United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2015 > August 24

Event Notification Report for August 24, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/21/2015 - 08/24/2015

** EVENT NUMBERS **


51051 51317 51320 51338 51339

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 51051
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: THE REGENTS OF THE UNIVERSITY OF CALIFORNIA - LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/07/2015
Notification Time: 12:21 [ET]
Event Date: 05/05/2015
Event Time: 10:00 [PDT]
Last Update Date: 08/21/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING LESS THAN THE PRESCRIBED DOSE DELIVERED TO PATIENT

The following report was received from the State of California via email:

"At approximately 1000 PDT on May 5, 2015, a medical event occurred during a Y-90 Therasphere procedure. The prescribed dose to the organ (liver) was 12,000 rem, but the delivered dose was 6,920 rem. This event meets the 10 CFR 35.3045(1)(i) 24-hour report criteria since the dose differed from the prescribed dose by more than 50 rem to an organ (5080 rem under dose) and the total dose delivered differed from the prescribed dose by 20 percent or more (42% under dose). Although the equipment indicated the entire dose had been delivered to the patient, a large amount of the dose was is still in the tubing and vial and had not actually been delivered to the patient as indicated. The licensee will contact the manufacturer to assist in finding the root cause of the malfunction to determine whether it was an equipment malfunction, operator error, or both. The treating physician is also the prescribing physician. The licensee has contacted the physician to verify if the physician has notified the patient and if there was any effect on the individual from this event. The licensee will provide the written report within 15 days as required which will also describe what actions will be taken to prevent reoccurrence."

California Report Number: 050616.

* * * RETRACTION AT 1229 EDT ON 8/21/2015 FROM ROBERT GREGER TO MARK ABRAMOVITZ * * *

The following was received via e-mail:

"The California Radiation Control Program would like to retract the subject event notification for the medical event at UCLA. Subsequent evaluation determined that the patient received the prescribed dosage. Some contamination on the exterior of the equipment utilized in the therapeutic dosage administration was determined to have misled the licensee staff to initially believe that an under-dosage to the patient had occurred."

Notified the R4DO (Hay) and NMSS Events Resource (via e-mail).

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.

To top of page
Non-Agreement State Event Number: 51317
Rep Org: MIDDLESEX HOSPITAL
Licensee: MIDDLESEX HOSPITAL
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 06-00649-03
Agreement: N
Docket:
NRC Notified By: JOAN MERTIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/13/2015
Notification Time: 12:03 [ET]
Event Date: 08/11/2015
Event Time: 12:00 [EDT]
Last Update Date: 08/13/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

MEDICAL EVENT - PATIENT RECEIVED UNDERDOSE OF YTTRIUM 90

During a treatment of the left lobe of the liver, the dose delivered to the patient was discovered to differ greater than 20 percent than the intended dose. 120 Gray was prescribed by the physician and 72 Gray was delivered. During the procedure the Radose meter did not appear to be operating properly. Subsequent investigation determined that there was some radioactivity that remained in the vial. The technologist called the manufacturer who advised to perform several flushes and the Radose meter still did not change. The procedure was ended at that point. After ending the procedure when the survey was performed on the waste jar, it was discovered that only 60% of the dose was delivered. The activity appeared to be concentrated in the plunger attached to the vial. A new Radose detector will be obtained prior to the next procedure.

The patient will be informed of the issue by the physician.

Source Material: Yttrium 90, 7.03 GBq.

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.

To top of page
Agreement State Event Number: 51320
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: AVID RADIOPHARMACEUTICALS PHILADELPHIA PA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0023
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/14/2015
Notification Time: 17:14 [ET]
Event Date: 08/13/2015
Event Time: [EDT]
Last Update Date: 08/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - EXTERNAL RADIATION LEVELS ON SHIPPING PACKAGE ABOVE LIMITS

The following report was received from the Pennsylvania Department of Environmental Protection via facsimile:

"NOTIFICATIONS: On August 13, 2015, Avid Radiopharmaceuticals (a PA licensee) informed the Department [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] of a shipment of fluorine-18 (F-18) from IBA Molecular Inc. (a New Jersey radiopharmaceutical licensee) with a maximum surface reading of 210 mR/hr. The event is immediately reportable per 10 CFR 20.1906 and 10 CFR 71.47.

"EVENT DESCRIPTION: The licensee informed the Department that upon inspection of the package, the following was determined:
1. The area along the gap between the lid and the body of the shipping package gave the highest dose rates (180-230 mR/hr).
2. The licensee opened the package to [examine] the interior for any damage, but instead determined that the lid of the secondary shield was not present.
3. The licensee removed the 'Biodex pig' containing the F-18 activity in a vial to determine damage or contamination. It was observed that the screw top of the 'pig' was not secured properly (the thread of the lid and the body did not align), therefore there was a gap in the shielding.

"The licensee determined that there was no observable damage to the activity, vial and an absence of removable contamination from the surface of the shipper. The F-18 is in the custody of the licensee.

"CAUSE OF THE EVENT: Possible human error.

"ACTIONS: The Department notified New Jersey's Department of Environmental Protection Radiation Control Program. Pennsylvania will follow-up during the next routine inspection of Avid."

Event Report ID No: PA150023

To top of page
Power Reactor Event Number: 51338
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KEN GRACIA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/22/2015
Notification Time: 20:14 [ET]
Event Date: 08/22/2015
Event Time: 16:28 [EDT]
Last Update Date: 08/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DUE TO A SINGLE MSIV CLOSURE

"On Saturday, August 22, 2015, at 1628 [EDT], with the reactor at 100% core thermal power (CTP) the Pilgrim Nuclear Power Station (PNPS) experienced an automatic reactor scram signal due to the rapid closure of one main steam isolation valve (MSIV). Other than the MSIV all other plant systems responded as designed. Plant cooldown is in progress using steam bypass to the main condenser.

"The plant is in hot shutdown. The cause of the MSIV closure is still under investigation. This event has no impact on the health and safety of the public. The licensee has notified the NRC Senior Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'Any event that results in actuation of the reactor protection system (RPS) when the reactor is critical'.

"Subsequent to the reactor scram the plant experienced the following isolation signals:
- Group 2 Isolation: Miscellaneous containment isolation valves
- Group 6 Isolation: Reactor Water Clean-up
- Reactor Building Isolation Actuation

"This notification is also being made in accordance with 10 CFR 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section' (B)(2) 'General containment isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs).'"

Plant response was considered normal and the plant is in a stable shutdown / cooldown condition. The license will be notifying the Commonwealth of Massachusetts.

To top of page
Power Reactor Event Number: 51339
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JASON BERRIO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/23/2015
Notification Time: 17:37 [ET]
Event Date: 08/23/2015
Event Time: 13:00 [CDT]
Last Update Date: 08/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MICHAEL HAY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

GRASS FIRE IN OWNER CONTROLLED AREA

"A fire was reported to the unit 2 control room at 1300 central time [CDT]. The fire was reported to be in the owner controlled area 3/4 of a mile west of the protected area and switchyard. The local fire department was dispatched to fight the fire. The fire burned approximately 1.5 acres. The fire was reported to be out at 1417 central time. No plant equipment was damaged and the operation of the plant was not affected. Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of the event at 1509 for visible emissions resulting from the grass fire. No further actions are required by the TCEQ at this time and no press release is planned."

The fire was caused by a downed 12.5 kV power line which powers outlying plant areas.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, August 24, 2015
Monday, August 24, 2015