for all prior, successful, administrations. [The radiologist] reports that he did not encounter any difference in resistance in the syringe, nor did [medical center staff] note any difference in the appearance of the solution flowing through the three way stopcock. The administration was completed and the residual immediately checked using the method of pre vs post assay of delivery vial then delivery vial and associated tubing. The post reading was initially higher than the pre. The vial and tubing was carefully put onto a plastic backed pad and it was determined that there were higher readings from the vicinity of the three way stopcock.
"This patient was scheduled for two infusions due to their vasculature, and after much discussion it was decided, based on our prior success with treatments, to proceed with the second but pay very close attention to whether there were some spheres that were backed up at the three way. In the past, [medical center staff] have been able to dislodge such an occurrence by gentle knocking of the three way prior to the clearing of the vial with air. A new administration set was installed and the administration proceeded. Frustratingly, it was immediately apparent that some of the spheres were clumping at the three way but that some had passed through and were then in the patient. With gentle knocking of the stopcock, it was possible to dislodge many of the spheres. However, the after reading again showed that there was a measurable amount of activity that had stuck somewhere in the delivery tubing.
"Because the pre and post readings are so dependent on the presence of the plastic for both stopping the electrons and production of Bremmstrahlung, it was not possible to get any type of accurate assessment of the activity remaining. However, it was possible to evaluate the last three Sirsphere post Brem SPECT scans, determine a counts/administered activity, and evaluate that number. For the three patients the values were acceptably comparable, that this calibration value was then used to determine the activity present for the after study Brem scan on today's patient. This gave an estimate of approximately 70% of the written directive.
"Please note that this report is a preliminary report and an updated will be forwarded as this is reviewed by all concerned and also further evaluations performed."
The licensee will contact the manufacturer to troubleshoot the issue, and will notify the patient, prescribing physician, and NRC Region 1.
* * * RETRACTION FROM MARLEEN MOORE TO HOWIE CROUCH AT 1613 EDT ON 9/29/15 * * *
Based on re-analysis of the data, and with concurrence of USNRC Region I DNMS Inspector (Nguyen), it was determined that the patient received between 82% and 90% of the prescribed dose. Based on this information, this event no longer meets the reporting criteria and is being retracted by the licensee.
Notified R1DO (Bower) and NMSS Events Resource (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.
"SirSphere administration to [the patient] on Wednesday Sept 23, 2015.
"[The patient] was prescribed, with appropriate written directives, 0.27 GBq and 0.29 GBq to segments in the posterior and anterior right lobe of the liver. Paperwork for determination of the activities and volumes are available.
"The SirSpheres were received on Sept 22, 2015, calibrated for 1800 [EDT] on Sept 23, 2015. The two doses were prepared between 0900 and 0930 AM on Wed Sept 23, 2015. The procedure used is attached as are the worksheets for verification of activity. No unusual behavior was observed (e.g. clumping or unusual settling of the spheres).
"The posterior right lobe treatment was given first. The system was set up with D5W for the agitating solution and contrast in a three way set up for the contrast flush. The interventional radiologist administered in the method that has been used for all prior, successful, administrations. [The radiologist] reports that he did not encounter any difference in resistance in the syringe, nor did [medical center staff] note any difference in the appearance of the solution flowing through the three way stopcock. The administration was completed and the residual immediately checked using the method of pre vs post assay of delivery vial then delivery vial and associated tubing. The post reading was initially higher than the pre. The vial and tubing was carefully put onto a plastic backed pad and it was determined that there were higher readings from the vicinity of the three way stopcock.
"This patient was scheduled for two infusions due to their vasculature, and after much discussion it was decided, based on our prior success with treatments, to proceed with the second but pay very close attention to whether there were some spheres that were backed up at the three way. In the past, [medical center staff] have been able to dislodge such an occurrence by gentle knocking of the three way prior to the clearing of the vial with air. A new administration set was installed and the administration proceeded. Frustratingly, it was immediately apparent that some of the spheres were clumping at the three way but that some had passed through and were then in the patient. With gentle knocking of the stopcock, it was possible to dislodge many of the spheres. However, the after reading again showed that there was a measurable amount of activity that had stuck somewhere in the delivery tubing.
"Because the pre and post readings are so dependent on the presence of the plastic for both stopping the electrons and production of Bremmstrahlung, it was not possible to get any type of accurate assessment of the activity remaining. However, it was possible to evaluate the last three Sirsphere post Brem SPECT scans, determine a counts/administered activity, and evaluate that number. For the three patients the values were acceptably comparable, that this calibration value was then used to determine the activity present for the after study Brem scan on today's patient. This gave an estimate of approximately 70% of the written directive.
"Please note that this report is a preliminary report and an updated will be forwarded as this is reviewed by all concerned and also further evaluations performed."
The licensee will contact the manufacturer to troubleshoot the issue, and will notify the patient, prescribing physician, and NRC Region 1.
* * * RETRACTION FROM MARLEEN MOORE TO HOWIE CROUCH AT 1613 EDT ON 9/29/15 * * *
Based on re-analysis of the data, and with concurrence of USNRC Region I DNMS Inspector (Nguyen), it was determined that the patient received between 82% and 90% of the prescribed dose. Based on this information, this event no longer meets the reporting criteria and is being retracted by the licensee.
Notified R1DO (Bower) and NMSS Events Resource (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.