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Event Notification Report for August 17, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/16/2017 - 08/17/2017

** EVENT NUMBERS **


52890 52893 52909

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Agreement State Event Number: 52890
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNARDINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: KATHLEEN HARKNESS
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/08/2017
Notification Time: 17:12 [ET]
Event Date: 08/04/2017
Event Time: [PDT]
Last Update Date: 08/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - Y-90 TREATMENT UNDERDOSE

The following information was provided by the State of California via email:

"The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office on August 7, 2017, that a medical event occurred on Friday, August 4, 2017. A patient was admitted to the hospital for treatment of liver carcinoma. The treatment plan involved use of Nordion model TheraSpheres (Y-90 glass microspheres manual brachytherapy) for radio-embolism to the right lobe of the liver. The patient's written directive called for aggregate treatment of 121Gy (5.241 GBq) of Y-90 to the right lobe target area, but only 9.7 Gy (0.420 GBq) was delivered. The overall percent delivery to target tissue was 8.1%.

"The patient's lung dose from shunting was 1.01 Gy at 4.8% lung shunting factor. The patient and referring physician were informed of the event on 8/4/2017. The medical event is still being investigated, but is thought that a slow injection flowrate may have caused sedimentation of the microspheres in the delivery system. After a few days for decay, a more intensive review of the delivery system will be conducted."

CA 5010 Number: 080417

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: 52893
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: HILLIS-CARNES
Region: 1
City: ANNAPOLIS JUNCTION State: MD
County:
License #: MD-03-054-01
Agreement: Y
Docket:
NRC Notified By: CHARLES COX
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/09/2017
Notification Time: 15:27 [ET]
Event Date: 08/08/2017
Event Time: [EDT]
Last Update Date: 08/09/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN AND RECOVERED MOISTURE DENSITY GAUGE

The following was received from the Maryland Department of the Environment via email:

"On August 8, 2017, Hillis-Carnes, Maryland Licensee MD-03-054-01, notified the Maryland Radiological Health Program (RHP) that a field technician had his van carjacked at the Key's Point temporary job site. His Troxler moisture density gauge model 3430 (serial number 31733) was still in the van and locked. The licensee notified Baltimore police.

"On August 9, 2017, the Maryland Department of the Environment Emergency Response Division was notified by the Baltimore police that the van and the Troxler gauge were recovered at O'Donnell Heights the evening of August 8. An RHP inspector went to the site and took possession of the gauge and is notifying the licensee so they can retrieve it.

"Troxler 3430 has a Cesium 137 sealed source less that 9 milliCuries and a 44 milliCurie AmBe source. No indication of any damage."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 52909
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: JEREMY PETERS
HQ OPS Officer: VINCE KLCO
Notification Date: 08/16/2017
Notification Time: 15:41 [ET]
Event Date: 08/16/2017
Event Time: 10:39 [EDT]
Last Update Date: 08/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HAROLD GRAY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF POWER TO TECHNICAL SUPPORT CENTER

"On 8/16/2017, at 1039 [EDT], an un-planned trip of the Peach Bottom Station Blackout Transformer 34.5 kV feeder breaker 1005 and a loss of the 191-00 line occurred causing a loss of power to Unit 1 and the TSC. Power was not restored to the TSC or the ventilation system within 1 hour. Power was subsequently restored to the TSC at 1207 hours [EDT] and the ventilation system was restored to available.

"This report is being submitted pursuant to 10CFR50.72(b)(3)(xiii) as a Major Loss of Emergency Preparedness Capabilities due to a reduction in the effectiveness of the Onsite Technical Support Center (TSC).

"The NRC Resident Inspector has been informed of this notification."

Page Last Reviewed/Updated Thursday, August 17, 2017
Thursday, August 17, 2017