Event Notification Report for June 06, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/05/2018 - 06/06/2018
Agreement State
Event Number: 53448
Rep Org: OK DEPT OF ENVIRONMENTAL QUALITY
Licensee: SW REGIONAL MEDICAL CENTER dba CANCER TREATMENT CENTERS
Region: 4
City: TULSA State: OK
County:
License #: OK-27041-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BETHANY CECERE
Licensee: SW REGIONAL MEDICAL CENTER dba CANCER TREATMENT CENTERS
Region: 4
City: TULSA State: OK
County:
License #: OK-27041-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: BETHANY CECERE
Notification Date: 06/07/2018
Notification Time: 16:09 [ET]
Event Date: 06/06/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2018
Notification Time: 16:09 [ET]
Event Date: 06/06/2018
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION
The following was received from the State of Oklahoma by email:
"We [the Oklahoma Department of Environmental Quality] were just informed of a medical event and abnormal occurrence that happened yesterday at Southwestern Regional Medical Center dba Cancer Treatment Centers of America (OK-27041-01) in Tulsa, OK. The incident involved a patient who was supposed to receive a 110.8 Gy dose of Yt-90 SIR Spheres to the right lobe of the liver. A CT [scan] of the patient after the procedure showed that the microspheres had actually been delivered to the left lobe."
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 was received from the State of Oklahoma by email:
"We [the Oklahoma Department of Environmental Quality] were just informed of a medical event and abnormal occurrence that happened yesterday at Southwestern Regional Medical Center dba Cancer Treatment Centers of America (OK-27041-01) in Tulsa, OK. The incident involved a patient who was supposed to receive a 110.8 Gy dose of Yt-90 SIR Spheres to the right lobe of the liver. A CT [scan] of the patient after the procedure showed that the microspheres had actually been delivered to the left lobe."
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.
Fuel Cycle Facility
Event Number: 54324
Facility: LOUISIANA ENERGY SERVICES
Region: 2 State: NM
Unit: [] [] []
RX Type:
NRC Notified By: JIM RICKMAN
HQ OPS Officer: DONALD NORWOOD
Region: 2 State: NM
Unit: [] [] []
RX Type:
NRC Notified By: JIM RICKMAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/10/2019
Notification Time: 17:35 [ET]
Event Date: 06/06/2018
Event Time: 10:30 [MDT]
Last Update Date: 10/10/2019
Notification Time: 17:35 [ET]
Event Date: 06/06/2018
Event Time: 10:30 [MDT]
Last Update Date: 10/10/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
EUGENE GUTHRIE (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EUGENE GUTHRIE (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PRESSURE INSTRUMENT ISOLATION VALVE FOUND IN INCORRECT OPEN POSITION
"On October 10, 2019, at approximately 1830 MDT, a responsible individual at Louisiana Energy Services LLC, dba URENCO USA, was informed that on June 5, 2018, at approximately 1600 MDT, pressure instrument isolation valve, 1001-471-1A12, was found open when it should have been shut to maintain the pressure boundary of autoclave 1LS1. The autoclave is used to homogenize UF6 and obtain samples. The autoclave pressure boundary forms IROFS10 [Item Relied on for Safety].
"Prior to the event, on May 31, 2018, annual maintenance was performed on the autoclave as required by the IROFS10 surveillance requirements. Subsequently, a homogenization and UF6 sampling was performed June 1st through June 5th on a 30B cylinder of UF6. During preparations for a subsequent homogenization cycle, valve 1001-471-1A12 was found open. The valve should have remained closed from the previous homogenization. There was not an initiating event (no release of UF6) and no initiation of an accident sequence. The valve has been shut and the IROFS boundary has been restored. The plant is in a safe configuration.
"This event has been identified in UUSA's corrective action program as EV 133619 and a causal investigation is planned."
"On October 10, 2019, at approximately 1830 MDT, a responsible individual at Louisiana Energy Services LLC, dba URENCO USA, was informed that on June 5, 2018, at approximately 1600 MDT, pressure instrument isolation valve, 1001-471-1A12, was found open when it should have been shut to maintain the pressure boundary of autoclave 1LS1. The autoclave is used to homogenize UF6 and obtain samples. The autoclave pressure boundary forms IROFS10 [Item Relied on for Safety].
"Prior to the event, on May 31, 2018, annual maintenance was performed on the autoclave as required by the IROFS10 surveillance requirements. Subsequently, a homogenization and UF6 sampling was performed June 1st through June 5th on a 30B cylinder of UF6. During preparations for a subsequent homogenization cycle, valve 1001-471-1A12 was found open. The valve should have remained closed from the previous homogenization. There was not an initiating event (no release of UF6) and no initiation of an accident sequence. The valve has been shut and the IROFS boundary has been restored. The plant is in a safe configuration.
"This event has been identified in UUSA's corrective action program as EV 133619 and a causal investigation is planned."