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Event Notification Report for May 5, 2017

U.S. Nuclear Regulatory Commission
Operations Center

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

** EVENT NUMBERS **


52709 52711 52712 52731 52732 52733

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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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Agreement State Event Number: 52712
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BLANCHARD REFINING COMPANY LLC
Region: 4
City: TEXAS CITY State: TX
County:
License #: 06526
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2017
Notification Time: 12:58 [ET]
Event Date: 04/27/2017
Event Time: [CDT]
Last Update Date: 04/27/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED NUCLEAR GAUGE

The following information was received from the state of Texas via email:

"On April 27, 2017, the Agency [Texas Department of State Health Services] was notified by the radiation safety officer of a licensee that a fixed gauge was discovered with a stuck shutter. The gauge is a line level indicator on a hydrogen fluoride tank and was stuck in the normal operating position. The gauge is a Vega SHLG containing cesium-137, 300 milliCuries, serial number 321300. The gauge is scheduled for repair and an amendment to the license is in process to operate the gauge in the open position until repaired. There is no risk of exposure to an individual. Updates will be provided as acquired."

Texas Incident No.: I-9481

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Part 21 Event Number: 52731
Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: TOPWORX
Region: 1
City: LOUISVILLE State: KY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MARK BROZAK
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/04/2017
Notification Time: 13:14 [ET]
Event Date: 05/02/2017
Event Time: [CDT]
Last Update Date: 05/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JAMES DWYER (R1DO)
RANDY MUSSER (R2DO)
ROBERT ORLIKOWSKI (R3DO)
MARK HAIRE (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 - C8, M8 AND H8 SWITCHES EXHIBITED CONTINUITY FROM INTERNAL CIRCUITRY TO CASE GROUND DURING INSPECTION AND TEST

The following report was received via email:

"TopWorx Information Notice: TIN 2017-01

"04 May 2017

"Subject: C8, M8 and H8 Switches

"From:

James McDill
Director of Operations
TopWorx
3300 Fern Valley Road
Louisville, KY 40213
Fax: (502) 969-7315

"Equipment Affected by this Information Notice: C8, M8 & H8 Series Products released prior to April 01, 2017.

"Purpose: The purpose on this TopWorx Information Notice (TIN) is to alert that as of 02 May 2017 TopWorx was made aware of a situation which may affect the performance of the equipment listed above. TopWorx is informing its customers of this circumstance in accordance with Section
21.21 (b) and 50.55 (e) of 10CFR21.

"Applicability: This notice applies only to the C8, M8, and H8 series of switches.

"Discussion: A potential nonconformance was discovered during product review when X-Ray analysis revealed a small piece of loose solder inside a completed C8 switch. Investigations revealed that the cause of this defect was the amount of solder used to hermetically seal the switch and enclosure together. Under the right conditions and circumstances, excessive solder on this specific switch model could potentially bridge between a circuit connection and the internal surface of the switch enclosure causing a high potential (Hipot) failure.

"Extent of Condition: No other series of switches are affected by this information notice.

"Actions Required: The recommended corrective action for installed switches is to continue monitoring for ground fault indications. If you do not currently monitor for ground fault indications, then a resistance check using an ohmmeter from each contact to the case to ensure no continuity to ground exists. Any switches exhibiting continuity to ground should be returned to TopWorx for replacement.

"10CFR21 Implications: TopWorx requests that the recipient of this notice review it and take appropriate action in accordance with 10CFR21.

Customer notifications [Quantity purchased and Customer Purchase Order numbers]:

Nuclear Logistics Inc.
[Qty 2 - PO #NLI57759, Qty 1 - PO #NLI-50192 REPL]

Control Southern Inc.
[Qty 10 - PO #X230280199, Qty 24 - PO #X230303436, Qty 1 - PO #X230315950, Qty 14 - PO #X230336922]

Ralph A. Hiller Co.
[Qty 10 - PO #NUC9868]

Weir Valves & Controls USA Inc.
[Qty 1 - PO #2022132/0, Qty 1 - PO #202321/0]

Emerson Process Mgmt (Bettis)
[Qty 4 - PO #4125106730, Qty 8 - PO #4125084349]

Fisher Controls
[Qty 4 - PO #G133492, Qty 4 - PO #4123340399, Qty 0 - PO #G132951 (ordered but not shipped), Qty 18 - PO #G132951, Qty 1 - PO #G133421]

"If there are any technical questions or concerns, please contact:

Mark Brozak
Manger, Quality
TopWorx
3300 Fern Valley Road
Louisville, KY 40213
Fax: (502) 969-8000
Phone: (502) 873-4689
Mark.Brozak@emerson.com"

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Power Reactor Event Number: 52732
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILL SPRINKLE
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/04/2017
Notification Time: 19:53 [ET]
Event Date: 05/04/2017
Event Time: 17:09 [EDT]
Last Update Date: 05/04/2017
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):
RANDY MUSSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 28 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO FAILED REACTOR COOLANT PUMP POWER TRANSFER

"On May 4th, 2017, at 1709 EDT, Watts Bar Nuclear Plant Unit 1 reactor was manually tripped due to a failure of the #3 Reactor Coolant Pump normal feeder breaker to close during the planned power transfer to unit power following startup. Concurrent with the reactor trip, the Auxiliary Feedwater system actuated as designed.

"All Control and Shutdown rods fully inserted. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and Steam Generator Atmospheric Dump Valves. Unit 1 is in a normal shutdown electrical alignment.

"This reactor trip and system actuation is being reported under 10CFR 50.72(b)(3)(iv)(A) and 10CFR 50.72(b)(2)(iv)(B).

"There was no effect on WBN Unit 2.

"The NRC Senior Resident [Inspector] has been notified."

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Power Reactor Event Number: 52733
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARC HILL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/05/2017
Notification Time: 00:45 [ET]
Event Date: 05/04/2017
Event Time: 21:03 [CDT]
Last Update Date: 05/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK HAIRE (R4DO)

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 MISCOMMUNICATION DURING ON-THE-JOB TRAINING

"On 5/4/17 at 2103 CDT, the South Texas Project [STP] Security Department was conducting on-the-job training for Bomb Threat response. While simulating the Bomb Threat Checklist via phone call, the trainer mistakenly contacted the Brazoria County, TX Child Protective Services (CPS) and reported a bomb threat. In response, the Child Protective Services notified the City of Brazoria, TX Police Department of the threat. The Brazoria Police Dept. then contacted both the Bay City, TX Police Department and the STP Security Department. By approximately 2130 CDT, all agencies had been notified by the STP Security Department of the mistaken phone call and that no actual bomb threat existed.

"The NRC Senior Resident Inspector was notified of the issue."

Page Last Reviewed/Updated Friday, May 05, 2017
Friday, May 05, 2017