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Event Notification Report for April 27, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/26/2018 - 04/27/2018

** EVENT NUMBERS **


53009 53343 53344 53345 53346 53365 53366

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Agreement State Event Number: 53009
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: JOSEPH ROSS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/11/2017
Notification Time: 13:58 [ET]
Event Date: 08/11/2017
Event Time: [CDT]
Last Update Date: 04/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017.

"DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event."

Wisconsin Event Report: WI170016

* * * UPDATE ON 4/26/18 AT 1238 EDT FROM JOSEPH ROSS TO BETHANY CECERE * * *

The following update was received from the Wisconsin Department of Health Services (DHS) by email:

"During the ongoing investigations of other medical events reported to the Wisconsin Department of Health Services in 2017, licensee reviewed historic permanent implants of I-125 seeds for prostate manual brachytherapy. The licensee recently identified two additional implants that resulted in a D90 dose to the prostate that was greater than 130 percent of the prescribed dose. The licensee noted that there were no adverse outcomes to the patients.

"The first implant occurred on August 28, 2015. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 192 Gy.

"The second implant occurred on June 17, 2016. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 189 Gy.

"DHS is reviewing the circumstances surrounding these two implants as part of the investigation into the previously reported medical events."

Notified R3DO (Stone) and NMSS Events.

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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Non-Agreement State Event Number: 53343
Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: SOUTHFIELD State: MI
County:
License #: 21-280203
Agreement: N
Docket:
NRC Notified By: MICHELLE KRITZMAN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/18/2018
Notification Time: 13:14 [ET]
Event Date: 04/17/2018
Event Time: [EDT]
Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH RIEMER (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

WRITTEN DIRECTIVE FOR RA-223 ADMINISTRATION INCORRECT

A quarterly review conducted on 4/17/18, identified that the written directive for administration of Ra-223 was incorrect. The written directive stated that the Ra-223 should be administered orally, but should have stated that it was to be administered intravenously (IV). The review determined that there was no impact to any patients as a result of the error in the written directive. The review identified one case where the written directive was used. However, the technician administered the Ra-223 to the patient via IV and not orally.

The corrective actions taken by the licensee were to correct the written directive, and review the directive with the technician to understand why the technician did not consult with the physician when there was an error in the directive.

The licensee notified the NRC R3 Office (Warren).

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: 53344
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: Seattle State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: STEVEN VITTO
Notification Date: 04/18/2018
Notification Time: 13:50 [ET]
Event Date: 03/30/2018
Event Time: [PDT]
Last Update Date: 04/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MISADMINISTRATION OF SIR-SPHERES Y-90 MICROSPHERES RESULTING IN AN UNDERDOSE

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

"Patient was under treated with Y-90 SIR-Spheres Microspheres. Prescribed dose was 24.59 mCi. Patient was treated with 8.9 mCi.

"Background: SIR-Spheres Microspheres Activity Calculator determined a treatment dose of 0.91 GBq (24.59 mCi). Written Directive was signed for 0.91 GBq. Prescribed dose was entered into the Treatment Worksheet as 0.91 mCi. Dose activity delivered to the interventional radiology procedure room (Dose In-Vial) was recorded as 0.96 mCi.

"Analysis: Radioactivity units of measurement varied between Written Directive and Treatment Worksheet. Radioactivity activity readings from the dose calibrator were recorded with a systematic error. Calibrator reading multiplication factor(x10) was not applied. Therefore, the vial pre-dispense Y-90 activity reading of 8.62 mCi should have been recorded as 86.2 mCi. Dose activity delivered to the IR procedure room was in fact 9.60 mCi rather than 0.96 mCi.

"Y-90 SIR-Spheres treatment on 3/30/2018 was incomplete because the prescribed 0.91 GBq prescribed dose was not administered. Standard post-procedure verification check identified the under treatment. The patient was informed by the prescribing physician and scheduled for a second treatment on 4/6/2018. The second Y-90 SIR-Spheres treatment was performed on 4/6/2018 and the remaining dose was administered to complete administration of the prescribed 0.91 GBq."

Washington State Incident Number: WA-18-010.

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: 53345
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: OUR SAVIOR LUTHERAN CHURCH
Region: 4
City: NORFOLK State: NE
County:
License #: GL0595
Agreement: Y
Docket:
NRC Notified By: MALISA MCCOWN
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/19/2018
Notification Time: 12:47 [ET]
Event Date: 04/19/2018
Event Time: [CDT]
Last Update Date: 04/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following report was received from the Nebraska Department of Health via email:

"Eagle Distributing of Norfolk, LLC sold their building which contained tritium exit signs to Our Savior Lutheran Church on October 17, 2017. Eagle Distributing did not inform Our Savior Lutheran Church of the General License [GL] responsibility until March of 2018 when the Annual Renewal for GL0595 came overdue. After Our Savior Lutheran Church was informed of the exit signs and their GL responsibility, Our Savior Lutheran Church conducted a search to locate the signs within the building resulting in 3 missing signs. They have no information as to what could have happened or specific dates of their removal."

NE Item Number: NE180003

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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Agreement State Event Number: 53346
Rep Org: COLORADO DEPT OF HEALTH
Licensee: A G WASSENAAR INC
Region: 4
City: LITTLETON State: CO
County:
License #: CO 212-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/19/2018
Notification Time: 18:16 [ET]
Event Date: 04/19/2018
Event Time: 15:52 [MDT]
Last Update Date: 04/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

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

"The Department [Colorado Department of Public Health and Environment] was notified via phone on 4/19/18 at approximately 1552 MDT. A G Wassenaar's RSO notified the Department that a portable gauge had been run over by a vehicle and the vehicle did not stop. At the time of the phone call, the gauge was broken into multiple pieces and the RSO was about to go out on-site to assess the damage.

"State inspectors are responding immediately as well."

Colorado Event Report ID No.: CO180008

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Power Reactor Event Number: 53365
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MIKE BRANSCUM
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/26/2018
Notification Time: 18:50 [ET]
Event Date: 04/26/2018
Event Time: 15:31 [CDT]
Last Update Date: 04/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL VASQUEZ (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

Event Text

INADVERTENT INJECTION OF HIGH PRESSURE CORE SPRAY

"River Bend Station experienced an inadvertent initiation and injection of High Pressure Core Spray (HPCS) at 1531 [CDT] on 4/26/2018 while operating at 100 percent power.

"During replacement of Level Transmitter B21-LTN081C 'Reactor Vessel Low Water Level 1', Main Control Room received an inadvertent initiation and injection of High Pressure Core Spray. The HPCS injection valve was open for approximately 40 seconds before the operators manually closed the valve.

"Feedwater Level Control responded per design and maintained Reactor Water Level nominal values. The Division 3 Diesel Generator (DG) also automatically started in response to the actuation signal. The DG did not automatically connect to the Division 3 switchgear since there was not a low voltage condition on the bus.

"The manual closure of the injection isolation valve caused the system to be incapable of responding to an automatic actuation signal. The manual override of the injection isolation valve was reset approximately 16 minutes after the event, restoring the system to its standby condition. This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(A) as a condition that caused ECCS [Emergency Core Cooling System] discharge to RCS [Reactor Coolant System] and 10 CFR 50.72(b)(3)(v)(D) as a condition that caused the loss of function of the HPCS System.

"The Senior NRC Resident inspector has been notified."

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Power Reactor Event Number: 53366
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: SARAH MCDANIEL
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/26/2018
Notification Time: 20:23 [ET]
Event Date: 04/26/2018
Event Time: 18:00 [EDT]
Last Update Date: 04/26/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Refueling

Event Text

LOSS OF EMERGENCY ASSESSMENT CAPABILITY

"This is an eight-hour, non-emergency notification for a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because planned maintenance activities were performed on April 23rd through April 25th on the seismic monitoring system without viable compensatory measures established.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Friday, April 27, 2018
Friday, April 27, 2018