Event Notification Report for October 15, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/14/2019 - 10/15/2019
Agreement State
Event Number: 54334
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GRADY HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF HERRERA
Licensee: GRADY HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/16/2019
Notification Time: 17:20 [ET]
Event Date: 10/15/2019
Event Time: 00:00 [EDT]
Last Update Date: 11/26/2019
Notification Time: 17:20 [ET]
Event Date: 10/15/2019
Event Time: 00:00 [EDT]
Last Update Date: 11/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE
The following report was received from the Georgia Radioactive Materials Program via email:
"A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU [authorized user] that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO [Radiation Safety Officer]. The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks.
"The RSO took the scrub pants and sock and shoes and placed them in an area for DIS [decay in storage]. He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area.
"The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water.
"The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event."
* * * UPDATE AT 1733 EST ON 11/26/2019 FROM IRENE BENNETT TO JEFF HERRERA * * *
The following is a synopsis of a report received from the Georgia Radioactive Materials Program via email:
On October 30, 2019 a reactive inspection was performed by the Georgia Radioactive Materials Program. The areas of contamination were verified to have a physical barrier to prevent inadvertent entry and signs posted to warn individuals of the contaminated areas. The Grady Memorial Hospital Radiation Safety officer (RSO) stated that the lab will not re-open until the contamination level reaches background, approximately 80 days from the time of the incident.
The RSO temporarily removed the authorized user from administrating any therapeutic doses indefinitely. The RSO reported that there will be proper training for authorized users, technologists and residents who are involved in administering radioactive materials. A technologist will be required to be present in the room where I-131 is administered. Instructions will be added about not opening or breaking capsules containing radioactive materials to hospital procedures and refresher training will encompass the procedures.
The physician did not think a bioassay was necessary for the patient as they were not exposed.
Notified the R1DO (Henrion) and NMSS via email.
The following report was received from the Georgia Radioactive Materials Program via email:
"A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU [authorized user] that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO [Radiation Safety Officer]. The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks.
"The RSO took the scrub pants and sock and shoes and placed them in an area for DIS [decay in storage]. He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area.
"The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water.
"The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event."
* * * UPDATE AT 1733 EST ON 11/26/2019 FROM IRENE BENNETT TO JEFF HERRERA * * *
The following is a synopsis of a report received from the Georgia Radioactive Materials Program via email:
On October 30, 2019 a reactive inspection was performed by the Georgia Radioactive Materials Program. The areas of contamination were verified to have a physical barrier to prevent inadvertent entry and signs posted to warn individuals of the contaminated areas. The Grady Memorial Hospital Radiation Safety officer (RSO) stated that the lab will not re-open until the contamination level reaches background, approximately 80 days from the time of the incident.
The RSO temporarily removed the authorized user from administrating any therapeutic doses indefinitely. The RSO reported that there will be proper training for authorized users, technologists and residents who are involved in administering radioactive materials. A technologist will be required to be present in the room where I-131 is administered. Instructions will be added about not opening or breaking capsules containing radioactive materials to hospital procedures and refresher training will encompass the procedures.
The physician did not think a bioassay was necessary for the patient as they were not exposed.
Notified the R1DO (Henrion) and NMSS via email.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 54330
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: JEREMY PETERS
HQ OPS Officer: BRIAN LIN
Region: 1 State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: JEREMY PETERS
HQ OPS Officer: BRIAN LIN
Notification Date: 10/15/2019
Notification Time: 19:14 [ET]
Event Date: 10/15/2019
Event Time: 12:10 [EDT]
Last Update Date: 11/22/2019
Notification Time: 19:14 [ET]
Event Date: 10/15/2019
Event Time: 12:10 [EDT]
Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DON JACKSON (R1DO)
DON JACKSON (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 81 | Power Operation | 81 | Power Operation |
HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE
"On 10/15/19 at 1210 [EDT] Peach Bottom discovered a degraded spring hanger (23DBN-H39) associated with Unit 3 High Pressure Coolant Injection (HPCI) system. The hanger is located downstream of MO-3-23-14 HPCI Steam Supply Valve before the HO-3-23-4513 Turbine Stop Valve. A review of the piping and support design analysis were performed and concluded the U3 HPCI turbine inlet nozzle would potentially exceed its allowable stresses. Following Engineering review, U3 HPCI was declared inoperable at 1743 [EDT].
"This report is being submitted pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 11/22/19 AT 0851 EST FROM DAN DULLUM TO BETHANY CECERE * * *
"Additional evaluation by Engineering personnel determined that the degraded spring hanger would have no adverse effect on the subject piping or HPCI turbine nozzle structural integrity. Pressure, deadweight, and seismic stresses were within allowable limits. Non-destructive examination (NDE) of the piping and nozzle was performed to identify any signs of cracking, yielding, or defects. NDE results were satisfactory. The degraded spring hanger did not effect the Unit 3 HPCI system operability and this call is being retracted.
"The NRC Resident Inspector has been notified."
Notified R1DO (Cahill).
"On 10/15/19 at 1210 [EDT] Peach Bottom discovered a degraded spring hanger (23DBN-H39) associated with Unit 3 High Pressure Coolant Injection (HPCI) system. The hanger is located downstream of MO-3-23-14 HPCI Steam Supply Valve before the HO-3-23-4513 Turbine Stop Valve. A review of the piping and support design analysis were performed and concluded the U3 HPCI turbine inlet nozzle would potentially exceed its allowable stresses. Following Engineering review, U3 HPCI was declared inoperable at 1743 [EDT].
"This report is being submitted pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 11/22/19 AT 0851 EST FROM DAN DULLUM TO BETHANY CECERE * * *
"Additional evaluation by Engineering personnel determined that the degraded spring hanger would have no adverse effect on the subject piping or HPCI turbine nozzle structural integrity. Pressure, deadweight, and seismic stresses were within allowable limits. Non-destructive examination (NDE) of the piping and nozzle was performed to identify any signs of cracking, yielding, or defects. NDE results were satisfactory. The degraded spring hanger did not effect the Unit 3 HPCI system operability and this call is being retracted.
"The NRC Resident Inspector has been notified."
Notified R1DO (Cahill).