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Event Notification Report for January 31, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/30/2017 - 01/31/2017

** EVENT NUMBERS **


52500 52504 52506 52507 52518 52519

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Agreement State Event Number: 52500
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY
Region: 1
City: DURHAM State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/20/2017
Notification Time: 15:04 [ET]
Event Date: 01/19/2017
Event Time: 13:00 [EST]
Last Update Date: 01/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - INCORRECT DRUG DELIVERED TO PATIENT

The following was received via E-mail:

"The North Carolina Radioactive Materials Branch (RMB) is submitting a report of a possible Medical Event reportable under 10 CFR 35.3045(a)(2)(i). Specifically, a dose was delivered to a patient with an effective dose equivalent (50 rem) to an organ through the administration of a wrong radioactive drug containing byproduct material. The RMB received the report of the possible Medical Event on 1/19/2017.

"NC Licensee Duke University, License 0247-4, reported to the RMB that around 1300 EST on 1/19/2017 a patient scheduled for a thyroid uptake scan in the Diagnostic Nuclear Medicine Department was incorrectly identified and received an oral dose of 2.0 mCi of Iodine-123 instead of the intended dose of 5-12 microCi of Iodine-131.

"An investigation was held on 1/20/2017 with members of Duke University to include the individual that delivered the incorrect dose to the patient. Following a review of the licensee's current procedures, it was noted that there is a minimum of two methods of patient verification prior to the administration of any diagnostic radioactive drug to any patient. An interview was conducted with the CNMT [Certified Nuclear Medicine Technologist] that delivered the incorrect dose and they freely admitted to not following the proper protocol which consists of confirming the Name and Date of Birth of the patient. Other factors may have attributed to this misadministration to include the volume of patients being treated that day and that there were two patients present that day with very similar first and last names. The patient with the similar name received the proper dose for their procedure.

"Following interviews with Duke personnel, it was determined that the CNMT received the proper training to adhere to this two factor authentication as dictated by internal procedures and was authorized under an approved AU for such uses. At this time, it appears the cause for this misadministration is due to human error.

"This investigation is ongoing and more details are to follow to update this report. Several records were requested of the licensee to include a dose assessment to verify the EDE of 50 rem or any excess of 50 rem delivered to the organ. The licensee is compiling it's 15 Day Report and will be providing it to the RMB as required by the Rule. Following receipt of that report, this event will be updated."

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: 52504
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: BETHANY CECERE
Notification Date: 01/23/2017
Notification Time: 08:53 [ET]
Event Date: 01/19/2017
Event Time: [EST]
Last Update Date: 01/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RECEIVED DOSE LESS THAN PRESCRIBED DOSE

The following is excerpted from an email:

"On January 20, 2017 the licensee informed the Department [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] of an under dose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable as per 10 CFR 35.3045(a)(1)(i).

"On January 19, 2017 a patient underwent a Y-90 TheraSphere treatment. The staff reported the procedure went as planned; however, upon surveying the waste and performing a dose calculation it was found that the patient received approximately 29% of the prescribed dose. The patient was notified of this under dose on January 20, 2017. The physician utilized contrast medium to view the flow prior to the procedure and no issues were seen. No increased resistance was noted and the physician was able to flush the line post administration. The manufacturer was notified and will be conducting a joint investigation with the hospital staff. No harm is expected to the patient.

"A reactive inspection is planned by the Department. More information will be provided upon receipt.

"PA Event Report ID No: PA 170001"

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: 52506
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: URI, INC.
Region: 4
City: KINGSVILLE State: TX
County: KLEBERG
License #: R03653
Agreement: Y
Docket:
NRC Notified By: M ABBASZADEH
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/23/2017
Notification Time: 12:27 [ET]
Event Date: 01/22/2017
Event Time: [CST]
Last Update Date: 01/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIRE AT A URANIUM RECOVERY FACILITY

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

"On Sunday, January 22, 2017, at 1041 [CST], [the Texas Commission on Environmental Quality] CID [Critical Infrastructure Division] received a call from URI's Radiation Safety Officer [RSO], for the Kingsville Dome facility, that a fire occurred on the west side of well field 17 in Production Area 3, on Sunday morning, January 22, 2017. [The RSO] stated the cause of the fire appeared to be a cigarette butt. A URI operator working at the site noticed the fire. When the operator arrived at the fire location, he noticed that the fire department (FD) was already putting out the fire. At the time of the call, according to [the RSO], the fire was under control and the FD was making sure to put out the hot spots. At the time of the fire, the well field was on a shutdown status and there were no other activities at the well field. The preliminary findings were damage to some of the well field fences and wells in the well field."

The extent of damage is still being evaluated and there are no reports of contamination or exposures, outside of the facility, at this time.

The URI, Inc., Kingsville Dome is an In-Situ Uranium Recovery facility in Texas.

Texas Report Number: None assigned at this time.

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Agreement State Event Number: 52507
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: STOCKYARD MOVIES 8 - QUICK TRIP
Region: 4
City: OMAHA State: NE
County:
License #: GL0336
Agreement: Y
Docket:
NRC Notified By: MELISSA MCCOWN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/23/2017
Notification Time: 15:11 [ET]
Event Date: 01/12/2017
Event Time: [CST]
Last Update Date: 01/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JESSE ROLLINS (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

"[The licensee] contacted [the Nebraska Office of Radiological Health] on January 12, 2017. The licensee indicated that they purchased the theater from Perkins Delaware, LLC but were not informed of the Tritium exit signs or the related license. The licensee became aware of the signs and the related license when they received the annual renewal and related inventory. The licensee opted to dispose of the signs with SRB technologies. During the packing process, the licensee discovered two signs missing from the inventory and is unable to ascertain when they were lost."

Lost Source Number: 1, Source/Radioactive Material: SEALED SOURCE LUMINOUS, Manufacturer: Isolite, Model Number: 2040, Serial Number: A4N1925, Radionuclide: H-3, 7.5 Ci 277.5 GBq.
Lost Source Number: 2, Source/Radioactive Material: SEALED SOURCE LUMINOUS, Manufacturer: NRD, INC., Model Number: T4001, Serial Number: 61821, H-3, 25 Ci 925 GBq.

Cause: Human Error. Corrective Action: None. The State of Nebraska considers this event to be closed.

Nebraska Item Number: NE170001.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 52518
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MATTHEW NORRIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/30/2017
Notification Time: 14:38 [ET]
Event Date: 01/30/2017
Event Time: 11:43 [EST]
Last Update Date: 01/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BRANNEN ADKINS (R2DO)
MICHAEL F. KING (NRR)
BERNARD STAPLETON (IRD)

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

OFFSITE NOTIFICATION DUE TO ONSITE FATALITY

"At approximately 1049 EST, an individual was discovered to be unresponsive at a site training facility outside of the Protected Area. The individual was transported via ambulance to the Burke County Hospital and was declared deceased at 1143 EST.

"The licensee has notified the NRC Resident Inspector. The licensee notified the State of Georgia Department of Labor - OSHA at 1414 EST."

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Power Reactor Event Number: 52519
Facility: LASALLE
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: WAYNE CLAYTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/30/2017
Notification Time: 23:34 [ET]
Event Date: 01/30/2017
Event Time: 19:08 [CST]
Last Update Date: 01/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ERIC DUNCAN (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 98 Power Operation 98 Power Operation

Event Text

ONE DIVISION EMERGENCY DIESEL GENERATOR COOLING WATER SYSTEM DECLARED INOPERABLE

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. During routine surveillance testing of the Unit 2 Division 3 Emergency Diesel Generator (LOS-DG-M3), the Cooling Water Strainer Backwash Valve, 2E22-F319, was identified to have stem/disk separation and could not be opened.

"This condition has been evaluated and the Division 3 Diesel Generator Cooling Water system has been declared inoperable. The Division 3 Diesel Generator Cooling Water system is a support system for the Division 3 Emergency Diesel Generator and the High Pressure Core Spray System (HPCS). The required actions of Technical Specification (TS) 3.5.1 were entered on 1/30/17 at 1908 CST when the HPCS system was determined to be inoperable.

"This condition could have prevented the HPCS, a single train safety system, from performing its design function."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, January 31, 2017
Tuesday, January 31, 2017