Event Notification Report for June 16, 2016

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG PATIENT

The following information was received from the State of California via email:

"On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. The event resulted in a dose to the wrong patient that exceeded 20 percent of the prescribed dose (the dose that was likely to be given to another patient scheduled to be treated on June 17, 2016). The patient was given an activity of 4.02 GBq of Yttrium 90 (Nordion TheraSphere), resulting in a dose to the liver of 226.3 Gray. This dose exceeded the prescribed dose of 120 Gray. This activity was later discovered to be the activity that was most likely to have been ordered for a patient that was to be treated on June 17, 2016. The patient that was treated on June 16, 2016 has been notified. The investigation is ongoing to determine the cause of the event."

5010 Number: 061616

* * * UPDATE AT 1740 EDT ON 06/21/16 FROM ANDREW TAYLOR TO S. SANDIN VIA EMAIL * * *

"This is a revision/update of EN #52014.

"On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event.

"Two patients were scheduled to be treated with Nordion TheraSpheres containing yttrium 90, one on June 16 and the other on June 17. The first treatment occurred on June 16; however, the treatment dosage of 4.02 GBq (108.6 mCi) was approximately 1.9 times the prescribed dosage, apparently because the dosage for the second patient was given to the first patient. As a result, the first patient received a liver dose of 226.3 gray (22,630 rad) instead of the prescribed dose of 120 gray (12,000 rad).

"The patient has been notified, and the licensee is investigating to determine the cause of the event."

Notified R4DO (Rollins) and NMSS Events Notification via email.

* * * UPDATE AT 0611 EDT ON 07/07/16 FROM ROBERT GREGER TO S. SANDIN VIA EMAIL * * *

"This is a revision/update of EN #52014.

"On 7/1/16 UCLA submitted a written report of this medical event. That report noted that in addition to the incorrect treatment dosage, the incorrect liver lobe was treated. As a result, the dose to the incorrect liver lobe was calculated as 328 Gy (32,800 rad). This differs from the previously reported liver dose of 226.3 Gy (22,630 rad) due to the difference in the sizes of the liver lobes."

Notified R4DO (Drake) and NMSS Events Notification via 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.

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON NUCLEAR GAUGE

The following information was received from the State of Texas via email:

"On June 17, 2016, the Agency was notified by the licensee that it had discovered the shutter on a Ohmart model SH-F1 nuclear gauge containing a 50 millicurie (original activity) Cs-137 source would not close. Open is the normal position for the gauge. The licensee stated the gauge does not create an exposure risk to it's employees or members of the general public. The licensee stated a service company will be on site the week of June 27, 2016 to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9413

* * * UPDATE FROM ARTHUR TUCKER TO RICHARD SMITH AT 0814 ON 07/08/16 * * *

The following update was received via email from the state of Texas:

"Update to correct licensee's name.

"Should have been recorded as Flint Hills Resources Longview. Additional information will be provided as it is received in accordance with SA-300."

The R4DO (Drake) was notified and NMSS Event Notification via email.

UNANALYZED CONDITION OF EMERGENCY DIESEL GENERATOR DURING TORNADO LOW PRESSURE

"Upon review of recent industry operating experience, an issue was identified for the potential impact of the low barometric pressure associated with a tornado on the Emergency Diesel Generators (EDGs). The Davis-Besse Nuclear Power Station EDGs are equipped with a crankcase positive pressure trip with a set point of approximately 1 inch of water. This crankcase pressure trip is bypassed during an emergency start signal of the EDG from the Safety Features Actuation System or from an essential bus under voltage condition. Engineering has determined that a design basis tornado could create sufficient low pressure to potentially actuate the crankcase positive pressure trip due to different vent paths between the EDG Room and the EDG crankcase. If the crankcase pressure trip occurs before the EDG starts on an emergency signal due to the tornado, the crankcase pressure trip would cause an EDG lockout condition. The EDG lockout condition would then prevent either normal or emergency start of the EDG until operators could manually reset the lockout condition locally at the EDG. This condition could potentially affect both EDGs simultaneously.

"No severe weather warnings or watches are forecast in the local areas that could challenge the crankcase pressure trip. Compensatory measures are being established that upon notification of a Tornado Watch or Tornado Warning that would be implemented to defeat the crankcase pressure trip function and allow the EDGs to perform their required safety function during a potential tornado."

The NRC Resident Inspector has been notified.

FITNESS FOR DUTY - UNOPENED HERBAL TEA IDENTIFIED IN THE PROTECTED AREA

An employee self-reported possession of an unopened herbal tea containing naturally occurring alcohol in the protected area. The drink was removed from the protected area.

The licensee will notify the NRC Resident Inspector.


* * * UPDATE FROM MATTHEW PLEASANT TO DONALD NORWOOD AT 1955 EDT ON 6/16/2016 * * *

"While investigating the incident for EN #52011, it was determined that 'cooking wine' used in the cafeteria should be removed from the protected area."

The licensee will notify the NRC Resident Inspector. Notified R4DO (Proulx) and FFD Group via email.

AGREEMENT STATE REPORT - TWO SOURCES STUCK IN DIP TUBES DURING ANNUAL SHUTTER TEST

The following information was received from the State of Louisiana via fax:

"On June 16, 2016, at approximately 1500 CDT, [the] Radiation Safety Officer of ExxonMobil notified LDEQ [Louisiana Department of Environmental Quality] of a potential equipment malfunction. A custom built Berthold level/density gauge installed on G-Line Reactor Vessel, V5300 and possessing seven 10 mCi Co-60 sealed sources, was undergoing a routine annual shutter test in which the sealed sources were pulled upwards in their dip tubes via connecting cables to the top of the source holder. The sources in dip tubes #2 and #6 became stuck in the dip tubes and could not be pulled upward further. The other sources were pulled up to the top of the source holder successfully. All sources were successfully returned to their normal operating positions. [The RSO] called Berthold contract service engineer [at] Radcon, LLC and discussed the potential malfunction. [The service engineer] stated that differential thermal expansion between the source capsules and dip tubes under heating within the reactor vessel likely caused the sources to begin sticking as they were being pulled upward in their dip tubes. The licensee placed another service call to [the service engineer] on June 17, 2016, but was unable to contact him, but left a message. Radcon, LLC will conduct a maintenance inspection and repair of the gauge which is tentatively planned for July 11, 2016. This is not an emergency situation. ExxonMobil Radiation Safety Office staff are monitoring the vessel condition and have the situation under control. There is no potential for off-site exposure."

Event Report ID No.: LA160007