Event Notification Report for November 15, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/14/2017 - 11/15/2017
Agreement State
Event Number: 53073
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEISINGER HEALTH SYSTEM
Region: 1
City: DANVILLE State: PA
County:
License #: PA170016
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JEFF HERRERA
Licensee: GEISINGER HEALTH SYSTEM
Region: 1
City: DANVILLE State: PA
County:
License #: PA170016
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/15/2017
Notification Time: 13:25 [ET]
Event Date: 11/15/2017
Event Time: 00:00 [EST]
Last Update Date: 11/15/2017
Notification Time: 13:25 [ET]
Event Date: 11/15/2017
Event Time: 00:00 [EST]
Last Update Date: 11/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - INCORRECT WRITTEN DIRECTIVE FOR LIVER PATIENT
The following report was received from the Pennsylvania Bureau of Radiation Protection via facsimile:
"The event involved a patient who was scheduled to be treated with 16 mCi of Y-90 SirSpheres to the left lobe of the liver. The written directive (WD), however, was incorrectly written for the right lobe of the liver. The authorized user (AU) did in fact deliver the correct dose to the correct lobe and the discrepancy was only noticed after the procedure was complete. No harm is expected as the patient received the intended dose to the correct location. The cause of the event was noted as human error resulting from:
(1) Failure of the AU to indicate the correct treatment site on the WD.
(2) Failure of the AU to forward documentation of the pre-therapy information to the RSO (or designee) prior to the therapy.
(3) Failure of clinical staff to identify the discrepancy on the WD during the patient time out just before implantation of the microspheres.
"Corrective actions include: Before drawing up the dose/activity in Nuclear Medicine (and preferably before the dose/activity is ordered from the manufacturer), the AU must forward pre-therapy documentation (WD, pre-post therapy worksheet, etc.) to the RSO (or designee) to ensure documentation is correct/appropriate.
"The Department [Pennsylvania Bureau of Radiation Protection] will perform a reactive inspection. The licensee will update their procedure to include additional checks for the written directive."
Event Report ID No: PA 170016
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 from the Pennsylvania Bureau of Radiation Protection via facsimile:
"The event involved a patient who was scheduled to be treated with 16 mCi of Y-90 SirSpheres to the left lobe of the liver. The written directive (WD), however, was incorrectly written for the right lobe of the liver. The authorized user (AU) did in fact deliver the correct dose to the correct lobe and the discrepancy was only noticed after the procedure was complete. No harm is expected as the patient received the intended dose to the correct location. The cause of the event was noted as human error resulting from:
(1) Failure of the AU to indicate the correct treatment site on the WD.
(2) Failure of the AU to forward documentation of the pre-therapy information to the RSO (or designee) prior to the therapy.
(3) Failure of clinical staff to identify the discrepancy on the WD during the patient time out just before implantation of the microspheres.
"Corrective actions include: Before drawing up the dose/activity in Nuclear Medicine (and preferably before the dose/activity is ordered from the manufacturer), the AU must forward pre-therapy documentation (WD, pre-post therapy worksheet, etc.) to the RSO (or designee) to ensure documentation is correct/appropriate.
"The Department [Pennsylvania Bureau of Radiation Protection] will perform a reactive inspection. The licensee will update their procedure to include additional checks for the written directive."
Event Report ID No: PA 170016
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: 53074
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ROY GILES
HQ OPS Officer: VINCE KLCO
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ROY GILES
HQ OPS Officer: VINCE KLCO
Notification Date: 11/16/2017
Notification Time: 08:17 [ET]
Event Date: 11/15/2017
Event Time: 20:07 [CST]
Last Update Date: 11/16/2017
Notification Time: 08:17 [ET]
Event Date: 11/15/2017
Event Time: 20:07 [CST]
Last Update Date: 11/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JASON KOZAL (R4DO)
JASON KOZAL (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF PUBLIC PROMPT NOTIFICATION SYSTEM CAPABILITY
"At 0008 CST on 11/16/2017, Cooper Nuclear Station [CNS] was notified by Omaha Weather that the NOAA broadcast and the Shubert radio tower for this area is off. This affects the tone alert radios used to notify the public in event of an emergency condition. This is considered to be a major loss of the Public Prompt Notification System capability, and is reportable under 10CFR50.72(b)(3)(xiii).
"The transmission outage actually began at 2007 [CST], 11/15/2017, but CNS was not notified until 0008 [CST], 11/16/2017. Backup notification methods remained available throughout the period.
"At time 0447 CST on 11/16/2017, Cooper Nuclear Station was notified that the NOAA broadcast and Shubert radio transmission tower was returned to service.
"Nemaha County, NE, Richardson County, NE, and Atchison County, MO authorities within the 10 mile EPZ were notified by Cooper Nuclear Station of the condition and the effect on the tone alert radios at 0642 [CST], 11/16/2017. This is reportable under 10CFR50.72(b)(2)(xi) as a 4 hour report.
"The NRC Senior Resident has been informed."
"At 0008 CST on 11/16/2017, Cooper Nuclear Station [CNS] was notified by Omaha Weather that the NOAA broadcast and the Shubert radio tower for this area is off. This affects the tone alert radios used to notify the public in event of an emergency condition. This is considered to be a major loss of the Public Prompt Notification System capability, and is reportable under 10CFR50.72(b)(3)(xiii).
"The transmission outage actually began at 2007 [CST], 11/15/2017, but CNS was not notified until 0008 [CST], 11/16/2017. Backup notification methods remained available throughout the period.
"At time 0447 CST on 11/16/2017, Cooper Nuclear Station was notified that the NOAA broadcast and Shubert radio transmission tower was returned to service.
"Nemaha County, NE, Richardson County, NE, and Atchison County, MO authorities within the 10 mile EPZ were notified by Cooper Nuclear Station of the condition and the effect on the tone alert radios at 0642 [CST], 11/16/2017. This is reportable under 10CFR50.72(b)(2)(xi) as a 4 hour report.
"The NRC Senior Resident has been informed."
Agreement State
Event Number: 53075
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: 33-51220-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: DONALD NORWOOD
Licensee: DESERT NDT, LLC dba SHAWCOR
Region: 4
City: ABILENE State: TX
County:
License #: 33-51220-01
Agreement: Y
Docket:
NRC Notified By: DAVID STRADINGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/16/2017
Notification Time: 15:43 [ET]
Event Date: 11/15/2017
Event Time: 00:00 [CST]
Last Update Date: 11/16/2017
Notification Time: 15:43 [ET]
Event Date: 11/15/2017
Event Time: 00:00 [CST]
Last Update Date: 11/16/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE FAILED TO RETRACT
The following information was received via E-mail:
"Desert NDT, LLC dba Shawcor (Shawcor) reported that a 3.15 TBq (85 Ci) Ir-192 sealed source (SPEC model G-60, serial #YJ2608) had disconnected from a drive cable connected to a SPEC model SPEC-150 radiography exposure device (serial #786) at a temporary job site in Watford City, ND on 11/15/2017.
"Upon completion of an exposure, the radiography crew performed a radiation survey while approaching the exposure device. At approximately 35 feet from the device, they noticed an elevated reading of approximately 20 mR/hr. At this point, the crew determined the source had not retracted into the safe, shielded position. The crew moved away from the device, secured the area, maintained a 2 mR/hr barrier and contacted the Branch Manager. The Branch Manager, who is trained in source retrieval, responded to the site. He successfully recovered the source following Shawcor established procedures. The Branch Manager inspected the exposure device and associated equipment. He determined no damage had occurred to the exposure device, guide tube, and/or crank assembly, rather the drive cable was not properly connected to the source pigtail.
"At no time during the event did the radiography crew member's pocket dosimeters go off-scale. In response to the initial notification, the North Dakota Department of Health requested the licensee send the exposure device and associated equipment involved in the event to the manufacturer for further evaluation."
North Dakota Item Number: ND170001
The following information was received via E-mail:
"Desert NDT, LLC dba Shawcor (Shawcor) reported that a 3.15 TBq (85 Ci) Ir-192 sealed source (SPEC model G-60, serial #YJ2608) had disconnected from a drive cable connected to a SPEC model SPEC-150 radiography exposure device (serial #786) at a temporary job site in Watford City, ND on 11/15/2017.
"Upon completion of an exposure, the radiography crew performed a radiation survey while approaching the exposure device. At approximately 35 feet from the device, they noticed an elevated reading of approximately 20 mR/hr. At this point, the crew determined the source had not retracted into the safe, shielded position. The crew moved away from the device, secured the area, maintained a 2 mR/hr barrier and contacted the Branch Manager. The Branch Manager, who is trained in source retrieval, responded to the site. He successfully recovered the source following Shawcor established procedures. The Branch Manager inspected the exposure device and associated equipment. He determined no damage had occurred to the exposure device, guide tube, and/or crank assembly, rather the drive cable was not properly connected to the source pigtail.
"At no time during the event did the radiography crew member's pocket dosimeters go off-scale. In response to the initial notification, the North Dakota Department of Health requested the licensee send the exposure device and associated equipment involved in the event to the manufacturer for further evaluation."
North Dakota Item Number: ND170001