United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2018 > January 24

Event Notification Report for January 24, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/23/2018 - 01/24/2018

** EVENT NUMBERS **


53168 53180

To top of page
Agreement State Event Number: 53168
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/16/2018
Notification Time: 21:14 [ET]
Event Date: 01/05/2018
Event Time: [CST]
Last Update Date: 01/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED

The following was received from the State of Wisconsin via email:

"An email the department received on January 5, 2018 was believed to be an update to the previous notification [EN #53148]. Upon further review by the department, it was discovered that the email pertained to a second medical event identified by the licensee on January 5, 2018. This was a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 70 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) < 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 48% of the intended dose. The licensee has an additional criterion that the volume of the CTV to which 100% of the prescription dose delivered must be above 80%. The licensee determined only 62% of the volume received the required dose.

"The implant was initially performed on November 10, 2017. A post implant CT scan was performed on December 14, 2017. The physician completed the contour for the dosimetrist to run a Post Seed Plan on January 3, 2018. The dosimetrist notified the physicist of a possible medical event on January 5, 2018.

"DHS is investigating and will be performing a site visit in regards to this event."

Wisconsin Event Report ID: WI180002

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.

To top of page
Power Reactor Event Number: 53180
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RYAN CRAGG
HQ OPS Officer: VINCE KLCO
Notification Date: 01/23/2018
Notification Time: 05:02 [ET]
Event Date: 01/23/2018
Event Time: 04:00 [CST]
Last Update Date: 01/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF ASSESSMENT CAPABILITY DUE TO TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"At 0400 [CST] on 1/23/2018 the Braidwood Technical Support Center (TSC) HVAC [Heating, Ventilation and Air Conditioning] Emergency Makeup Air Filter train was taken out of service to perform a planned Makeup Air Filter charcoal replacement. The TSC HVAC Makeup Air Filter train will be rendered nonfunctional during the charcoal replacement. Subsequent charcoal and HEPA filter testing will restore functionality of the TSC HVAC Makeup Air Filter train. The expected duration of the charcoal replacement and subsequent testing is 30 hours.

"If an emergency is declared requiring TSC activation during the time TSC HVAC is non-functional, the TSC will be staffed and activated using existing emergency planning procedure unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a major loss of emergency preparedness capability. An update will be provided once the TSC HVAC Emergency Makeup Air Filter train functionality has been restored.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, January 24, 2018
Wednesday, January 24, 2018