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Event Notification Report for January 15, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/14/2019 - 1/15/2019

** EVENT NUMBERS **


53814 53825 53827

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53814
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS   State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: MAXWELL AMURAO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/04/2019
Notification Time: 12:15 [ET]
Event Date: 01/03/2019
Event Time: 16:00 [CST]
Last Update Date: 01/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT

A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead.

The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.

* * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *

The following was received via email from the licensee:

"As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, [the licensee radiation safety officer] is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive."

Notified R3DO (PELKE) and NMSS vis email.

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: 53825
Facility: FERMI
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: JEFF MYERS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 01/14/2019
Notification Time: 13:12 [ET]
Event Date: 01/14/2019
Event Time: 09:58 [EST]
Last Update Date: 01/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATRICIA PELKE (R3DO)
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

ACTIVE SEISMIC MONITORING SYSTEM INOPERABLE

"On 01/11/2019 at 0958 EST, the Fermi 2 Active Seismic Monitoring system was taken out of service for planned maintenance. During the maintenance activity, the Active Seismic Monitoring System failed a planned surveillance test and was not restored to operability within 72 hours. Compensatory measures to provide alternative methods for event classification of a seismic event were implemented in accordance with the Fermi 2 Emergency Plan procedures prior to the start of the planned maintenance outage. The planned outage time to restore operability exceeded 72 hours on January 14th, 2019, at 0958 EST. Repairs have been completed, the Active Seismic Monitoring System has been declared Functional at 1037 EST, January 14th, 2019, and declared Operable at 1109 EST, January 14th, 2019.

"The loss of the Active Seismic Monitoring System is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).

"No seismic activity has been felt onsite and the United States Geological Survey (USGS) recorded no seismic activity in the area.

"The NRC Resident Inspector has been notified."

Femi 2 has two seismic monitors, one on the Reactor Pressure Vessel Pedestal and one in the High Pressure Core Injection (HPCI) room. Only the HPCI room monitor was inoperable.

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Power Reactor Event Number: 53827
Facility: FARLEY
Region: 2     State: AL
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DOUGLAS HOBSON
HQ OPS Officer: ANDREW WAUGH
Notification Date: 01/15/2019
Notification Time: 12:25 [ET]
Event Date: 01/15/2019
Event Time: 08:00 [CST]
Last Update Date: 01/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
NICOLE COOVERT (R2DO)
FFD GROUP (EMAIL)
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

FITNESS-FOR-DUTY VIOLATION

At 0800 CST on January 15, 2019, a non-licensed employee supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The employee's access to the plant has been placed on hold.

The NRC Resident Inspector has been notified.


Page Last Reviewed/Updated Friday, May 03, 2019
Friday, May 03, 2019