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Event Notification Report for August 15, 2017

U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/14/2017 - 08/15/2017 ** EVENT NUMBERS ** 52887 52903 Agreement State Event Number: 52887 Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: MIDWEST REGIONAL MEDICAL CENTER Region: 3 City: ZION State: IL County: License #: IL-01104-01 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: DONALD NORWOOD Notification Date: 08/04/2017 Notification Time: 17:24 [ET] Event Date: 08/04/2017 Event Time: [CDT] Last Update Date: 08/04/2017 Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE Person (Organization): RICHARD SKOKOWSKI (R3DO) NMSS_EVENTS_NOTIFICA (EMAI) Event Text AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT The following information was received via E-mail: "The licensee's RSO reported an event that resulted in an underdose to the patient. At 1215 CDT on August 4, 2017, licensee staff were administering a 40.4 mCi dose of Y-90 microspheres to the patient. The preliminary finding is that the patient took a deep inspiration which moved the base catheter and possibly changed its position or created a kink in the catheter. The first 3-4 aliquots were delivered before the plunger met resistance and the procedure aborted. The licensee estimates that 21.5 mCi was delivered (underdose 46.9%). They estimate that the patient received 50+ Gy to the intended area and there were no microspheres to an unintended target. Written report forthcoming." Illinois Item Number: IL177016 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: 52903 Facility: PERRY Region: 3 State: OH Unit: [1] [ ] [ ] RX Type: [1] GE-6 NRC Notified By: STEPHEN J. KAPOSTASY HQ OPS Officer: DONG HWA PARK Notification Date: 08/15/2017 Notification Time: 04:58 [ET] Event Date: 08/14/2017 Event Time: 22:57 [EDT] Last Update Date: 08/15/2017 Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION Person (Organization): AARON McCRAW (R3DO) Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode 1 N Y 100 Power Operation 100 Power Operation Event Text SECONDARY CONTAINMENT MOMENTARY LOW VACUUM "On August 14th, 2017 at 2257 [EDT], while shutting down the Annulus Exhaust Gas Treatment System (AEGTS) Train B, secondary containment pressure momentarily lowered. This resulted in the Technical Specification (TS) for Secondary Containment to not be met for 15 seconds. The minimum Secondary Containment vacuum observed during that time was 0.52 inch of vacuum water gauge. "Secondary Containment pressure was returned to within the TS operability limit of 0.66 inch of vacuum water gauge (TS SR 3.6.4.1.1) by the AEGTS Train A that remained in operation. There were no radiological releases associated with this event. "Declaring Secondary Containment inoperable is reportable under [10 CFR] 50.72(b)(3)(v)(C) & (D) for an event or condition that could have prevented the fulfillment of a safety function of a system that is needed to:(C) Control the release of radioactive material; or (D) Mitigate the consequences of an accident. "The licensee has notified the NRC Resident Inspector."

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