Event Notification Report for December 15, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/14/2017 - 12/15/2017
Agreement State
Event Number: 53127
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: VINCE KLCO
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: GIBB VINSON
HQ OPS Officer: VINCE KLCO
Notification Date: 12/19/2017
Notification Time: 17:05 [ET]
Event Date: 12/15/2017
Event Time: 00:00 [CST]
Last Update Date: 12/19/2017
Notification Time: 17:05 [ET]
Event Date: 12/15/2017
Event Time: 00:00 [CST]
Last Update Date: 12/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
BILLY DICKSON (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - UNDERDOSE
The following information was received from the State of Illinois:
"The University of Chicago Medical Center reported an underdose of Y90 Theraspheres today [12/19/17] to a patient. 53.4 % of dose was delivered with 46.6% stuck in catheter. 21 mCi was ordered and 11.21 was delivered. CT scan verified dose administered in correct location. On 12/18/17, it was still undetermined why remaining dose hung up in catheter. Additional dose [is] being ordered to complete the therapy as a fractionated dose. The licensee is investigating why the catheter became blocked. A 15 day written report will follow."
Illinois Incident: IL177059
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 information was received from the State of Illinois:
"The University of Chicago Medical Center reported an underdose of Y90 Theraspheres today [12/19/17] to a patient. 53.4 % of dose was delivered with 46.6% stuck in catheter. 21 mCi was ordered and 11.21 was delivered. CT scan verified dose administered in correct location. On 12/18/17, it was still undetermined why remaining dose hung up in catheter. Additional dose [is] being ordered to complete the therapy as a fractionated dose. The licensee is investigating why the catheter became blocked. A 15 day written report will follow."
Illinois Incident: IL177059
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.
General Information
Event Number: 53122
Rep Org: EXELON NUCLEAR CORPORATE
Licensee: EXELON NUCLEAR CORPORATE
Region: 3
City: WARRENVILLE State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID GULLOTT
HQ OPS Officer: ANDREW WAUGH
Licensee: EXELON NUCLEAR CORPORATE
Region: 3
City: WARRENVILLE State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID GULLOTT
HQ OPS Officer: ANDREW WAUGH
Notification Date: 12/16/2017
Notification Time: 08:10 [ET]
Event Date: 12/15/2017
Event Time: 14:30 [CST]
Last Update Date: 04/10/2018
Notification Time: 08:10 [ET]
Event Date: 12/15/2017
Event Time: 14:30 [CST]
Last Update Date: 04/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ANN MARIE STONE (R3DO)
FFD GROUP (EMAIL)
ANN MARIE STONE (R3DO)
FFD GROUP (EMAIL)
CORPORATE INDIVIDUALS REMOVED FROM THE FITNESS FOR DUTY RANDOM POOL
"On 12/15/17 at 1430 [CST], it was discovered by corporate Fitness for Duty (FFD) personnel that two individuals in the Corporate Emergency Response Organization (ERO) and one Corporate FFD Authorization (FFDA) individual were removed from the random FFD testing pool by the security database, Illuminate. It was identified that a database coding error removed the FFD random pool flag when an additional clearance was requested for these individuals. The individuals involved did not have Unescorted Access (UA) or Unescorted Access Authorized (UAA).
"Review by corporate FFD personnel and the security database vendor (Endevor) found this coding error affected only those individuals not holding UA/UAA but who require additional clearances which require being in the FFD random pool (e.g., ERO, FFDA). Corporate security personnel found no other individuals to be affected by this issue. No individuals with UA/UAA are affected by this issue.
"Affected individuals have been added to the FFD random pool and pre-access testing will be performed for the three identified individuals prior to resuming duties requiring inclusion in the FFD random pool. A code modification for the security database has been created to prevent error recurrence, testing has begun with implementation targeted for Monday 12/18/17. Quarterly reviews will continue to take place for verification purposes.
"The issue does not affect any Exelon Sites or the process for granting UA/UAA.
"No other utilities are known to use the Illuminate security database."
* * * UPDATE ON 04/10/18 AT 1919 EDT FROM MARK HAWES TO ANDREW WAUGH * * *
"On 7/25/17, it was determined that on 4/1/17, when James A. FitzPatrick Nuclear Power Plant (JAF) changed ownership and transferred individuals into the Exelon Fitness for Duty (FFD) security program Illuminate, one individual was inadvertently excluded from the Follow-up portion of the program. This individual's record in the industry Personnel Access Data System (PADS) remained accurate and Illuminate was updated on 7/12/17; however, this individual did not receive four months of Follow-up FFD testing as required by 10 CFR 26.69(b)(4)(iii). No additional FFD program violations occurred by this individual and no other individuals involved in the transfer were affected by this error. A computer code modification by the Illuminate database vendor (Endevor) was created to prevent error recurrence.
"The failure to transfer an individual into the FFD Follow-up Program on 4/1/17, is a significant FFD programmatic failure which is reportable per 10 CFR 26.719(b)(4)."
The individual was a non-licensed JAF employee who had Unescorted Access.
The licensee notified the NRC Resident Inspector.
Notified R1DO (Jackson), R3DO (Stone), and FFD Group (email).
"On 12/15/17 at 1430 [CST], it was discovered by corporate Fitness for Duty (FFD) personnel that two individuals in the Corporate Emergency Response Organization (ERO) and one Corporate FFD Authorization (FFDA) individual were removed from the random FFD testing pool by the security database, Illuminate. It was identified that a database coding error removed the FFD random pool flag when an additional clearance was requested for these individuals. The individuals involved did not have Unescorted Access (UA) or Unescorted Access Authorized (UAA).
"Review by corporate FFD personnel and the security database vendor (Endevor) found this coding error affected only those individuals not holding UA/UAA but who require additional clearances which require being in the FFD random pool (e.g., ERO, FFDA). Corporate security personnel found no other individuals to be affected by this issue. No individuals with UA/UAA are affected by this issue.
"Affected individuals have been added to the FFD random pool and pre-access testing will be performed for the three identified individuals prior to resuming duties requiring inclusion in the FFD random pool. A code modification for the security database has been created to prevent error recurrence, testing has begun with implementation targeted for Monday 12/18/17. Quarterly reviews will continue to take place for verification purposes.
"The issue does not affect any Exelon Sites or the process for granting UA/UAA.
"No other utilities are known to use the Illuminate security database."
* * * UPDATE ON 04/10/18 AT 1919 EDT FROM MARK HAWES TO ANDREW WAUGH * * *
"On 7/25/17, it was determined that on 4/1/17, when James A. FitzPatrick Nuclear Power Plant (JAF) changed ownership and transferred individuals into the Exelon Fitness for Duty (FFD) security program Illuminate, one individual was inadvertently excluded from the Follow-up portion of the program. This individual's record in the industry Personnel Access Data System (PADS) remained accurate and Illuminate was updated on 7/12/17; however, this individual did not receive four months of Follow-up FFD testing as required by 10 CFR 26.69(b)(4)(iii). No additional FFD program violations occurred by this individual and no other individuals involved in the transfer were affected by this error. A computer code modification by the Illuminate database vendor (Endevor) was created to prevent error recurrence.
"The failure to transfer an individual into the FFD Follow-up Program on 4/1/17, is a significant FFD programmatic failure which is reportable per 10 CFR 26.719(b)(4)."
The individual was a non-licensed JAF employee who had Unescorted Access.
The licensee notified the NRC Resident Inspector.
Notified R1DO (Jackson), R3DO (Stone), and FFD Group (email).