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Event Notification Report for September 03, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/31/2018 - 9/3/2018

** EVENT NUMBERS **


53560 53561 53564 53575 53576 53578 53579

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Agreement State Event Number: 53560
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH UNIVERSITY MEDICAL CENTER
Region: 3
City: CHICAGO   State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/23/2018
Notification Time: 18:12 [ET]
Event Date: 08/23/2018
Event Time: 16:00 [CDT]
Last Update Date: 08/23/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the State of Illinois via email:

"The RSO [Radiation Safety Officer] for Rush University Medical Center in Chicago (IL-01766-01) notified the Agency [Illinois Emergency Management Agency, Bureau of Radiation Safety] at approximately 1600 [CDT] today that a reportable event transpired while attempting to administer Y-90 TheraSpheres. The licensee attempted to administer Y-90 to a patient this morning and was unable to move the dose through the tubing to the patient. A different administration route was selected and also met with inability to deliver the dose. This treatment was aborted.

"A second patient was scheduled for Y-90 administration this afternoon. The licensee encountered resistance in the second delivery system and was unable to deliver the Y-90 dose. This treatment was also aborted. Both patients were imaged and verified to not have been administered any Y-90. The licensee is currently performing a PET [Positron Emission Tomography] scan on the delivery systems to look for occlusions that may have impeded delivery. IEMA [Illinois Emergency Management Agency] staff has requested information on lot numbers for the individual doses.

"Details are pending from the licensee on root cause and lot numbers. The licensee will not administer any additional doses from this lot number until root cause is identified. Further details are pending."

Illinois Item No.: IL180033

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: 53561
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: STERICYCLE
Region: 4
City: STROUD   State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2018
Notification Time: 11:29 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 08/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF RADIOACTIVE MATERIAL

The following information was received via E-mail:

"This morning Oklahoma DEQ [Department of Environmental Quality] Radiation Management learned of an improper disposal of radioactive material in Oklahoma. Stericycle, an autoclave facility authorized to treat biomedical waste, rejected a load of material from a Kansas facility due to radioactivity. It appears the waste was received by SteriCycle on Wednesday, August 22 (because of an error in the report, this isn't totally clear), and is being picked up today (August 24) for return to the generating facility. SteriCycle did not provide DEQ with any specifics on radiation levels measured, quantity, etc. DEQ has notified the Kansas radiation program, which will investigate.

"SteriCycle identified the waste generator as: Cancer Center of KS - Wichita

"SteriCycle is located at: Stroud, OK

"We are informed that Kansas radiation control regulates the facility under the name Via Christi.

"Since the material is being picked up today, Oklahoma DEQ did not attempt a site visit to investigate the material. We have informed the Kansas radiation program and understand they will be following up. There are no known significant exposures to workers or the public, and none are expected at this time. It is not clear that this is reportable, but we are notifying NRC out of an abundance of caution."

See EN# 53564.

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Agreement State Event Number: 53564
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: STERICYCLE
Region: 4
City: STOUD   State: OK
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID LAWRENZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2018
Notification Time: 16:35 [ET]
Event Date: 08/24/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF RADIOACTIVE MATERIAL

The following information was received via E-mail:

"Oklahoma DEQ [Department of Environmental Quality] notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas.

"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr on surface of the waste package."

See EN 53561.

* * * UPDATE ON 8/25/2018 AT 1737 EDT FROM DAVID LAWRENZ TO OSSY FONT * * *

The following update was provided via E-mail:

"The originator of the waste has a radioactive material license, however the package containing the contaminated waste was not from the radiology department where licensed activity occurs. Furthermore the licensee does not use I-131 or any isotope with a half-life nearly as long. [Kansas Radiation Control] will visit the site next week to determine what the dose estimates are for those in the waiting room, lab staff (both blood draw and blood testing), waste transporter and waste handlers. [Kansas Radiation Control] also intend to identify where the blood vial and associated potentially contaminated waste is stored/disposed.

"It will likely prove impossible to discover the licensee who administered the I-131 to the patient as the individual did not report they were recently treated, there was no surveys in their unrestricted portion of their facility that is unaffiliated with their RAM [radioactive material] work, and the waste is mixed in with several other patients over the course of several days."

* * * UPDATE FROM DAVID LAWRENZ TO VINCE KLCO ON 9/24/2018 AT 1509 EDT * * *

The following update was provided via E-mail:

"Oklahoma DEQ notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas on 8/24/2018. This was reported to the HOO by David Lawrenz on the same day.

"The Cancer Center of Kansas (CCK) was contacted by Stericycle, the company that handles sharps disposal, August 23, 2018. Stericycle stated they had received a radioactive sharps container from CCK. During a phone call with Stericycle, David Lawrenz learned the sharps container had been picked up last week and delivered to the incinerator facility on Monday August 20th.

"Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn, and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr. on surface of the waste package on 8/24/18 when [redacted] picked up the container from Stericycle.

"After [redacted] picked up the sharps container on 8/24/18, it was determined the sharps container came from the CCK lab. [redacted] took surveys on the exterior of the container and found 500 microR/hr for the highest reading prior to returning to CCK. The CCK lab is separate from the CCK radiology department and the sharps containers are used separately as well. The CCK lab is not a restricted area and no radioactive material is used there. Consequently, the sharps from the lab were not monitored for radioactive contamination.

"With the knowledge that the sharps came from a department that does not handle radioactive material and the fact that so much time had passed we determined the radioactive contamination must have originated from outside CCK. CCK only uses Tc99m. CCK is authorized for 35.100 and 35.200 use only. CCK is a cancer specialty clinic so the most likely scenario is that a patient had very recently undergone I-131 therapy at another facility and then came to CCK for lab work. The discarded lab detritus from that patient was then placed in the sharps container that Stericycle collected.

"On August 27, 2018 [two individuals from the Kansas Department of Health and Environment] arrived at CCK and met with [the Lab Supervisor]. [redacted] took surveys of the sharps container and lab area. This area is separate from the radiology department. No areas were above background.

"[The Lab Supervisor took Kansas personnel] to the hot lab used under the Adams Diagnostics 12-B880. The rejected waste is now stored for decay in the regulated area. [The Lab Supervisor] surveyed the container at 259 microR/hr on contact.

"New procedures are being written to include surveys of the labs sharps container to prevent the issue from happening in the future. The licensee was found to not be in violation of any requirements and there will be no enforcement action as a result of this investigation unless new information comes to light.

"Root cause analysis is a patient failed to follow instructions after the medical procedure."

Notified the R4DO (Alexander) and NMSS Events via email.

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Power Reactor Event Number: 53575
Facility: PALO VERDE
Region: 4     State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAVID HECKMAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/31/2018
Notification Time: 16:04 [ET]
Event Date: 08/31/2018
Event Time: 05:44 [MST]
Last Update Date: 08/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GEOFFREY MILLER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNPLANNED LOSS OF STEAM LINE MONITOR CHANNELS

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) as a Loss of Emergency Preparedness Capabilities at Palo Verde Nuclear Generating Station (PVNGS) Unit 2. On August 31, 2018, at approximately 0544 Mountain Standard Time (MST), the Unit 2 control room experienced an unplanned loss of Steam Generator #1 steam line monitor (RU-139), Channels A and B.

"This main steam line monitor is used in the PVNGS Emergency Plan to perform dose assessment in the event of a steam generator tube rupture.

"The NRC Resident Inspectors have been notified."

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Power Reactor Event Number: 53576
Facility: LASALLE
Region: 3     State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: RICHARD CALVIN
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/31/2018
Notification Time: 23:26 [ET]
Event Date: 08/31/2018
Event Time: 21:05 [CDT]
Last Update Date: 08/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 29 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO MAIN CONDENSER DEGRADATION

"This notification is being provided in accordance with 10 CFR 50.72(b)(2)(iv)(B).

"On August 31, 2018 at 2105 CDT, Unit 2 Reactor Manual Scram signal was inserted due to Main Condenser vacuum degrading. The turbine was tripped following the scram. Main Condenser vacuum is at 6 inches of backpressure slowly improving following the scram and turbine trip. During the scram, one Control Rod (30-31) did not fully insert. Control Rod 30-31 has been manually inserted to position 00 with the first position identified as position 24. Plant is in a stable condition with reactor pressure being maintained by the Turbine Bypass valves. Reactor water level is being controlled with feedwater. Investigation into the cause of the elevated condenser in leakage is in progress.

"The Senior NRC Resident has been notified."

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Power Reactor Event Number: 53578
Facility: INDIAN POINT
Region: 1     State: NY
Unit: [] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: THOMAS NASTASI
HQ OPS Officer: KENNETH MOTT
Notification Date: 09/01/2018
Notification Time: 13:52 [ET]
Event Date: 09/01/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/01/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JON LILLIENDAHL (R1DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY - CONTRABAND DISCOVERED IN PROTECTED AREA

Twelve (12) cans of an alcoholic beverage were discovered inside the protected area.

The 12 cans were removed from the protected area and taken to and secured by site station security.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53579
Facility: NORTH ANNA
Region: 2     State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: DAVID MOSSER
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/03/2018
Notification Time: 15:20 [ET]
Event Date: 09/03/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BINOY DESAI (R2DO)
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

AUTOMATIC START OF THE EMERGENCY DIESEL GENERATOR

"At 1045 [EDT] on 9/3/18, with Unit 1 and Unit 2 at 100% power, off-site power feed to the 'A' Reserve Station Transformer was lost which resulted in a loss of power to Unit 1'J' Emergency Bus. As a result of the power loss, the 1'J' Emergency Diesel Generator started as designed and restored power to the Emergency Bus. During this event, the Unit 1 'A' Charging Pump, 1-CH-P-1A automatically started as designed due to the loss of power event.

"The valid actuation of these ESF [Engineered Safety Features] components due to the loss of power is reportable per 10 CFR 50.72 (b)(3)(iv)(A).

"The Unit 1 'J' Emergency bus off-site power source was restored via the Unit 2 'B' Station Service bus and the 1 'J' Emergency Diesel was secured and returned to Automatic. The Unit 1 'A' Charging pump has been stopped and returned to Automatic.

"Both Units are in a stable condition. The apparent cause for the loss of power appears to be a bird strike to the 'A' RSST [Reserve Station Service Transformer] Overhead Cable."

The licensee notified the NRC Resident Inspector.


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