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Event Notification Report for January 29, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/28/2019 - 1/29/2019

** EVENT NUMBERS **

Non-Agreement State	Event Number: 53835
Rep Org: NUCOR STEEL CORPORATION Licensee: NUCOR STEEL CORPORATION Region: 3 City: Crawfordsville State: IN County: License #: 13-25975-01 Agreement: N Docket: NRC Notified By: MARK WASHER HQ OPS Officer: JEFF HERRERA	Notification Date: 01/18/2019 Notification Time: 14:00 [ET] Event Date: 01/18/2019 Event Time: 00:00 [EST] Last Update Date: 01/18/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): PATRICIA PELKE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PROCESS GAUGE CLOSED SHUTTER INDICATION NOT FUNCTIONAL

A process gauge shutter indication did not properly indicate that the shutter was in the closed position. A survey was performed and verified that the shutter was indeed in the closed position. The system has been locked out to prevent access and the licensee stated that repairs to the gauge shutter are in progress.

Gauge Model No.: DMC-AM-5A
Source: Am-241
Activity: 1.0 Curies
Serial Number: 1979LQ

Agreement State	Event Number: 53836
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: TEXAS ONCOLOGY PA Region: 4 City: DALLAS State: TX County: License #: L04878 Agreement: Y Docket: NRC Notified By: ART TUCKER HQ OPS Officer: JEFFREY WHITED	Notification Date: 01/18/2019 Notification Time: 16:49 [ET] Event Date: 01/18/2019 Event Time: 00:00 [CST] Last Update Date: 01/18/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF RADIUM-223 TO PATIENT

The following was received via e-mail:

"On January 18, 2019, the Texas Department of State Health Services was contacted by the licensee's radiation safety officer (RSO) and notified that they had a treatment error occur at their facility. The error occurred to a patient who was to be treated with multiple fractions of radium-223. The treatment was to relieve bone pain in the patient. The dose from each fraction was based on the weight of the patient. The fraction activity was determined to be 75 microCuries based on the weight in pounds of the patient involved. The technician involved with administering the dose mistook the weight units and ordered the fraction dose based on the patients weight measured in kilograms. As a result the patient was administered 165 microCuries of radium-223 instead of the 75 microCuries. The error was discovered as they were preparing to administer the second dose (The date of the first dose was not provided). The RSO stated the patient and prescribing physician have been contacted and notified of the error. The RSO stated the patient would not experience any adverse effects from the dose received. The RSO stated the patient's treatment going forward is being reviewed. The RSO stated they would provide a written report next week.

"At 1530 hours the Agency contacted the RSO and confirmed the dose to the patient. The RSO stated the dose to the bones from the activity given would be 693 rad instead of 315 rad.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Department of State Health Services Incident Number 9651

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.

Non-Power Reactor	Event Number: 53849
Facility: UNIV OF MISSOURI-COLUMBIA RX Type: 10000 KW TANK Comments: Region: 0 City: COLUMBIA State: MO County: BOONE License #: R-103 Agreement: N Docket: 05000186 NRC Notified By: BRUCE MEFFERT HQ OPS Officer: BRIAN P. SMITH	Notification Date: 01/28/2019 Notification Time: 15:01 [ET] Event Date: 01/27/2019 Event Time: 19:13 [CST] Last Update Date: 01/28/2019
Emergency Class: NON EMERGENCY 10 CFR Section: NON-POWER REACTOR EVENT	Person (Organization): GEOFFREY WERTZ (NRR) ELIZABETH REED (NRR)

Event Text

CONTROL BLADE INOPERABLE

"On January 27, 2019, at 1913 CST, with the University of Missouri-Columbia Research Reactor (MURR) operating at 10 MW in the automatic control mode, the Lead Senior Reactor Operator (LSRO) was conducting surveillance Technical Specification (TS) 4.2.a, which states, 'All control blades, including the regulating blade, shall be verified operable within a shift.' During this shiftily verification of control blade operability, all blades were initially verified operable. However, when banking the control blades to their final position after all blades were satisfactorily tested a few seconds earlier, shim control blade 'A' would not move in the inward direction. The LSRO then immediately shut down the reactor by initiating a manual scram by placing the Master Control Switch 1S1 to the 'TEST' position. The LSRO completed all immediate and subsequent actions of reactor emergency procedure REP-2, 'Reactor Scram,' and verified all shim control blades were fully inserted.

"The inability to manually insert shim control blade 'A' with Control Rod Operate Switch 1S4, which inserts and withdraws the control blade, is a deviation from TS 3.2.a, which states, 'All control blades, including the regulating blade, shall be operable during reactor operation.'

"Troubleshooting revealed a problem with an electrical contact on Control Rod Operate Switch 1S4, and it has since been replaced. The reactor has not returned to operation at the time of this email. However, permission from the Reactor Facility Director has been obtained to restart the reactor once scheduled maintenance activities have been completed. A detailed event report will follow within 14 days as required by MURR TS 6.6.c(3)."

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