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Event Notification Report for June 9, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/08/2017 - 06/09/2017

** EVENT NUMBERS **


52711 52717 52779 52780 52795

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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: 06/08/2017
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

* * * UPDATE ON 6/8/17 AT 1515 EDT FROM JOSEPH NOBLE TO BETHANY CECERE * * *

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

"Investigated by LA:
Preliminary: Phone Investigation Event was discovered by the wrong organ uptake for the patient scan to be performed.
Facility findings wrong study ordered and wrong unit dose ordered and administered.
Facility request a site visit when fact can be delivered and management can be present.
Facility Investigation Visit, on 05/01/2017

"Findings:
PA ordered the unit dose without a written directive.
PA ordered the scan through the OMCBR electronic order/records system.
Patient was administered the I-131 and counselled when to return for the scan.
[Patient] returned after numerous attempts to contact [patient].
The desired scan was different from the wrong scan ordered.
At the scan time was when the ERROR was discovered.
The wrong activity was ordered and administered due to electronic ordering and records system without confirmations of orders.

"Facility Calculations: from 2.0 mCi NaI-131 unit absorbed dose. 10% to 30% uptake from 2 mCi NaI-131.
Absorbed Radiation Dose range to thyroid 1100 to 3200 rads with the thyroid gland dose approximately 1630 rads at 15.7 percent uptake from 1.65 NaI-131.
State Confirmation From FDA Prescribing Dosage for NaI-131, Table 1, Absorbed Radiation Doses.

"Corrective Actions:
'PROOF' of EPIC electronic patients records system and for ordering studies
Suspension of I-131 usage until system is corrected and staff training is complete
Training for Written Physician's orders and ordering scans
Confirming orders before administering drugs/isotopes"

NMED #170217

Notified R4DO (Rollins) and NMSS Events Notification by 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: 52717
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: VERSA INTEGRITY
Region: 4
City: HOUSTON State: TX
County:
License #: L06669
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/29/2017
Notification Time: 19:27 [ET]
Event Date: 04/28/2017
Event Time: [CDT]
Last Update Date: 06/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER TRAINEE BADGE READ GREATER THAN 5 REM

"On April 29, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee that on April 28, 2017, one of its radiographer trainees had reported their self-reading dosimeter had gone off-scale. The licensee stopped all work and sent the trainee's OSL [Optically Stimulated Luminescence] dosimeter to be processed. The licensee received a verbal report from the processer on April 29, 2017, and the dose was reported as 5.392 REM. The licensee did not know if the dose was static or dynamic. The licensee stated that the trainee had not operated the exposure device and did not know how the trainee could have received the exposure. The licensee stated there was a chance that the dose was to the badge only. The licensee is conducting a formal investigation into the event. No other individual reported an unusual exposure. The exposure device was a QSA 880D camera containing a 51 Ci Ir-192 source. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9482

* * * UPDATE AT 1121 EDT ON 06/08/17 FROM IRENE CASARES TO STEVE SANDIN VIA EMAIL * * *

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

"On May 30, 2017 a detailed report was received by the corporate RSO [Radiation Safety Officer] stating the details of this event. The amount of information was limited and an on-site investigation was conducted on June 7, 2017. By interviewing employees who were at the event, it was determined that the individual did receive the dose of 5.392 REM (whole body) on April 28, 2017 as indicated on his badge reading. He was wearing monitoring devices and an alarming rate meter. There was extreme noise in the area. The exposed employee was a trainee and did not operate the radiography device, although the trainee was experienced in rope repelling in this specific situation and positioned the camera 30 feet above the floor in a pipe rack and collected the film. He did not crank the source in or out. He mounted the camera in the pipes, repelled down the ropes out of the area while the weld was imaged. He returned to the area after the trainer cranked in the source, checked a survey meter on the floor level, 30 feet below the camera, and shielded (there were pipes containing fluids and concrete columns shielding the area), while the trainee climbed the distance to collect the film. The trainee did not take the survey meter with him to do a post exposure survey near the camera or film (the meter is routinely snapped on the harness or cow-tail lanyard, but not this time). He collected the film and lowered it by rope to the trainer. The trainee decided on his own to stay in the rope harness near the camera, unknown to him that the source was slightly exposed. His alarming rate meter may have alarmed although he wouldn't have heard it, nor did he check it. The trainer took the film to the developer in another trailer onsite. When he returned (about 20 minutes) to say, film good, the trainee tried to unhook the cable. When it failed to unhook, another trainer in the crew had seen him and turned the crank handle to fully retract the source (uncertain, about half a turn). The trainee immediately lowered himself to the ground and both went to the vehicle. It was found that his pocket dosimeter was off scale, alarming rate meter was not alarming at this point and trainer phoned the RSO to get advice. Work stopped and the employees stayed on site. The RSO collected badge and sent it for immediate processing and gathered as much information as possible. It is believed the trainee's dose, according to the trainers, was to his whole body and possibly a few seconds to his right hand while trying to disconnect the cable. Within days, the trainee was released from employment from the company and disciplinary action taken against the other trainers. In an attempt to contact the trainee, the trainee responded to a phone text message stating he has not had any redness or tingling in his hand. He also stated he did not touch the collimator. The hand dose is estimated to be less than 2.5 millirem for three seconds or less."

Notified R4DO (Rollins), NSIR (Milligan), NMSS (Rivera-Capella), and NMSS Events Notification via email.

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Non-Agreement State Event Number: 52779
Rep Org: VETERANS HEALTH ADMINISTRATION
Licensee: VETERANS HEALTH ADMINISTRATION
Region: 4
City: NORTH LITTLE ROCK State: AR
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/31/2017
Notification Time: 20:08 [ET]
Event Date: 05/30/2017
Event Time: 07:00 [CDT]
Last Update Date: 05/31/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

EXTERNAL CONTAMINATION ON PACKAGE GREATER THAN ALLOWABLE LIMITS

"Pursuant to 10 CFR 20.1906, Veterans Health Administration (VHA) National Health Physics Program is notifying NRC of the receipt of two packages of radioactive material with removable surface contamination on the outside that exceeded NRC reporting limits.

"The packages were received on the morning of Tuesday, May 30, 2017, by the Robert J. Dole VA Medical Center in Wichita, Kansas. This facility is a site of use under the VA St. Louis Health Care System, St. Louis, Missouri, which holds VHA permit number 24-00144-05 under the VHA master materials license. The packages were surveyed at about 0700 CDT. The wipe tests performed on the external surfaces of the packages indicated removable contamination of about 1,450 and 1,390 dpm/cm2 as compared to the regulatory limit of 240 dpm/cm2 for beta-gamma emitters. The packages contained unit dosages of fluorine-18 fluorodeoxyglucose. The packages were shipped from Cardinal Health in Wichita, Kansas, which was also the final delivery carrier. A facility nuclear medicine technologist notified the final delivery carrier by telephone of the contaminated packages soon after discovery of the contamination. VHA National Health Physics Program, which manages the master materials license, was notified of the incident at about 1700 CDT on Wednesday May 31, 2017.

"The VHA is aware that this notification does not conform to the timeliness requirements in 10 CFR 20.1906. VHA will take appropriate action regarding this apparent noncompliance. VHA will notify our NRC Region III Project Manager of this incident."

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Non-Agreement State Event Number: 52780
Rep Org: KARMANOS CANCER INSTITUTE
Licensee: KARMANOS CANCER INSTITUTE
Region: 3
City: DETROIT State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: JOE RAKOWSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/01/2017
Notification Time: 12:25 [ET]
Event Date: 05/31/2017
Event Time: 12:45 [EDT]
Last Update Date: 06/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - PATIENT RECEIVED LESS DOSE THAN PRESCRIBED

"On May 31, 2017, the licensee's gamma knife model 'C' failed during treatment delivery. The couch retracted from the treatment position at 1245 [EDT] due to a clutch malfunction. Three out of five shots were delivered to the single planned lesion. The prescribed volume received a dose of 15 Gy versus the prescribed 20 Gy. Due to uncertainty regarding repair, the fixation frame was removed from the patient's head. Repair was completed at 1845 [EDT]."

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: 52795
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DARVIN DUTTRY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/08/2017
Notification Time: 19:10 [ET]
Event Date: 06/08/2017
Event Time: 15:27 [EDT]
Last Update Date: 06/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BLAKE WELLING (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

AUTOMATIC REACTOR SCRAM AFTER MAIN TURBINE CONTROL LOGIC LOSS OF POWER

"At 1527 hrs [EDT] on June 8, 2017, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed due to a loss of Main Turbine Electro-Hydraulic Control (EHC) logic power causing a High Flux Reactor Power RPS [Reactor Protection System] trip.

"All control rods [fully] inserted and both reactor recirculation pumps tripped due to reaching reactor water level 2. Reactor water level lowered to -49 inches causing Level 3 (+13 inches) and Level 2 (-38 inches) isolations. HPCI [High Pressure Coolant Injection] and RCIC [Reactor Core Isolation Cooling] automatically initiated and were overridden by control room operators after RPV [Reactor Pressure Vessel] water level was restored to the normal band with feedwater. HPCI and RCIC injected to the Reactor Coolant System during reactor level stabilization. All isolations and initiations occurred as expected. No main steam relief valves opened. Pressure was controlled via main turbine bypass valve operation. All safety systems operated as expected.

"Secondary Containment Zone 1, 2, and 3 differential pressure lowered to 0 inch WG [Water Gauge] due to a trip of the Reactor Building Ventilation system that resulted from Unit 1 Level 2 isolation. Differential pressure was restored to Zones 1, 2, and 3 by the initiation of Standby Gas Treatment System on the Unit 1 Level 2 initiation.

"Unit 1 reactor is currently stable in Mode 3. Investigation into the loss of Main Turbine EHC logic power is underway.

"The NRC Resident Inspector has been notified. A voluntary notification to PEMA and press release will occur."

The suspected cause of the loss of power to the EHC logic circuit is ongoing maintenance on the system.

Page Last Reviewed/Updated Friday, June 09, 2017
Friday, June 09, 2017