Event Notification Report for August 11, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/10/2017 - 08/11/2017
Agreement State
Event Number: 53009
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/11/2017
Notification Time: 13:58 [ET]
Event Date: 08/11/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/26/2018
Notification Time: 13:58 [ET]
Event Date: 08/11/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following report was received via e-mail:
"On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017.
"DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event."
Wisconsin Event Report: WI170016
* * * UPDATE ON 4/26/18 AT 1238 EDT FROM JOSEPH ROSS TO BETHANY CECERE * * *
The following update was received from the Wisconsin Department of Health Services (DHS) by email:
"During the ongoing investigations of other medical events reported to the Wisconsin Department of Health Services in 2017, licensee reviewed historic permanent implants of I-125 seeds for prostate manual brachytherapy. The licensee recently identified two additional implants that resulted in a D90 dose to the prostate that was greater than 130 percent of the prescribed dose. The licensee noted that there were no adverse outcomes to the patients.
"The first implant occurred on August 28, 2015. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 192 Gy.
"The second implant occurred on June 17, 2016. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 189 Gy.
"DHS is reviewing the circumstances surrounding these two implants as part of the investigation into the previously reported medical events."
Notified R3DO (Stone) and NMSS Events.
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.
The following report was received via e-mail:
"On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017.
"DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event."
Wisconsin Event Report: WI170016
* * * UPDATE ON 4/26/18 AT 1238 EDT FROM JOSEPH ROSS TO BETHANY CECERE * * *
The following update was received from the Wisconsin Department of Health Services (DHS) by email:
"During the ongoing investigations of other medical events reported to the Wisconsin Department of Health Services in 2017, licensee reviewed historic permanent implants of I-125 seeds for prostate manual brachytherapy. The licensee recently identified two additional implants that resulted in a D90 dose to the prostate that was greater than 130 percent of the prescribed dose. The licensee noted that there were no adverse outcomes to the patients.
"The first implant occurred on August 28, 2015. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 192 Gy.
"The second implant occurred on June 17, 2016. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 189 Gy.
"DHS is reviewing the circumstances surrounding these two implants as part of the investigation into the previously reported medical events."
Notified R3DO (Stone) and NMSS Events.
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.
Power Reactor
Event Number: 52898
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JONATHAN BAIN
HQ OPS Officer: JEFF HERRERA
Region: 4 State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JONATHAN BAIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/11/2017
Notification Time: 16:12 [ET]
Event Date: 08/11/2017
Event Time: 11:24 [CDT]
Last Update Date: 08/11/2017
Notification Time: 16:12 [ET]
Event Date: 08/11/2017
Event Time: 11:24 [CDT]
Last Update Date: 08/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
HEATHER GEPFORD (R4DO)
HEATHER GEPFORD (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 10 | Power Operation | 3 | Startup |
COMANCHE PEAK AUTOMATIC TURBINE TRIP FROM 10 PERCENT POWER
"At 1124 CDT on 11 August 2017, CPNPP [Comanche Peak Nuclear Power Plant] Unit 2 experienced an automatic turbine trip and trip of both main feedwater pumps on high steam generator water level (P-14, 81.5 percent level) in steam generator 2-02. Following the turbine trip, the auxiliary feedwater system actuated as required. The plant was stabilized at 2-3 percent reactor power with auxiliary feedwater feeding all steam generators with all levels within their normal bands.
"The cause of the high steam generator level appears to be a mechanical malfunction of steam generator 2-02 flow control valve bypass valve 2-LV-2163 (SG 2-02 FW BYP CTRL VLV) to close when demanded. Troubleshooting and repair of 2-LV-2163 is in progress.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) for an actuation of auxiliary feedwater.
"The NRC Resident Inspector has been notified."
"At 1124 CDT on 11 August 2017, CPNPP [Comanche Peak Nuclear Power Plant] Unit 2 experienced an automatic turbine trip and trip of both main feedwater pumps on high steam generator water level (P-14, 81.5 percent level) in steam generator 2-02. Following the turbine trip, the auxiliary feedwater system actuated as required. The plant was stabilized at 2-3 percent reactor power with auxiliary feedwater feeding all steam generators with all levels within their normal bands.
"The cause of the high steam generator level appears to be a mechanical malfunction of steam generator 2-02 flow control valve bypass valve 2-LV-2163 (SG 2-02 FW BYP CTRL VLV) to close when demanded. Troubleshooting and repair of 2-LV-2163 is in progress.
"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) for an actuation of auxiliary feedwater.
"The NRC Resident Inspector has been notified."