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Event Notification Report for January 19, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/15/2016 - 01/19/2016

** EVENT NUMBERS **


51640 51641 51655 51659 51660

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Non-Agreement State Event Number: 51640
Rep Org: HENRY FORD HOSPITAL
Licensee: HENRY FORD HOSPITAL
Region: 3
City: DETROIT State: MI
County:
License #: 21-04109-16
Agreement: N
Docket: 03002043
NRC Notified By: ALAN JACKSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/07/2016
Notification Time: 15:08 [ET]
Event Date: 01/06/2016
Event Time: 10:27 [EST]
Last Update Date: 01/08/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KARLA STOEDTER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

POTENTIALLY REPORTABLE UNDERDOSE TO PATIENT

A patient at the Henry Ford Hospital Interventional Radiology Department received a Y-90 Theraspheres treatment of 120 Gray to a portion of the left lobe of the liver via a written directive from the referring physician. The Interventional Radiologist administered the prescribed dose to the entire left lobe of the liver, and the hospital believes that will result in an underdose to the patient. The exact amount of the underdose has not determined at the time of this report. The referring physician has been notified and the licensee will inform the NRC when the patient has been notified. It is believed that this event will not result in any harm to the patient. The licensee is in the process of determining corrective action to prevent reoccurrence.


* * * UPDATE FROM ALAN JACKSON TO JEFF ROTTON AT 1543 EST ON 01/08/2016 * * *

The following update information was provided by the licensee via email:

"Providing additional materials related to a potential medical event that was reported on January 7, 2016 by Henry Ford Hospital (License 21-04109-16; Docket: 030-02043). Hospital reported an apparent deviation from the written directive of a Y-90 TheraSpheres treatment done on January 6, 2016. The written directive was prepared in tandem by a Radiation Oncologist and a Nuclear Medicine Authorized User physicians for the major portion of the left lobe of the liver, omitting segments 4A and 4B. The entire left lobe of the liver, including segments 4A and 4B, was treated by the Interventional Radiologist. The written directive called for the administration of 2.3 GBq (62.2 mCi) of Y-90. The activity delivered was 2.37 GBq (64 mCi) which properly conformed with the activity specified in the written directive. However, the dose delivered to the liver deviates from the intended dose in two important ways. First, the written directive did not include treating segments 4A and 4B of the left lobe of the liver. Secondly, the dose delivered of 94 Gy (9,400 rad) to the left lobe of the liver was lower (21.5%) than the intended dose of 120 Gy (12,000 rad). The Interventional Radiologist, who is the referring physician for this patient, originally intended to treat the entire left lobe of the liver, including segments 4A and 4B. This Interventional Radiologist, while very experienced in TheraSpheres treatments was new to the institution and proper communication of the intended treatment site did not occur.

"It is important to note that all of the physicians involved indicated that no harm resulted to the patient as a result of this deviation. According to the TheraSpheres package insert, the recommended therapeutic dose to the liver is 80 Gy to 150 Gy (8,000 rad to 15,000 rad). Thus the treatment dose of 94 Gy (9,400 rad) is well within the therapeutic range. The referring physician was notified about this case and he notified the patient about the treatment deviation."

Notified R3DO (Stoedter) and NMSS Events Notification group via 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.

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Agreement State Event Number: 51641
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS GROUP, INC.
Region: 4
City: GEISMAR State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/07/2016
Notification Time: 16:45 [ET]
Event Date: 12/19/2015
Event Time: [CST]
Last Update Date: 01/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - HUMAN ERROR PREVENTS A RADIOGRAPHY SOURCE FROM RETRACTING

The following report was received via e-mail:

"On December 19, 2015, a crew from Mistras was working at a temporary jobsite [Donaldsonville, LA] located at CF Industries. The crew set up 2 mR boundaries for the duration of the 'shots'/exposures. The crew cranked out the source and made the exposure. When the crew tried to retract the source into the shielded position, [the source] would not [retract] because the guide tube was improperly connected to the exposure device. The source assembly remained out of the shielded position. When it was determined the source could not be retracted, immediately the area was cleared and the boundaries were reestablished for the 2 mR/hr distance.

"The lead radiographer contacted the RSO, and received instructions on how to secure/shield the area from potential/unnecessary exposures. The unshielded source and incident duration was from 1.5 hours to 2 hours.

"The initial notice to the Department [LA Department of Environmental Quality] was made at approximately 1257 CST after the source was secured in the shielded position. The RSO did the actual retrieval and securing of the source. His time in the radiation field was approximately 30 to 40 minutes. He used the standards of time, distance and shielding to protect himself. His direct read pocket dosimeter reading was approximately 60 mR. The crew members pocket dosimeter readings were 50 mR and 20 mR.

"The exposure device and associated equipment (crank out control and source guide tube) were SPEC 150 exposure device S/N 1106 and a SPEC G-60 source. The source was 61 Ci of Ir-192. The equipment was evaluated and passed the quality assurance requirements. The radiography staff was reinstructed in the Mistras' Operation and Equipment Manual. Specifically the setup and equipment assembly, connecting and cranking out of the source and operating in potentially occupied areas."

Louisiana Report: LA-150023

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Power Reactor Event Number: 51655
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN CLIPPERTON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/14/2016
Notification Time: 18:10 [ET]
Event Date: 01/14/2016
Event Time: 14:43 [PST]
Last Update Date: 01/14/2016
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RAY KELLAR (R4DO)
M DAPAS (RA)
SCOTT MORRIS (NRR)
M EVANS (NRR)
B HOLIAN (NSIR)
BERNARD STAPLETON (IRD)
DENNIS ALLSTON (ILTA)
J KOZAL (R4)

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

Event Text

NOTIFICATION OF UNUSUAL EVENT - SECURITY CONDITION THAT DOES NOT INVOLVE HOSTILE ACTION

A security condition that does not involve a hostile action was reported by the Diablo Canyon security watch commander.

At 1443 PST on 1/14/16, Diablo Canyon declared an Unusual Event, due to an unauthorized person in the Owner Controlled Area. Site Security was dispatched and assistance was requested from the local Sheriff's Department. The individual was apprehended.

At 1602 PST on 1/14/16, Diablo Canyon terminated the Unusual Event after the individual was apprehended and placed in custody of local law enforcement. Diablo Canyon remained at 100 percent power for the duration of the event. No radiological release has occurred and all radiation levels are normal on both units. A press release is planned.

The licensee has notified the NRC Resident Inspector and state and local authorities.

Notified FEDS (DHS SWO, FEMA Ops, DHS NICC, and NuclearSSA via email.)

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Power Reactor Event Number: 51659
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RICH MARTENS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/16/2016
Notification Time: 01:42 [ET]
Event Date: 01/15/2016
Event Time: 20:38 [CST]
Last Update Date: 01/16/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
ERIC DUNCAN (R3DO)

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

Event Text

MOMENTARY LOSS OF SECONDARY CONTAINMENT

"On January 15, 2016 at 2038 CST, an alarm was received indicating Secondary Containment Differential Pressure rose unexpectedly above the Technical Specification Surveillance Requirement, SR 3.6.4.1.1, limit of 0.10 inch of vacuum water gauge. This loss of differential pressure occurred when Operations had entered the 2A Reactor Water Cleanup Pump room. The pump room door was closed and Secondary Containment Differential Pressure returned to Technical Specification limits in approximately 4 minutes. The Standby Gas Treatment System remained in standby and fully operable.

"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.1. As a result, entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to secondary containment being inoperable.

"Given the temporary loss of secondary containment, this event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.

"The NRC Senior Resident Inspector has been notified." The licensee also notified the State of Illinois Emergency Management Agency.

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Fuel Cycle Facility Event Number: 51660
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
                   COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA State: SC
County: RICHLAND
License #: SNM-1107
Agreement: Y
Docket: 07001151
NRC Notified By: NANCY PURR
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/17/2016
Notification Time: 07:22 [ET]
Event Date: 01/17/2016
Event Time: 05:29 [EST]
Last Update Date: 01/17/2016
Emergency Class: ALERT
10 CFR Section:
70.32(i) - EMERGENCY DECLARED
Person (Organization):
DEBORAH SEYMOUR (R2DO)
LAURA DUDES (R2)
CRAIG ERLANGER (NMSS)
SCOTT MOORE (NMSS)
BERNARD STAPLETON (IRD)

Event Text

ALERT DECLARED FOR FIRE NOT EXTINGUISHED WITHIN 15 MINUTES

A plant employee discovered a fire in the mechanical factory strap plating room and activated the fire alarm. At 0529 EST, the licensee notified the Richland County Fire Department. The fire was extinguished and the Alert declaration was terminated at 0709 EST. No radioactive materials were involved and no injuries were reported.

The licensee notified the State and R2 (Michel).

Notified DHS, FEMA, USDA, HHS, DOE, DHS NICC, EPA EOC, FEMA NWC (via email), FDA EOC (via email) and Nuclear SSA (via email).

Page Last Reviewed/Updated Tuesday, January 19, 2016
Tuesday, January 19, 2016