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Event Notification Report for January 27, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/26/2016 - 01/27/2016

** EVENT NUMBERS **


51520 51661 51687

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 51520
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT 1800494
Agreement: Y
Docket:
NRC Notified By: MIKE GIVENS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/06/2015
Notification Time: 20:24 [ET]
Event Date: 11/05/2015
Event Time: [MST]
Last Update Date: 01/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

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

"On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma.

"It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.)

"The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation."

Utah Event Report No.: UT150005

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.

* * * EVENT RETRACTION FROM GYWN CALLOWAY TO JOHN SHOEMAKER AT 1919 EST ON 1/26/16 * * *

The State of Utah (Division of Waste Management) has received additional information, from the licensee, indicating that the actual underdose to the patient was < 5% and does not meet the reportability criteria. Therefore, this event is being retracted.

Notified the R4DO (Farnholtz) and NMSS Events Notification via email.

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Agreement State Event Number: 51661
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: UNIVERSITY OF OKLAHOMA
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-03176-04MD
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/19/2016
Notification Time: 09:09 [ET]
Event Date: 01/14/2016
Event Time: [CST]
Last Update Date: 01/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - COMTAMINATION FOUND ON SHIPMENT

The following report was received from the Oklahoma Department of Environmental Quality via email:

"On January 14, 2016, [the Oklahoma Department of Environmental Quality] was informed that a package containing licensed material shipped from the University of Oklahoma Pharmacy (license OK-03176-04MD) to the University of Oklahoma Medical Center (OK-21035-01) was found to have approximately 17,000 DPM of removable contamination. The contamination appeared to be confined to a plastic sleeve the address label was in. There was no reported damage to the package or contents."

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Power Reactor Event Number: 51687
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SILVESTRE ROMERO JR
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/27/2016
Notification Time: 01:44 [ET]
Event Date: 01/26/2016
Event Time: 23:25 [CST]
Last Update Date: 01/27/2016
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):
THOMAS FARNHOLTZ (R4DO)

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

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF FEEDWATER TO A SINGLE STEAM GENERATOR

"At 2325 [CST] on 01/26/2016, Unit 1 was manually tripped due to loss of Feedwater on 'C' S/G [Steam Generator]. The loss of Feedwater was a result of a failure on 'C' S/G Main Feedwater Regulating Valve that caused the valve to travel closed with no Operator action. Auxiliary Feedwater and Feedwater Isolation actuated as designed. All Control and Shutdown Rods fully inserted. Intermediate Range Nl 36 [Nuclear Instrument] failed above P10 and, as a result, Source Range Nuclear Instruments were manually energized. No primary or secondary relief valves opened. There were no electrical problems. Normal operating temperature and pressure (NOT/NOP) is 567 degrees F and 2235 psig. There were no significant TS LCOs entered.

"This event was not significant to the health and safety of the public based on all safety systems performed as designed.

"Unit 2 was not affected."

Decay heat removal is being controlled via Steam Dumps. Offsite power is in the normal electrical lineup.

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Wednesday, January 27, 2016
Wednesday, January 27, 2016