Event Notification Report for March 20, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/19/2020 - 03/20/2020
Agreement State
Event Number: 54595
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: OSSY FONT
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1017-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: OSSY FONT
Notification Date: 03/20/2020
Notification Time: 18:30 [ET]
Event Date: 03/20/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/25/2020
Notification Time: 18:30 [ET]
Event Date: 03/20/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNPLANNED DOSE TO AN ORGAN
The following was received from the state of Wisconsin's Radiation Protection Section [the Department] via email:
"On March 20, 2020, the [Wisconsin Radiation Protection Section] Department was notified by the licensee of a medical event which occurred the same day. The licensee was performing the first fraction of a vaginal cylinder treatment using a Varian VariSource iX high dose rate remote afterloader unit. Licensee staff had difficulty removing the cylinder post-treatment, and they determined that the cylinder had perforated the patient's tissue at some point following pre-treatment imaging. The licensee estimates the cylinder moved 3-4 cm from its original position. Dose reconstruction is ongoing, but is expected to exceed the 0.5 Sv threshold to the bowel. This is all the information available at this time. The Department will determine follow-up actions and provide additional information when available."
* * * UPDATE ON 3/25/20 AT 1612 EDT FROM MEGAN SHOBER TO BETHANY CECERE * * *
"The Department performed an investigation on March 25, 2020 to review this incident. For this fraction, the patient was prescribed a 6 Gy dose to the surface of the vaginal cylinder. Using CT imaging the licensee confirmed the proper placement of the cylinder prior to treatment. The licensee performed all pre-treatment checks, connected the patient to the HDR unit, and initiated treatment. Everything appeared to be as expected. However, following treatment it was very difficult for the authorized user to remove the cylinder; there appeared to be a vacuum suction seal. The licensee determined that the cylinder had been pulled an additional 3.5 cm into the patient, perforating the vaginal wall and protruding into the bowel space. The licensee believes that the bowel conformed to the shape of the cylinder during part or all of treatment, causing a much larger volume of the bowel to receive an elevated radiation dose as compared to the treatment plan. Based on the prescribed dose, the maximum unintended dose to the bowel is 6 Gy. The patient and referring physician were immediately informed of the event. The authorized user does not expect the patient to experience any radiological consequences from this event."
Wisconsin Event Report ID No.: WI200010
Notified R3DO (Hanna) and NMSS Events Notification 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.
The following was received from the state of Wisconsin's Radiation Protection Section [the Department] via email:
"On March 20, 2020, the [Wisconsin Radiation Protection Section] Department was notified by the licensee of a medical event which occurred the same day. The licensee was performing the first fraction of a vaginal cylinder treatment using a Varian VariSource iX high dose rate remote afterloader unit. Licensee staff had difficulty removing the cylinder post-treatment, and they determined that the cylinder had perforated the patient's tissue at some point following pre-treatment imaging. The licensee estimates the cylinder moved 3-4 cm from its original position. Dose reconstruction is ongoing, but is expected to exceed the 0.5 Sv threshold to the bowel. This is all the information available at this time. The Department will determine follow-up actions and provide additional information when available."
* * * UPDATE ON 3/25/20 AT 1612 EDT FROM MEGAN SHOBER TO BETHANY CECERE * * *
"The Department performed an investigation on March 25, 2020 to review this incident. For this fraction, the patient was prescribed a 6 Gy dose to the surface of the vaginal cylinder. Using CT imaging the licensee confirmed the proper placement of the cylinder prior to treatment. The licensee performed all pre-treatment checks, connected the patient to the HDR unit, and initiated treatment. Everything appeared to be as expected. However, following treatment it was very difficult for the authorized user to remove the cylinder; there appeared to be a vacuum suction seal. The licensee determined that the cylinder had been pulled an additional 3.5 cm into the patient, perforating the vaginal wall and protruding into the bowel space. The licensee believes that the bowel conformed to the shape of the cylinder during part or all of treatment, causing a much larger volume of the bowel to receive an elevated radiation dose as compared to the treatment plan. Based on the prescribed dose, the maximum unintended dose to the bowel is 6 Gy. The patient and referring physician were immediately informed of the event. The authorized user does not expect the patient to experience any radiological consequences from this event."
Wisconsin Event Report ID No.: WI200010
Notified R3DO (Hanna) and NMSS Events Notification 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.
Power Reactor
Event Number: 54594
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: SAMUEL SHAVER
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: SAMUEL SHAVER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/20/2020
Notification Time: 17:47 [ET]
Event Date: 03/20/2020
Event Time: 10:25 [CDT]
Last Update Date: 03/20/2020
Notification Time: 17:47 [ET]
Event Date: 03/20/2020
Event Time: 10:25 [CDT]
Last Update Date: 03/20/2020
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):
JOHN HANNA (R3DO)
JOHN HANNA (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 92 | Power Operation | 92 | Power Operation |
LOW PRESSURE COOLANT INJECTION UNPLANNED INOPERABILITY
"On March 20, 2020, at 1025 hours [CDT], Unit 2 MCC [motor control center] 28/29-5 failed to transfer to its alternate feed during surveillance testing. This would result in MCC 28/29-5 being de-energized in the event of a DBA LOCA [design basis accident loss of coolant accident] in which the Unit 1 Emergency Diesel Generator fails to energize Bus 29. Consequently, the LPCI [low pressure coolant injection] Injection Valve (MO 2-1001-29A/B) would not have power to open on the loop selected by LPCI Loop Select. This renders both divisions of the LPCI mode of Residual Heat Removal system inoperable. Technical Specification 3.5.1, Condition E had previously been entered during testing, requiring restoration of LPCI in 72 hours. No other ECCS [emergency core cooling] systems were inoperable at the time of the event. Troubleshooting and repairs are in progress.
"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function."
The plant is still in its 72-hr. LCO action statement.
The licensee has notified the NRC Resident Inspector and the state of Illinois Emergency Management Agency.
"On March 20, 2020, at 1025 hours [CDT], Unit 2 MCC [motor control center] 28/29-5 failed to transfer to its alternate feed during surveillance testing. This would result in MCC 28/29-5 being de-energized in the event of a DBA LOCA [design basis accident loss of coolant accident] in which the Unit 1 Emergency Diesel Generator fails to energize Bus 29. Consequently, the LPCI [low pressure coolant injection] Injection Valve (MO 2-1001-29A/B) would not have power to open on the loop selected by LPCI Loop Select. This renders both divisions of the LPCI mode of Residual Heat Removal system inoperable. Technical Specification 3.5.1, Condition E had previously been entered during testing, requiring restoration of LPCI in 72 hours. No other ECCS [emergency core cooling] systems were inoperable at the time of the event. Troubleshooting and repairs are in progress.
"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function."
The plant is still in its 72-hr. LCO action statement.
The licensee has notified the NRC Resident Inspector and the state of Illinois Emergency Management Agency.
Agreement State
Event Number: 54686
Rep Org: NV DIV OF RAD HEALTH
Licensee: COMPREHENSIVE CANCER CENTERS OF NEVADA
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: COREY CREVELING
HQ OPS Officer: HOWIE CROUCH
Licensee: COMPREHENSIVE CANCER CENTERS OF NEVADA
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: COREY CREVELING
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/30/2020
Notification Time: 19:50 [ET]
Event Date: 03/20/2020
Event Time: 00:00 [PDT]
Last Update Date: 04/30/2020
Notification Time: 19:50 [ET]
Event Date: 03/20/2020
Event Time: 00:00 [PDT]
Last Update Date: 04/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE DUE TO AN ERROR IN THE TREATMENT PLAN
The following information is summarized from the report received from the state of Nevada via email:
A patient was scheduled to receive 34 Gy to the treatment site via a Nucletron brachytherapy device containing 444 GBq of Ir-192. The dose was to be received via two fractions-a-day for 5 days. All fractions were delivered as scheduled.
During the post-treatment review, it was determined that the delivery device was placed 8 mm proximal to the intended treatment site due to a digitization error in the treatment plan. This resulted in the patient receiving 71 percent of the intended dose.
At the time of the report, there were no acute ill-effects on the patient.
NMED Report No.: NV200006
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 is summarized from the report received from the state of Nevada via email:
A patient was scheduled to receive 34 Gy to the treatment site via a Nucletron brachytherapy device containing 444 GBq of Ir-192. The dose was to be received via two fractions-a-day for 5 days. All fractions were delivered as scheduled.
During the post-treatment review, it was determined that the delivery device was placed 8 mm proximal to the intended treatment site due to a digitization error in the treatment plan. This resulted in the patient receiving 71 percent of the intended dose.
At the time of the report, there were no acute ill-effects on the patient.
NMED Report No.: NV200006
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.