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Event Notification Report for May 4, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/03/2017 - 05/04/2017

** EVENT NUMBERS **


52706 52709 52711 52727 52729

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Agreement State Event Number: 52706
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EQUISTAR CHEMICAL LP
Region: 4
City: PASADENA State: TX
County:
License #: 01854
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/25/2017
Notification Time: 15:45 [ET]
Event Date: 04/25/2017
Event Time: [CDT]
Last Update Date: 04/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE STUCK SHUTTER

The following report was submitted via e-mail:

"On April 25, 2017, the Agency [Texas Department of State Health Services] was contacted by a licensee to report that a gauge would not close during a preventive maintenance check and the shutter is stuck. The gauge is an Ohmart SH-F1A, serial number 6228GK, containing a 50 mCi Cs-137 source. The shutter is stuck in the normal [open] operating position. The licensee is in contact with the manufacturer for a repair plan and with licensing for an exemption to operate the gauge temporarily with a stuck shutter. No exposures to the public are expected."

Texas Incident: I-9480

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Agreement State Event Number: 52709
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/26/2017
Notification Time: 13:44 [ET]
Event Date: 04/25/2017
Event Time: [EDT]
Last Update Date: 04/26/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO UNDERDOSE OF YITTRIUM-90 THERASPHERES

The following information was obtained from the Commonwealth of Pennsylvania via fax:

"Event Description: The event involved a patient who was scheduled to be treated with 11.87 mCi of Y-90 microspheres (TheraSphere), but only received an estimated 5.07 mCi, or 43% of the prescribed dose. The licensee reported the event to the Department [Pennsylvania Department of Environmental Protection] on April 25, 2017. Initial indication is that there was a faulty connection on the catheter line that allowed a leak to occur. The patient and referring physician were notified the day of the procedure. No Jefferson personnel skin contamination occurred. However, gloves, drapes and the patient's skin were contaminated. The patient was quickly decontaminated with alcohol wipes. All remaining areas were also decontaminated. A skin calculation is currently being completed by the licensee to determine the patient's exposure, if any. No overexposure is believed to have occurred.

"Cause of the Event: Unknown at this time. Suspected human error.

"Actions: The Department will perform a reactive inspection. The licensee will update their procedure to include additional checks of the Y-90 administration kit. More information will be provided upon receipt."

PA Event Report ID No.: PA170009

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: 52711
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: OCHSNER MEDICAL CENTER BATON ROUGE
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-0002-L01,
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/26/2017
Notification Time: 16:36 [ET]
Event Date: 04/20/2017
Event Time: [CDT]
Last Update Date: 04/26/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO INCORRECT NUCLEAR MEDICAL SCAN PERFORMED

The following information was obtained from the state of Louisiana via email:

"[On] April 21, 2017, [the licensee's RSO] called [Louisiana Department of Environmental Quality (LDEQ)] to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event'. The event occurred under the Ochsner Clinic Foundation Broad Scope Medical License (OCFBS), LA-0002-L01. The event involved 2 mCi of I-131 being administered as an error when the PA [Physician Assistant] was ordering a medical test/scan. The test should have been one for the parathyroid, but a thyroid scan was ordered in error in the EPIC System [health informatics software].

"[The] RSO for this licensee called in to see if the OMCBR [Ochsner Medical Center, Baton Rouge], Baton Rouge Medical Center error in administration had to be reported or just recorded for the OCFBS medical records. He was instructed it was a reportable event and he should investigate and make the appropriate corrective actions. The 2 mCi [of] I-131 was ordered and administered on [April] 18, 2017 and the error was discovered on April 20, 2017. The Nuclear Medicine Tech placed the patient on the table and the thyroid gland 'lit up' due to the I-131 uptake.

"According to [the RSO's] verbal report, the written orders were incomplete or did not exist; the parathyroid was the tissue to be scanned; and discovered on [April 20, 2017]. [The RSO] did a preliminary report on the phone April 21, 2017. His report gave an estimated target organ dose [of approximately] 600 rads to the thyroid. At that time, he stated there were additional aspects to be investigated, corrected, and reported.

"Corrective Action: The order capture procedure was changed recently and all of the Technologists, ordering Physicians, and Physician's Assistants will be re-trained in the current/new procedures. The wrong procedure was performed and the results will be sent to the referring physician. The patient was notified of the error.

"LDEQ considers this incident still open and subject to investigation and corrective action implementation."

LA Event Report ID No.: LA-170006

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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Power Reactor Event Number: 52727
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DAVE DUESING
HQ OPS Officer: STEVEN VITTO
Notification Date: 05/03/2017
Notification Time: 12:59 [ET]
Event Date: 04/30/2017
Event Time: 18:18 [EDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 74 Power Operation

Event Text

OPEN BYPASS VALVE CAUSES LOSS OF SAFETY FUNCTION

"On April 30, 2017, at 1818 [EDT], the main turbine steam bypass valve #1 partially opened. Power was incrementally lowered. While lowering power the bypass valve would shut and then reopen and power would again be lowered. When power was lowered to approximately 74 percent the bypass valve remained closed. During the transient the reactor protection system (RPS) Turbine Stop Valve Closure and Control Valve Fast Closure trip functions were declared inoperable due to the opening of the bypass valve which affects the bypass setpoint for those RPS trip functions. With the loss of these RPS trip functions a loss of safety function existed intermittently for approximately 37 minutes. The manual reactor trip function and other RPS functions remained operable.

"Both channels of the rod withdrawal limiter (RWL) and the end of cycle reactor recirculation pump trip (EOC-RPT) function were also declared inoperable. These functions are credited in accident analysis, this also resulted in a loss of safety function.

"Currently the bypass valve is closed and the RWL, EOC-RPT and RPS function are operable. Troubleshooting continues to determine the issue with the main turbine that caused the bypass valve to open."

NRC Resident Inspector has been notified.

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Power Reactor Event Number: 52729
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MARK MAYER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/03/2017
Notification Time: 15:04 [ET]
Event Date: 05/03/2017
Event Time: 02:04 [CDT]
Last Update Date: 05/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
FFD GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 92 Power Operation 92 Power Operation

Event Text

FITNESS FOR DUTY - PROHIBITED ITEM FOUND IN PROTECTED AREA

"At 0204 [CDT] on 5/3/2017, a facilities person was removing the trash bags from the garbage can in the restroom of the Administrative Building inside the Protected Area. While emptying the trash, they discovered a 100ml alcoholic beverage container in the trash. The container was empty, however, there was an odor of alcohol coming from the bottle. The item was turned over to the security department. The investigation identified the last time this trash bag had been changed out was on 5/2/2017 at 1530 [CDT]. This event is being reported per 10CFR26.719(b)."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, May 04, 2017
Thursday, May 04, 2017