Event Notification Report for October 05, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/04/2018 - 10/05/2018
EVENT NUMBERS
53648536495364753646536505370853843
Power Reactor
Event Number: 53648
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: KENNETH KNELL
HQ OPS Officer: DONG HWA PARK
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: KENNETH KNELL
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2018
Notification Time: 15:39 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2018
Notification Time: 15:39 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JON LILLIENDAHL (R1DO)
WILLIAM GOTT (IRD)
JON LILLIENDAHL (R1DO)
WILLIAM GOTT (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM DUE TO LOW REACTOR WATER LEVEL
"On Friday, October 5, 2018 at 1209 hours, with the reactor at 100 percent core thermal power, Pilgrim Nuclear Power
Station (PNPS) automatically tripped due to reactor water level perturbation and receipt of a low reactor water level Reactor Protection System (RPS) signal. The cause of the low reactor water level is under investigation. The plant is in hot shutdown.
"All other plant systems responded as designed. Pressure is being controlled using the Mechanical Hydraulic Control System and Main Condenser. Reactor water level is being maintained with the feedwater and condensate system.
"During the automatic reactor scram the plant experienced the following isolation signals as designed:
Group 2 Isolation: Miscellaneous containment isolation valves
Group 6 Isolation: Reactor Water Clean-up
Reactor Building Isolation System Actuation
"Due to the RPS actuation while critical, this event is being reported as a four-hour, non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'any event that results in actuation of the reactor protection system (RPS) when the reactor is critical.' This notification is also being made in accordance with 10 CFR 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section ... ' (B)(2) 'General containment isolation signals affecting containment isolation valves in more than one system.'
"This event has no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The licensee will notify the Massachusetts Emergency Management Agency.
"On Friday, October 5, 2018 at 1209 hours, with the reactor at 100 percent core thermal power, Pilgrim Nuclear Power
Station (PNPS) automatically tripped due to reactor water level perturbation and receipt of a low reactor water level Reactor Protection System (RPS) signal. The cause of the low reactor water level is under investigation. The plant is in hot shutdown.
"All other plant systems responded as designed. Pressure is being controlled using the Mechanical Hydraulic Control System and Main Condenser. Reactor water level is being maintained with the feedwater and condensate system.
"During the automatic reactor scram the plant experienced the following isolation signals as designed:
Group 2 Isolation: Miscellaneous containment isolation valves
Group 6 Isolation: Reactor Water Clean-up
Reactor Building Isolation System Actuation
"Due to the RPS actuation while critical, this event is being reported as a four-hour, non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'any event that results in actuation of the reactor protection system (RPS) when the reactor is critical.' This notification is also being made in accordance with 10 CFR 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section ... ' (B)(2) 'General containment isolation signals affecting containment isolation valves in more than one system.'
"This event has no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The licensee will notify the Massachusetts Emergency Management Agency.
Agreement State
Event Number: 53649
Rep Org: NV DIV OF RAD HEALTH
Licensee: RENOWN REGIONAL MEDICAL CENTER
Region: 4
City: RENO State: NV
County:
License #: 16-12-0016-01
Agreement: Y
Docket:
NRC Notified By: FAYNE MARTINI
HQ OPS Officer: DONG HWA PARK
Licensee: RENOWN REGIONAL MEDICAL CENTER
Region: 4
City: RENO State: NV
County:
License #: 16-12-0016-01
Agreement: Y
Docket:
NRC Notified By: FAYNE MARTINI
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2018
Notification Time: 17:33 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/05/2018
Notification Time: 17:33 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following was received via email from the State of Nevada:
"This is an email to report a possible medical event. The licensee is Renown Regional Medical Center, the license number is 16-12-0016-01. Occurrence was 10/5/2018 and reported the same day by Renown's RSO. The administration of Y-90 was given, prescribed dose was 15.66mCi and the delivered dose was 9.86mCi. The reason for this was due to patient intervention, apparently the patient moved and pulled the IV [Intravenous therapy] out. A full report from Renown's RSO has not been received, just the initial report."
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 was received via email from the State of Nevada:
"This is an email to report a possible medical event. The licensee is Renown Regional Medical Center, the license number is 16-12-0016-01. Occurrence was 10/5/2018 and reported the same day by Renown's RSO. The administration of Y-90 was given, prescribed dose was 15.66mCi and the delivered dose was 9.86mCi. The reason for this was due to patient intervention, apparently the patient moved and pulled the IV [Intravenous therapy] out. A full report from Renown's RSO has not been received, just the initial report."
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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 53647
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARCY BLOW
HQ OPS Officer: ANDREW WAUGH
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARCY BLOW
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/05/2018
Notification Time: 09:59 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/18/2018
Notification Time: 09:59 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
THOMAS FARNHOLTZ (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 |
UNPLANNED LOSS OF THE ASSESSMENT CAPABILITY DUE TO TECHNICAL SUPPORT DIESEL
"At 05:52 CDT on 10/5/2018, the [Wolf Creek Nuclear Operating Corporation] (WCNOC) Technical Support Center (TSC) Diesel fuel oil transfer pump would not run. There was ongoing modification to the facility Halon system at the time. The modification process had included a jumper to the fuel oil transfer pump to allow it to continue to be available. This issue was discovered during testing as the modification was progressing. The pump was verified to function on 10/4/2018 by normal operations rounds.
"If an emergency is declared requiring the TSC activation during the time the TSC diesel is non-functional, the TSC will be staffed and activated using existing emergency planning procedure. If offsite power is lost, the TSC will relocate to the Alternate TSC using existing emergency planning procedures.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 10/18/2018 AT 1306 EDT FROM MARCY BLOW TO ANDREW WAUGH * * *
"Event Notification (EN) 53647, made on October 8, 2018, is being retracted because during the time that the TSC Diesel fuel oil transfer pump was not available, normal power was continuously available. The Alternative TSC was also available.
"Consequently, the condition did not meet the criteria for a 8-hour notification per 10 CFR 50.72(b)(3)(xiii) for any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system).
"The NRC Resident Inspector has been notified of the Event Notification retraction."
Notified R4DO (Pick).
"At 05:52 CDT on 10/5/2018, the [Wolf Creek Nuclear Operating Corporation] (WCNOC) Technical Support Center (TSC) Diesel fuel oil transfer pump would not run. There was ongoing modification to the facility Halon system at the time. The modification process had included a jumper to the fuel oil transfer pump to allow it to continue to be available. This issue was discovered during testing as the modification was progressing. The pump was verified to function on 10/4/2018 by normal operations rounds.
"If an emergency is declared requiring the TSC activation during the time the TSC diesel is non-functional, the TSC will be staffed and activated using existing emergency planning procedure. If offsite power is lost, the TSC will relocate to the Alternate TSC using existing emergency planning procedures.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 10/18/2018 AT 1306 EDT FROM MARCY BLOW TO ANDREW WAUGH * * *
"Event Notification (EN) 53647, made on October 8, 2018, is being retracted because during the time that the TSC Diesel fuel oil transfer pump was not available, normal power was continuously available. The Alternative TSC was also available.
"Consequently, the condition did not meet the criteria for a 8-hour notification per 10 CFR 50.72(b)(3)(xiii) for any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system).
"The NRC Resident Inspector has been notified of the Event Notification retraction."
Notified R4DO (Pick).
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 53646
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: TERRELL HIGGINS
HQ OPS Officer: VINCE KLCO
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: TERRELL HIGGINS
HQ OPS Officer: VINCE KLCO
Notification Date: 10/05/2018
Notification Time: 09:52 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/24/2018
Notification Time: 09:52 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/24/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
THOMAS FARNHOLTZ (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
MAIN STEAM ISOLATION VALVES EXCEEDED PRIMARY CONTAINMENT LOCAL LEAK RATE ACCEPTANCE CRITERIA
"At 0520 (CDT), on October 05, 2018, it was discovered that a Primary Containment local leak rate test performed on Main Steam Isolation Valves (MSIV) exceeded its acceptance criteria.
"During Mode 1, 2, and 3, Surveillance Requirement 3.6.1.3.10 requires MSIV leakage for a single MSIV line to be less than or equal to 106 standard cubic feet per hour (scfh) when tested at 29 psig and Surveillance Requirement 3.6.1.3.12 requires the combined leakage rate for all MSIV leakage paths to be less than or equal to 212 scfh when tested at 29 psig.
"As-found for the 'C' MSIV line leakage results were unquantifiable and gave a [minimum] path value greeter than 160 scfh. This leakage rate lead to Surveillance Requirement 3.6.1.3.10 and 3.6.1.3.12 limits to be exceeded. This event is being reported as a condition of the nuclear power plant, including its principal safety barriers, being seriously degraded per 10 CFR 50.72(b)(3)(ii)(A) since the Primary Containment Isolation Valves leakage limits for MSIVs were exceeded.
"The NRC Resident Inspector has been notified."
* * * RETRACTION AT 2320 EDT ON 10/24/2018 FROM THOMAS FORLAND TO MARK ABRAMOVITZ * * *
"CNS [Cooper Nuclear Station] is retracting the 8-hour non-emergency notification made on October 5, 2018 at 0520 CDT (EN# 53646). Subsequent evaluation concluded that overall as-found 'C' MSIV leakage rate was not at a level that exceeded the surveillance requirement 3.6.1.3.10 and 3.6.1.3.12 limits and thus the Primary Containment Isolation Valve leakage rate limits for the MSIVs were not exceeded.
"The NRC Senior Resident Inspector has been notified."
Notified the R4DO (Drake).
"At 0520 (CDT), on October 05, 2018, it was discovered that a Primary Containment local leak rate test performed on Main Steam Isolation Valves (MSIV) exceeded its acceptance criteria.
"During Mode 1, 2, and 3, Surveillance Requirement 3.6.1.3.10 requires MSIV leakage for a single MSIV line to be less than or equal to 106 standard cubic feet per hour (scfh) when tested at 29 psig and Surveillance Requirement 3.6.1.3.12 requires the combined leakage rate for all MSIV leakage paths to be less than or equal to 212 scfh when tested at 29 psig.
"As-found for the 'C' MSIV line leakage results were unquantifiable and gave a [minimum] path value greeter than 160 scfh. This leakage rate lead to Surveillance Requirement 3.6.1.3.10 and 3.6.1.3.12 limits to be exceeded. This event is being reported as a condition of the nuclear power plant, including its principal safety barriers, being seriously degraded per 10 CFR 50.72(b)(3)(ii)(A) since the Primary Containment Isolation Valves leakage limits for MSIVs were exceeded.
"The NRC Resident Inspector has been notified."
* * * RETRACTION AT 2320 EDT ON 10/24/2018 FROM THOMAS FORLAND TO MARK ABRAMOVITZ * * *
"CNS [Cooper Nuclear Station] is retracting the 8-hour non-emergency notification made on October 5, 2018 at 0520 CDT (EN# 53646). Subsequent evaluation concluded that overall as-found 'C' MSIV leakage rate was not at a level that exceeded the surveillance requirement 3.6.1.3.10 and 3.6.1.3.12 limits and thus the Primary Containment Isolation Valve leakage rate limits for the MSIVs were not exceeded.
"The NRC Senior Resident Inspector has been notified."
Notified the R4DO (Drake).
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 53650
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: NATE BEGER
HQ OPS Officer: ANDREW WAUGH
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: NATE BEGER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/06/2018
Notification Time: 05:56 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 11/15/2018
Notification Time: 05:56 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 11/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
THOMAS FARNHOLTZ (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
CONTROL ROOM EMERGENCY FILTER SYSTEM INOPERABLE
"On 10/5/2018, at 2219 CDT, the Control Room Emergency Filter (CREF) System was determined to be inoperable during a required condition of applicability due to being aligned to a Division 2 power source with its associated emergency power supply (Diesel Generator #2) removed from service earlier in the day. The power supply alignment was not identified at the time Diesel Generator #2 was removed from service (Diesel Generator #2 was rendered inoperable on 10/5/2018 at 1728 CDT). Movement of lately irradiated fuel assemblies in the Secondary Containment was in progress at the time of discovery of this condition. This condition represents an unplanned loss of safety function for a single train system during its specified condition of applicability. Movement of irradiated fuel was suspended until the power supplies to CREFs could be realigned to Division 1 which was completed at 0004 CDT on 10/6/2018.
"This represents a condition that could have prevented the fulfillment of the safety function of CREFs needed to mitigate the consequences of a fuel handling accident."
The NRC Resident Inspector has been notified.
* * * RETRACTION AT 1533 EST ON 11/15/18 FROM THOMAS FORLAND TO JEFFREY WHITED * * *
"CNS [Cooper Nuclear Station] is retracting the 8-hour non-emergency notification made on October 5, 2018 at 2219 CDT (EN# 53650). A subsequent evaluation concluded that the Control Room Emergency Filter (CREF) system remained operable in accordance with the applicable Cooper Nuclear Station Technical Specification Requirements 3.7.4 CREF System, 3.8.2 AC Sources - Shutdown, and 3.8.8 Distribution Systems - Shutdown. As a result of CREFs remaining operable throughout this period, no loss of safety function occurred. The NRC Senior Resident Inspector has been notified."
Notified R4DO (Haire)
"On 10/5/2018, at 2219 CDT, the Control Room Emergency Filter (CREF) System was determined to be inoperable during a required condition of applicability due to being aligned to a Division 2 power source with its associated emergency power supply (Diesel Generator #2) removed from service earlier in the day. The power supply alignment was not identified at the time Diesel Generator #2 was removed from service (Diesel Generator #2 was rendered inoperable on 10/5/2018 at 1728 CDT). Movement of lately irradiated fuel assemblies in the Secondary Containment was in progress at the time of discovery of this condition. This condition represents an unplanned loss of safety function for a single train system during its specified condition of applicability. Movement of irradiated fuel was suspended until the power supplies to CREFs could be realigned to Division 1 which was completed at 0004 CDT on 10/6/2018.
"This represents a condition that could have prevented the fulfillment of the safety function of CREFs needed to mitigate the consequences of a fuel handling accident."
The NRC Resident Inspector has been notified.
* * * RETRACTION AT 1533 EST ON 11/15/18 FROM THOMAS FORLAND TO JEFFREY WHITED * * *
"CNS [Cooper Nuclear Station] is retracting the 8-hour non-emergency notification made on October 5, 2018 at 2219 CDT (EN# 53650). A subsequent evaluation concluded that the Control Room Emergency Filter (CREF) system remained operable in accordance with the applicable Cooper Nuclear Station Technical Specification Requirements 3.7.4 CREF System, 3.8.2 AC Sources - Shutdown, and 3.8.8 Distribution Systems - Shutdown. As a result of CREFs remaining operable throughout this period, no loss of safety function occurred. The NRC Senior Resident Inspector has been notified."
Notified R4DO (Haire)
Part 21
Event Number: 53708
Rep Org: FISHER CONTROLS INTERNATIONAL, LLC
Licensee: EMERSON PROCESS MANAGEMENT - FISHER VALVES
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KIM SAGAR
HQ OPS Officer: HOWIE CROUCH
Licensee: EMERSON PROCESS MANAGEMENT - FISHER VALVES
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KIM SAGAR
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/31/2018
Notification Time: 17:05 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/31/2018
Notification Time: 17:05 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DAN SCHROEDER (R1DO)
RANDY MUSSER (R2DO)
KARLA STOEDTER (R3DO)
CALE YOUNG (R4DO)
PART 21/50.55 REACTORS (EMAIL)
DAN SCHROEDER (R1DO)
RANDY MUSSER (R2DO)
KARLA STOEDTER (R3DO)
CALE YOUNG (R4DO)
PART 21/50.55 REACTORS (EMAIL)
PART 21 NOTIFICATION - FISHER DIGITAL VALVE CONTROLLERS 6000/6200 SERIES NOT ENVIRONMENTALLY QUALIFIED
The following information is summarized from information received from Fisher Valves via email:
A customer ordered a replacement digital valve controller. When the original controller was purchased, documentation indicated that it was qualified under IEEE 323-1974. The DVC6000 series and the DVC6200 series are not qualified in accordance with IEEE 323, nor was there any intent to qualify these devices to this standard.
The only customer that has requested Environmentally Qualified controllers is Seabrook Station.
Fisher requests that the recipient of this FIN review it and take appropriate action in accordance with 10 CFR 21. If there are any technical questions, please contact:
Jacob Clos
Quality Manager
Emerson Automation Solutions
Fisher Controls International LLC
301 South First Avenue
Marshalltown, IA 50158
Phone: (641) 754-2108
Jacob.Clos@Emerson.com
The following information is summarized from information received from Fisher Valves via email:
A customer ordered a replacement digital valve controller. When the original controller was purchased, documentation indicated that it was qualified under IEEE 323-1974. The DVC6000 series and the DVC6200 series are not qualified in accordance with IEEE 323, nor was there any intent to qualify these devices to this standard.
The only customer that has requested Environmentally Qualified controllers is Seabrook Station.
Fisher requests that the recipient of this FIN review it and take appropriate action in accordance with 10 CFR 21. If there are any technical questions, please contact:
Jacob Clos
Quality Manager
Emerson Automation Solutions
Fisher Controls International LLC
301 South First Avenue
Marshalltown, IA 50158
Phone: (641) 754-2108
Jacob.Clos@Emerson.com
Agreement State
Event Number: 53843
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: ROSWELL PARK CANCER INSTITUTE CORP
Region: 1
City: BUFFALO State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: ROSWELL PARK CANCER INSTITUTE CORP
Region: 1
City: BUFFALO State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: DANIEL SAMSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/23/2019
Notification Time: 13:49 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [EST]
Last Update Date: 01/23/2019
Notification Time: 13:49 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [EST]
Last Update Date: 01/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MISSING I-125 SEED
The following report was received via fax:
"On 11/28/2018 the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 186 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.
"Two lodine-125 breast localization seeds were placed into a patient on September 20, 2018 and removed on September 28, 2018. One seed was placed in a specimen container with the specimen, and the other seed was placed into a separate specimen container. Surgery has documentation that both seeds were sent to Pathology in separate containers; however, only one was returned to the Nuclear Medicine Department on October 4, 2018. The RSO was informed on October 5, 2018. The facility conducted searches and surveys of the Surgery, Pathology, Nuclear Medicine and Environmental Services areas, but could not locate the missing seed. Trash and regulated medical waste were also surveyed and inspected. Searches and surveys were repeated, but the seed was not found. It is believed that the seed was disposed of as regulated medical waste or in regular trash."
New York State ID: NYSDOH - 18-04
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
The following report was received via fax:
"On 11/28/2018 the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 186 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.
"Two lodine-125 breast localization seeds were placed into a patient on September 20, 2018 and removed on September 28, 2018. One seed was placed in a specimen container with the specimen, and the other seed was placed into a separate specimen container. Surgery has documentation that both seeds were sent to Pathology in separate containers; however, only one was returned to the Nuclear Medicine Department on October 4, 2018. The RSO was informed on October 5, 2018. The facility conducted searches and surveys of the Surgery, Pathology, Nuclear Medicine and Environmental Services areas, but could not locate the missing seed. Trash and regulated medical waste were also surveyed and inspected. Searches and surveys were repeated, but the seed was not found. It is believed that the seed was disposed of as regulated medical waste or in regular trash."
New York State ID: NYSDOH - 18-04
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