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Event Notification Report for September 14, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/13/2017 - 09/14/2017

** EVENT NUMBERS **


52949 52967

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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
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
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

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.

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Power Reactor Event Number: 52967
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RONNIE SIMMONS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/13/2017
Notification Time: 01:08 [ET]
Event Date: 09/13/2017
Event Time: 00:47 [EDT]
Last Update Date: 09/13/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KENNETH RIEMER (R3DO)
BERNARD STAPLETON (IRD)
CYNTHIA PEDERSON (R3RA)
BRIAN HOLIAN (NRR)
CHRIS MILLER (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby

Event Text

UNUSUAL EVENT DUE TO LETDOWN RELIEF VALVE DISCHARGE TO THE PRESSURIZER RELIEF TANK

At 0047 EDT, the licensee declared a notification of unusual event under emergency action level (EAL) S8 due to actuation of the letdown relief valve which resulted in reactor coolant system leakage to the pressurizer relief tank exceeding 10 gpm.

The plant was in mode 3 at the time making preparations to proceed to cold shutdown to support their refueling outage. Operators were in the process of reducing reactor coolant system letdown from 120 gpm to 45 gpm when the letdown system relief valve lifted. The relief discharged to the pressurizer relief tank at approximately 12 gpm. Operators isolated the letdown line which reduced the leakage to approximately 1 gpm.

Plant staff is in the process of determining where the 1 gpm leakage is from and evaluating the basis for terminating the unusual event.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA National Watch Center (email) and Nuclear SSA (email).

* * * UPDATE FROM BUD HINCKLEY TO HOWIE CROUCH AT 0807 EDT ON 9/13/17 * * *

At 0800 EDT, the licensee terminated the notification of unusual event. The basis for termination was that the letdown line was isolated which reduced leakage to less than the EAL threshold of 10 gpm.

The cause of the letdown relief lifting is still under investigation.

The licensee has notified the NRC Resident Inspector and will be notifying the state of Michigan and Berrien County.

The licensee has issued a press release to the media concerning this event.

Notified R3DO (Riemer), IRD MOC (Stapleton), NRR (Miller), DHS SWO, DHS NICC, FEMA Ops Center, FEMA National Watch Center (email) and Nuclear SSA (email).

Page Last Reviewed/Updated Thursday, September 14, 2017
Thursday, September 14, 2017