Event Notification Report for April 08, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/07/2016 - 04/08/2016
Power Reactor
Event Number: 51859
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: JOHN SHOEMAKER
Region: 3 State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/08/2016
Notification Time: 20:50 [ET]
Event Date: 04/08/2016
Event Time: 18:20 [EDT]
Last Update Date: 04/08/2016
Notification Time: 20:50 [ET]
Event Date: 04/08/2016
Event Time: 18:20 [EDT]
Last Update Date: 04/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
RICHARD SKOKOWSKI (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO OIL LEAK IN A SWITCHYARD TRANSFORMER OIL SYSTEM
"At 1657 EDT on April 8, 2016, an oil leak developed from the station's switchyard transformer no. 4. Approximately 25,000 gallons of oil has leaked within the transformer's containment berm. At 1820 EDT on April 8, 2016, DC Cook environmental personnel determined that approximately 2000 gallons of oil had leaked outside of the containment berm onto the ground. None of the oil has made it to any nearby drains. Leak has stopped and cleanup is ongoing. D.C. Cook has notified the State of Michigan and local authorities. The NRC Resident Inspector was notified.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies."
"At 1657 EDT on April 8, 2016, an oil leak developed from the station's switchyard transformer no. 4. Approximately 25,000 gallons of oil has leaked within the transformer's containment berm. At 1820 EDT on April 8, 2016, DC Cook environmental personnel determined that approximately 2000 gallons of oil had leaked outside of the containment berm onto the ground. None of the oil has made it to any nearby drains. Leak has stopped and cleanup is ongoing. D.C. Cook has notified the State of Michigan and local authorities. The NRC Resident Inspector was notified.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies."
Non-Agreement State
Event Number: 52520
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-0016711
Agreement: N
Docket:
NRC Notified By: SUSAN M. LANGHORST
HQ OPS Officer: JEFF HERRERA
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-0016711
Agreement: N
Docket:
NRC Notified By: SUSAN M. LANGHORST
HQ OPS Officer: JEFF HERRERA
Notification Date: 01/31/2017
Notification Time: 10:15 [ET]
Event Date: 04/08/2016
Event Time: 00:00 [CST]
Last Update Date: 02/20/2017
Notification Time: 10:15 [ET]
Event Date: 04/08/2016
Event Time: 00:00 [CST]
Last Update Date: 02/20/2017
Emergency Class:
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)
PATIENT DELIVERED RADIATION DOSE TO RIGHT LOBE OF LIVER VERSUS LEFT LOBE
The following was received via email:
"On 4/8/2016 a patient was being treated with Y-90 TheraSpheres. Written directive prescribed 4.15 GBq (117 mCi) Y-90 TheraSpheres to the left liver lobe. The catheter placement was confirmed by the Interventional Radiologist with an angiogram to administer the microspheres to the left liver lobe. The dose of 4.07 GBq of Y-90 TheraSpheres was administered. This patient was part of a study to image the location of the Y-90 TheraSpheres using a PET/MRI unit. The PET/MRI images were taken on 4/15/2016 and were read by a Radiation Oncology Authorized User on 4/16/2016. The PET/MRI images indicated that the majority of the microspheres were deposited in the right liver lobe. The Radiation Safety Officer (RSO) was immediately notified. Evaluation of the incident in accordance with the 'Yttrium-90 Microsphere Brachytherapy Sources and Devices TheraSphere and SIR-Spheres Licensing Guidance' (February 12, 2016, Revision 9) event reporting criteria was done by the RSO, Radiation Safety Committee (RSC) Chairman, Management and Radiation Oncology and the incident was judged not to be a medical event due to unintentional patient intervention. The patient and the physician were notified of the incident.
"The RSO has been discussing this incident with the University's NRC Region III Lead Inspector [Gattone] over the past few weeks. The Inspector let the RSO know that NRC Headquarters and Region III had determined that the incident is a medical event. The Inspector requested on 1/30/2017 that the RSO report the medical event to the NRC Operations Center."
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.
* * * UPDATE FROM SUSAN LANGHORST (RSO) TO HOWIE CROUCH ON 2/20/17 AT 0923 EST * * *
The RSO provided some minor corrections to the organization name as well as correcting one date in the original report. The original report stated that PET/MRI images were taken on 4/15/16 when they were actually taken on 4/8/16.
Notified the R3DO (Pelke) and NMSS (via email).
The following was received via email:
"On 4/8/2016 a patient was being treated with Y-90 TheraSpheres. Written directive prescribed 4.15 GBq (117 mCi) Y-90 TheraSpheres to the left liver lobe. The catheter placement was confirmed by the Interventional Radiologist with an angiogram to administer the microspheres to the left liver lobe. The dose of 4.07 GBq of Y-90 TheraSpheres was administered. This patient was part of a study to image the location of the Y-90 TheraSpheres using a PET/MRI unit. The PET/MRI images were taken on 4/15/2016 and were read by a Radiation Oncology Authorized User on 4/16/2016. The PET/MRI images indicated that the majority of the microspheres were deposited in the right liver lobe. The Radiation Safety Officer (RSO) was immediately notified. Evaluation of the incident in accordance with the 'Yttrium-90 Microsphere Brachytherapy Sources and Devices TheraSphere and SIR-Spheres Licensing Guidance' (February 12, 2016, Revision 9) event reporting criteria was done by the RSO, Radiation Safety Committee (RSC) Chairman, Management and Radiation Oncology and the incident was judged not to be a medical event due to unintentional patient intervention. The patient and the physician were notified of the incident.
"The RSO has been discussing this incident with the University's NRC Region III Lead Inspector [Gattone] over the past few weeks. The Inspector let the RSO know that NRC Headquarters and Region III had determined that the incident is a medical event. The Inspector requested on 1/30/2017 that the RSO report the medical event to the NRC Operations Center."
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.
* * * UPDATE FROM SUSAN LANGHORST (RSO) TO HOWIE CROUCH ON 2/20/17 AT 0923 EST * * *
The RSO provided some minor corrections to the organization name as well as correcting one date in the original report. The original report stated that PET/MRI images were taken on 4/15/16 when they were actually taken on 4/8/16.
Notified the R3DO (Pelke) and NMSS (via email).