Event Notification Report for September 05, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/04/2017 - 09/05/2017
Non-Agreement State
Event Number: 52949
Rep Org: WEST VIRGINIA UNIVERSITY HOSPITAL
Licensee: WEST VIRGINIA UNIVERSITY HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-23066-02
Agreement: N
Docket:
NRC Notified By: NASSER RAZMIANFAR
HQ OPS Officer: DONG HWA PARK
Licensee: WEST VIRGINIA UNIVERSITY HOSPITAL
Region: 1
City: MORGANTOWN State: WV
County:
License #: 47-23066-02
Agreement: N
Docket:
NRC Notified By: NASSER RAZMIANFAR
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/06/2017
Notification Time: 15:25 [ET]
Event Date: 09/05/2017
Event Time: 16:30 [EDT]
Last Update Date: 09/06/2017
Notification Time: 15:25 [ET]
Event Date: 09/05/2017
Event Time: 16:30 [EDT]
Last Update Date: 09/06/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
BRACHYTHERAPY TREATMENT DELIVERED DOSE LESS THAN PRESCRIBED DOSE
"In compliance with 10CFR35.3045(c), WVU [West Virginia University] Hospitals License # 47-23066-02, Docket # 03020233 is making telephone notification declaring a medical event.
"On September 5, 2017 a patient was being administered the first fraction of a planned five fraction HDR interstitial brachytherapy treatment, treating the cervix. The written directive prescribed 5, 5Gy fractions for a total dose of 25Gy. During the first fraction, 5 separate interlocks were tripped at which time the manufacturer was contacted [at] 1535 [EDT]. Based on discussions between the medical physics team and the manufacturer, the manufacturer determined the error was caused by fluid in the catheter which may have contaminated the source and the afterloader unit. The manufacturer advised to suspend treatment, and stop all use of the afterloader until it could be decontaminated and the source could be exchanged. (Scheduled for September 7, 2017).
"At the time the treatment was stopped, the patient received 0.32Gy of the planned 5Gy fraction, based on a 12.1 seconds treated of a planned 576.8 second treatment fraction.
"Based on 10CFR35.3045(a)(1), the fraction of the dose differed by more than 50 rem to organ or tissue, and 10CFR35.3045(a)(1)(iii) the fractionated dose delivered differs from the prescribed dose for a single fraction, by 50 percent or more.
"In compliance with 10CFR35.3045(e), the patient and referring physician have been notified.
"Upon decontamination and source exchange the patient is scheduled to complete the treatment per the written directive (September 7-9, 2017).
"In compliance with 10CFR35.3045(d), a written report will be submitted to the Region One Office within 15 days."
The Licensee has notified R1(Gallaghar).
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.
"In compliance with 10CFR35.3045(c), WVU [West Virginia University] Hospitals License # 47-23066-02, Docket # 03020233 is making telephone notification declaring a medical event.
"On September 5, 2017 a patient was being administered the first fraction of a planned five fraction HDR interstitial brachytherapy treatment, treating the cervix. The written directive prescribed 5, 5Gy fractions for a total dose of 25Gy. During the first fraction, 5 separate interlocks were tripped at which time the manufacturer was contacted [at] 1535 [EDT]. Based on discussions between the medical physics team and the manufacturer, the manufacturer determined the error was caused by fluid in the catheter which may have contaminated the source and the afterloader unit. The manufacturer advised to suspend treatment, and stop all use of the afterloader until it could be decontaminated and the source could be exchanged. (Scheduled for September 7, 2017).
"At the time the treatment was stopped, the patient received 0.32Gy of the planned 5Gy fraction, based on a 12.1 seconds treated of a planned 576.8 second treatment fraction.
"Based on 10CFR35.3045(a)(1), the fraction of the dose differed by more than 50 rem to organ or tissue, and 10CFR35.3045(a)(1)(iii) the fractionated dose delivered differs from the prescribed dose for a single fraction, by 50 percent or more.
"In compliance with 10CFR35.3045(e), the patient and referring physician have been notified.
"Upon decontamination and source exchange the patient is scheduled to complete the treatment per the written directive (September 7-9, 2017).
"In compliance with 10CFR35.3045(d), a written report will be submitted to the Region One Office within 15 days."
The Licensee has notified R1(Gallaghar).
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: 52947
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: JEFF FLOWERS
HQ OPS Officer: DONALD NORWOOD
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: JEFF FLOWERS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/05/2017
Notification Time: 17:16 [ET]
Event Date: 09/05/2017
Event Time: 11:11 [EDT]
Last Update Date: 09/05/2017
Notification Time: 17:16 [ET]
Event Date: 09/05/2017
Event Time: 11:11 [EDT]
Last Update Date: 09/05/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
GLENN DENTEL (R1DO)
GLENN DENTEL (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
PRIMARY CONTAINMENT DECLARED INOPERABLE DUE TO BOTH AIRLOCK DOORS OPEN SIMULTANEOUSLY
"On September 5, 2017 at 1111 EDT, with the reactor at 100 percent core thermal power and steady state conditions, plant personnel identified that both doors of the emergency personnel airlock of the equipment hatch were open simultaneously due to failure of the interlock. Personnel were at both the outside and inside doors, personnel heard air movement through the air lock. Immediate action was taken to close the inner containment personnel airlock door and it was verified closed. Both doors of the emergency personnel airlock of the equipment hatch were open for less than one minute. There was no radioactive release as a result of the event. The cause of the interlock failure is under investigation.
"This condition requires an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(ii)(A), the condition of the nuclear power plant, including its principal safety barriers (primary containment), being seriously degraded. This condition is also reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material.
"The NRC Resident Inspector has been notified."
"On September 5, 2017 at 1111 EDT, with the reactor at 100 percent core thermal power and steady state conditions, plant personnel identified that both doors of the emergency personnel airlock of the equipment hatch were open simultaneously due to failure of the interlock. Personnel were at both the outside and inside doors, personnel heard air movement through the air lock. Immediate action was taken to close the inner containment personnel airlock door and it was verified closed. Both doors of the emergency personnel airlock of the equipment hatch were open for less than one minute. There was no radioactive release as a result of the event. The cause of the interlock failure is under investigation.
"This condition requires an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(ii)(A), the condition of the nuclear power plant, including its principal safety barriers (primary containment), being seriously degraded. This condition is also reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 53293
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: SUMMA HEALTH SYSTEMS
Region: 3
City: AKRON State: OH
County:
License #: 2120780022
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: DAVID AIRD
Licensee: SUMMA HEALTH SYSTEMS
Region: 3
City: AKRON State: OH
County:
License #: 2120780022
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: DAVID AIRD
Notification Date: 03/27/2018
Notification Time: 15:59 [ET]
Event Date: 09/05/2017
Event Time: 00:00 [EDT]
Last Update Date: 03/27/2018
Notification Time: 15:59 [ET]
Event Date: 09/05/2017
Event Time: 00:00 [EDT]
Last Update Date: 03/27/2018
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 - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED
The following is an excerpt from a report received from the State of Ohio via email:
The criteria for a medical event supported by ODH (Ohio Department of Health) is if the 90% prostate volume receives less than 80% of the prescribed dose or more than 120% of the prescribed dose. Upon generating the post treatment plans for nine patients, the Dosimetry staff discovered that four were below 80%.
Summary of Prostate Implant Incidents:
Case #. Implant Date, Discovery Date, Prescribed Dose (Gy), Estimated D90 (Gy)
1. 9/05/2017, 3/26/2018, 110 Gy, 58.15 Gy
2. 9/28/2017, 3/26/2018, 145 Gy, 100.19 Gy
3. 2/13/2017, 3/26/2018, 110 Gy, 81.28 Gy
4. 2/19/2017, 3/26/2018, 145 Gy, 103.7 Gy
Manufacturer: Theragenics
Model Number: AgX100
Radionuclide: I-125
Item Number: OH180002
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 is an excerpt from a report received from the State of Ohio via email:
The criteria for a medical event supported by ODH (Ohio Department of Health) is if the 90% prostate volume receives less than 80% of the prescribed dose or more than 120% of the prescribed dose. Upon generating the post treatment plans for nine patients, the Dosimetry staff discovered that four were below 80%.
Summary of Prostate Implant Incidents:
Case #. Implant Date, Discovery Date, Prescribed Dose (Gy), Estimated D90 (Gy)
1. 9/05/2017, 3/26/2018, 110 Gy, 58.15 Gy
2. 9/28/2017, 3/26/2018, 145 Gy, 100.19 Gy
3. 2/13/2017, 3/26/2018, 110 Gy, 81.28 Gy
4. 2/19/2017, 3/26/2018, 145 Gy, 103.7 Gy
Manufacturer: Theragenics
Model Number: AgX100
Radionuclide: I-125
Item Number: OH180002
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.