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Event Notification Report for December 19, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/18/2018 - 12/19/2018

** EVENT NUMBERS **


53785 53787 53793

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Agreement State Event Number: 53785
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: OCHSNER CLINIC FOUNDATION
Region: 4
City: KENNER   State: LA
County:
License #: LA-0002-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 12/10/2018
Notification Time: 18:12 [ET]
Event Date: 12/07/2018
Event Time: 00:00 [CST]
Last Update Date: 12/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
ANDREA KOCK (NMSS)
PATRICIA MILLIGAN (INES)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

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

"[On 12/7/2018, the licensee's RSO reported to the Louisiana Department of Environmental Quality (LDEQ)] that his personnel monitoring provider had informed him of excessive exposures to a Nuclear Medicine Technologist's (NMT) monitors. The monitors had received a whole-body exposure of 6,358 mRem and an extremity exposure 29,245 mRem. The monitoring period was 9/20/20018 to 10/19/2018.

"[The RSO's] in-house investigation revealed he had a 'Reportable NMED Event'. The event occurred under the Ochsner Clinic Foundation Broad Scope Medical License (OCFBS), LA-0002-L01. The event involves two monitors, a whole-body and an extremity monitor. The monitoring company could not determine the type of exposure using their normal exposure filters.

"The RSO for this licensee did his own investigation after he was notified of the exposures on 12/5/2018. The RSO interviewed the NMT, reviewed area survey records, and did a bioassay of the NMT. The isotopes in use at the facility are Tc-99, Lu-177, and a Ga-68 generator. The NMT attaches both monitors together for storage after their use. The NMT did admit to not being in gloves at all times when handling radioactive isotopes. The RSO called in the possible NMED event [to the LDEQ] when he finished his investigation on 12/7/2018.

"This incident is being reported as a (potential) real or threatened excessive exposure NMED Event on 12/10/2018. The actual exposure determination will be up-dated when LDEQ concludes its investigation.

"LDEQ considers this incident still open and subject to investigation and corrective action implementation."

Event Report ID No.: LA-180020

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Agreement State Event Number: 53787
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: LAKES REGION GENERAL HOSPITAL
Region: 1
City: LACONIA   State: NH
County:
License #: 258R
Agreement: Y
Docket:
NRC Notified By: DAVID SCALISE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 12/11/2018
Notification Time: 16:18 [ET]
Event Date: 12/11/2018
Event Time: 00:00 [EST]
Last Update Date: 12/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the State of New Hampshire via email:

"On December 11, 2018, the NH Radiological Health Section (Agency) was notified by the Radiation Safety Officer at Lakes Region General Hospital of the administration of an incorrect radiopharmaceutical. On this date a patient received an injection of 7.7 milliCuries (mCi) of technicium-99m Sestamibi rather than 7.7 mCi technicium-99m Choletec. The consequence is a dose to an unintended organ.

"The patient, radiologist, and authorized providers were informed. No health effects are anticipated.

"The RSO will conduct a root cause analysis and present a written report of the findings and corrective actions to the Agency within 15 days."

New Hampshire Event Report ID No.: NH 18-005

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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Power Reactor Event Number: 53793
Facility: ARKANSAS NUCLEAR
Region: 4     State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: SEAN DAVIS
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/18/2018
Notification Time: 15:40 [ET]
Event Date: 12/18/2018
Event Time: 00:00 [CST]
Last Update Date: 12/18/2018
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
Person (Organization):
RYAN ALEXANDER (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP - LOSS OF NON-VITAL BUS

"On December 18, 2018 at 1126 CST, Arkansas Nuclear One, Unit 1 (ANO-1) reactor automatically tripped due to a loss of the A-1, non-vital 4160V bus. All control rods fully inserted. Loss of the A-1 bus resulted in de-energizing A-3 vital 4160V bus. Emergency Diesel Generator #1, K-4A, started automatically and is currently powering A-3 vital bus. Non-vital buses A-2, H-1, and H-2 and vital bus A-4 transferred power automatically to the Startup Transformer #1. Off-site power remains energized and available for ANO-1. The reason for loss of A-1 bus is unknown at this time. Currently, ANO-1 has stabilized in Mode 3, Hot Standby."

Decay heat is being removed by the main condenser using the turbine bypass valves. The loss of the A-1, non-vital bus, is under investigation. The licensee has notified the NRC Resident Inspector and the state.


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