Event Notification Report for August 23, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/22/2018 - 08/23/2018
Agreement State
Event Number: 53560
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/23/2018
Notification Time: 18:12 [ET]
Event Date: 08/23/2018
Event Time: 16:00 [CDT]
Last Update Date: 08/23/2018
Notification Time: 18:12 [ET]
Event Date: 08/23/2018
Event Time: 16:00 [CDT]
Last Update Date: 08/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received from the State of Illinois via email:
"The RSO [Radiation Safety Officer] for Rush University Medical Center in Chicago (IL-01766-01) notified the Agency [Illinois Emergency Management Agency, Bureau of Radiation Safety] at approximately 1600 [CDT] today that a reportable event transpired while attempting to administer Y-90 TheraSpheres. The licensee attempted to administer Y-90 to a patient this morning and was unable to move the dose through the tubing to the patient. A different administration route was selected and also met with inability to deliver the dose. This treatment was aborted.
"A second patient was scheduled for Y-90 administration this afternoon. The licensee encountered resistance in the second delivery system and was unable to deliver the Y-90 dose. This treatment was also aborted. Both patients were imaged and verified to not have been administered any Y-90. The licensee is currently performing a PET [Positron Emission Tomography] scan on the delivery systems to look for occlusions that may have impeded delivery. IEMA [Illinois Emergency Management Agency] staff has requested information on lot numbers for the individual doses.
"Details are pending from the licensee on root cause and lot numbers. The licensee will not administer any additional doses from this lot number until root cause is identified. Further details are pending."
Illinois Item No.: IL180033
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 via email:
"The RSO [Radiation Safety Officer] for Rush University Medical Center in Chicago (IL-01766-01) notified the Agency [Illinois Emergency Management Agency, Bureau of Radiation Safety] at approximately 1600 [CDT] today that a reportable event transpired while attempting to administer Y-90 TheraSpheres. The licensee attempted to administer Y-90 to a patient this morning and was unable to move the dose through the tubing to the patient. A different administration route was selected and also met with inability to deliver the dose. This treatment was aborted.
"A second patient was scheduled for Y-90 administration this afternoon. The licensee encountered resistance in the second delivery system and was unable to deliver the Y-90 dose. This treatment was also aborted. Both patients were imaged and verified to not have been administered any Y-90. The licensee is currently performing a PET [Positron Emission Tomography] scan on the delivery systems to look for occlusions that may have impeded delivery. IEMA [Illinois Emergency Management Agency] staff has requested information on lot numbers for the individual doses.
"Details are pending from the licensee on root cause and lot numbers. The licensee will not administer any additional doses from this lot number until root cause is identified. Further details are pending."
Illinois Item No.: IL180033
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.
Part 21
Event Number: 53673
Rep Org: ITT ENIDINE
Licensee: ITT ENIDINE
Region: 1
City: WESTMINSTER State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JEFFREY B GOTTHELF
HQ OPS Officer: OSSY FONT
Licensee: ITT ENIDINE
Region: 1
City: WESTMINSTER State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JEFFREY B GOTTHELF
HQ OPS Officer: OSSY FONT
Notification Date: 10/19/2018
Notification Time: 08:40 [ET]
Event Date: 08/23/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/19/2018
Notification Time: 08:40 [ET]
Event Date: 08/23/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
MATT YOUNG (R1DO)
GERALD MCCOY (R2DO)
DAVID HILLS (R3DO)
GREG PICK (R4DO)
PART 21 MATERIALS (EMAIL)
MATT YOUNG (R1DO)
GERALD MCCOY (R2DO)
DAVID HILLS (R3DO)
GREG PICK (R4DO)
PART 21 MATERIALS (EMAIL)
PART 21 REPORT - ENVIRONMENTAL QUALIFICATION TEST DISCREPANCY
The following report synopsis was received via fax from ITT Enidine:
On August 23, 2018, ITT Enidine discovered a discrepancy between the published specifications in sales literature, internal test acceptance procedures and the environmental qualification (EQ) test report for the ITT Conoflow model GT25 series. The current to pressure transducer EQ report 3419 lists the temperature range as -40 to 150 degrees Fahrenheit, and the linearity as 0.75 percent of span. The current temperature range specification is 0 to 150 degrees Fahrenheit, and the linearity is 1.5 percent of span. Units manufactured after October 2010 may not conform to the specifications of the EQ test report for linearity and temperature range.
Customers who procured safety related GT25 series I/P transducers and the specific part numbers since 2010 will be notified of this potential product defect by October 23, 2018.
ITT GT25 Series customer list (2010 to present):
- ALMARAZ: GT25CD1826
- ARIZONA PUBLIC SERVICE - GT25CA1826
- CALVERT CLIFFS NUCLEAR - GT25CD1826
- DUKE ENERGY (CATAWBA NUCLEAR STATION) - GT25CA1826; GT25CD1826
- CONTROL COMPONENTS INC - GT25CD1826
- ENERTECH - GT25CD1826
- ENRICO FERMI POWER - GT25CD1826
- FLOWSERVE - GT25CA1826
- TRACTABEL (VIA GEFRAN BENELUX) - GT25CA1826; GT25CD1826
- KHNP - GT25CA1826
- KOREA HYDRO - GT25CA1826
- KRSKO NUCLEAR PLANT - GT25CA1826
- NEBRASKA PUBLIC POWER - GT25CA1826
- ONTARIO POWER GENERATION - GT25CA1826
- SPX FLOW TECHNOLOGY (SPX MCKEAN) - GT25CA1826
- WEIR VALVES - GT25CA1826
- ERGYTECH - GT25CD1826
- OPPG FORT CALHOUN STATION - GT65FA1826
- BECHTEL POWER CORPORATION (TVA) - GT25CD1826; GT65CD1826
The following report synopsis was received via fax from ITT Enidine:
On August 23, 2018, ITT Enidine discovered a discrepancy between the published specifications in sales literature, internal test acceptance procedures and the environmental qualification (EQ) test report for the ITT Conoflow model GT25 series. The current to pressure transducer EQ report 3419 lists the temperature range as -40 to 150 degrees Fahrenheit, and the linearity as 0.75 percent of span. The current temperature range specification is 0 to 150 degrees Fahrenheit, and the linearity is 1.5 percent of span. Units manufactured after October 2010 may not conform to the specifications of the EQ test report for linearity and temperature range.
Customers who procured safety related GT25 series I/P transducers and the specific part numbers since 2010 will be notified of this potential product defect by October 23, 2018.
ITT GT25 Series customer list (2010 to present):
- ALMARAZ: GT25CD1826
- ARIZONA PUBLIC SERVICE - GT25CA1826
- CALVERT CLIFFS NUCLEAR - GT25CD1826
- DUKE ENERGY (CATAWBA NUCLEAR STATION) - GT25CA1826; GT25CD1826
- CONTROL COMPONENTS INC - GT25CD1826
- ENERTECH - GT25CD1826
- ENRICO FERMI POWER - GT25CD1826
- FLOWSERVE - GT25CA1826
- TRACTABEL (VIA GEFRAN BENELUX) - GT25CA1826; GT25CD1826
- KHNP - GT25CA1826
- KOREA HYDRO - GT25CA1826
- KRSKO NUCLEAR PLANT - GT25CA1826
- NEBRASKA PUBLIC POWER - GT25CA1826
- ONTARIO POWER GENERATION - GT25CA1826
- SPX FLOW TECHNOLOGY (SPX MCKEAN) - GT25CA1826
- WEIR VALVES - GT25CA1826
- ERGYTECH - GT25CD1826
- OPPG FORT CALHOUN STATION - GT65FA1826
- BECHTEL POWER CORPORATION (TVA) - GT25CD1826; GT65CD1826