Event Notification Report for September 29, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/28/2015 - 09/29/2015
Agreement State
Event Number: 51435
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: KU HOSPITAL AUTHORITY
Region: 4
City: KANSAS CITY State: KS
County:
License #: 18-C801
Agreement: Y
Docket:
NRC Notified By: JASON BARNEY
HQ OPS Officer: JOHN SHOEMAKER
Licensee: KU HOSPITAL AUTHORITY
Region: 4
City: KANSAS CITY State: KS
County:
License #: 18-C801
Agreement: Y
Docket:
NRC Notified By: JASON BARNEY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/01/2015
Notification Time: 10:23 [ET]
Event Date: 09/29/2015
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2015
Notification Time: 10:23 [ET]
Event Date: 09/29/2015
Event Time: 00:00 [CDT]
Last Update Date: 10/01/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN UNDERDOSE TO THE PATIENT
The following report was received from the State of Kansas via email:
"Yesterday afternoon [the State of Kansas] was contacted by [the licensee's], RSO [Radiation Safety Officer] for KU Hospital Authority lic# 18-C801, to report a medical event. On the morning of 9/29/15, a Thera-spheres Y-90 therapy procedure was found to have underdosed the patient by 36%. The details are as follows:
"A RADose RAD 60R personal electronic dosimeter is attached to the plexiglass 'box' which holds the vial containing the Y-90 Thera-spheres during the procedure. This dosimeter is the only method of detection to ensure that all of the Y-90 material is placed within the patient. In comparison, the Sir-sphere, similar material and procedure, utilizes a contrast to better ensure material is where it's supposed to be.
"Prior to the procedure, the dosimeter was checked for current calibration and source checked and found to be satisfactory including low battery indicator not active. During this pre-procedure check, the dosimeter exhibited fluctuating readings. A backup dosimeter of the same make and model was searched for but could not be located. The dosimeter was then re-checked and the fluctuations could not be duplicated, thus it was decided to utilize the dosimeter for the procedure. The Y-90 procedure was then completed, with the dosimeter reading at levels that indicated the required Y-90 had been placed within the patient. At this point, the 'waste' from the procedure i.e. vials, tubing, pads is taken back to the hot lab and surveyed to calculate the remaining Y-90. It was discovered that 36% still remained and that the patient did not receive the entire prescribed dose. It was determined that enough of the Y-90 had been administered to the patient to receive a satisfactory therapeutic dose thus another procedure would not be necessary.
"Exposure to staff was also determined to be negligible due to the nature of the material/shielding/remaining concentration. The RSO stated that the dosimeter was again rechecked and the low battery indicator was active during the check. The RSO made the preliminary assessment that the dosimeter was possibly functioning just above the 'cutoff' point of low battery.
"The licensee stated that a detailed report is in process and will be submitted within the required time parameters."
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 report was received from the State of Kansas via email:
"Yesterday afternoon [the State of Kansas] was contacted by [the licensee's], RSO [Radiation Safety Officer] for KU Hospital Authority lic# 18-C801, to report a medical event. On the morning of 9/29/15, a Thera-spheres Y-90 therapy procedure was found to have underdosed the patient by 36%. The details are as follows:
"A RADose RAD 60R personal electronic dosimeter is attached to the plexiglass 'box' which holds the vial containing the Y-90 Thera-spheres during the procedure. This dosimeter is the only method of detection to ensure that all of the Y-90 material is placed within the patient. In comparison, the Sir-sphere, similar material and procedure, utilizes a contrast to better ensure material is where it's supposed to be.
"Prior to the procedure, the dosimeter was checked for current calibration and source checked and found to be satisfactory including low battery indicator not active. During this pre-procedure check, the dosimeter exhibited fluctuating readings. A backup dosimeter of the same make and model was searched for but could not be located. The dosimeter was then re-checked and the fluctuations could not be duplicated, thus it was decided to utilize the dosimeter for the procedure. The Y-90 procedure was then completed, with the dosimeter reading at levels that indicated the required Y-90 had been placed within the patient. At this point, the 'waste' from the procedure i.e. vials, tubing, pads is taken back to the hot lab and surveyed to calculate the remaining Y-90. It was discovered that 36% still remained and that the patient did not receive the entire prescribed dose. It was determined that enough of the Y-90 had been administered to the patient to receive a satisfactory therapeutic dose thus another procedure would not be necessary.
"Exposure to staff was also determined to be negligible due to the nature of the material/shielding/remaining concentration. The RSO stated that the dosimeter was again rechecked and the low battery indicator was active during the check. The RSO made the preliminary assessment that the dosimeter was possibly functioning just above the 'cutoff' point of low battery.
"The licensee stated that a detailed report is in process and will be submitted within the required time parameters."
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: 51432
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CARL YOUNG
HQ OPS Officer: CHARLES TEAL
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CARL YOUNG
HQ OPS Officer: CHARLES TEAL
Notification Date: 09/29/2015
Notification Time: 14:56 [ET]
Event Date: 09/29/2015
Event Time: 10:30 [EDT]
Last Update Date: 09/29/2015
Notification Time: 14:56 [ET]
Event Date: 09/29/2015
Event Time: 10:30 [EDT]
Last Update Date: 09/29/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
FRED BOWER (R1DO)
FRED BOWER (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
BOTH TRAINS OF THE STANDBY GAS TREATMENT SYSTEM DECLARED INOPERABLE
"On 9/29/15 at 1020 EDT, the 'B' train of Standby Gas Treatment System was declared inoperable for planned testing. On 9/29/15 at 1030 EDT, during performance of a surveillance on Unit 1 Reactor Pressure Vessel water level instrumentation, one channel was found to not meet acceptance criteria. The failed level channel is part of the initiation logic for the 'A' train of Standby Gas Treatment. This resulted in a loss of safety function for the Standby Gas Treatment System. On 9/29/15 at 1145 EDT, the 'B' train of Standby Gas Treatment was restored to operable by restoring from the planned testing.
"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function."
The NRC Resident Inspector has been informed.
"On 9/29/15 at 1020 EDT, the 'B' train of Standby Gas Treatment System was declared inoperable for planned testing. On 9/29/15 at 1030 EDT, during performance of a surveillance on Unit 1 Reactor Pressure Vessel water level instrumentation, one channel was found to not meet acceptance criteria. The failed level channel is part of the initiation logic for the 'A' train of Standby Gas Treatment. This resulted in a loss of safety function for the Standby Gas Treatment System. On 9/29/15 at 1145 EDT, the 'B' train of Standby Gas Treatment was restored to operable by restoring from the planned testing.
"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function."
The NRC Resident Inspector has been informed.