Event Notification Report for February 28, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/27/2019 - 02/28/2019
EVENT NUMBERS
53904539055390153903
Agreement State
Event Number: 53904
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF KENTUCKY (HOSPITAL)
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: CATY NOLAN
Licensee: UNIVERSITY OF KENTUCKY (HOSPITAL)
Region: 1
City: LEXINGTON State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: CATY NOLAN
Notification Date: 03/01/2019
Notification Time: 13:53 [ET]
Event Date: 02/28/2019
Event Time: 00:00 [CST]
Last Update Date: 03/01/2019
Notification Time: 13:53 [ET]
Event Date: 02/28/2019
Event Time: 00:00 [CST]
Last Update Date: 03/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE OF THERASPHERE Y-90 TREATMENT
The following report was received from the Kentucky Department of Public Health via email:
"The University of Kentucky RSO [Radiation Safety Officer] reports a patent delivery system failed to deliver part of a TheraSphere Y-90 treatment on February 28, 2019. A patient written directive indicated a prescribed dose of 208 Gy. The patient only received 145 Gy.
"The RSO indicated the first vial of Y-90 was administered without difficulty. The second vial failed to empty into the administration catheter. Calls were placed to the drug representative and unsuccessful attempts made to administer the remainder of the dose. Patient treatment was stopped with only partial dose delivery. At the time of the report, March 1, 2019, the University is establishing the reason for the administration failure. The patient had been notified and the physician and referring physician are being notified. The university plans an update in 15 days."
Kentucky Event Report ID No.: Ky190002.
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 report was received from the Kentucky Department of Public Health via email:
"The University of Kentucky RSO [Radiation Safety Officer] reports a patent delivery system failed to deliver part of a TheraSphere Y-90 treatment on February 28, 2019. A patient written directive indicated a prescribed dose of 208 Gy. The patient only received 145 Gy.
"The RSO indicated the first vial of Y-90 was administered without difficulty. The second vial failed to empty into the administration catheter. Calls were placed to the drug representative and unsuccessful attempts made to administer the remainder of the dose. Patient treatment was stopped with only partial dose delivery. At the time of the report, March 1, 2019, the University is establishing the reason for the administration failure. The patient had been notified and the physician and referring physician are being notified. The university plans an update in 15 days."
Kentucky Event Report ID No.: Ky190002.
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.
Agreement State
Event Number: 53905
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: HOLCIM (US), INC.
Region: 1
City: WHITEHALL State: PA
County:
License #: PA-1336
Agreement: Y
Docket:
NRC Notified By: JOHN S. CHIPPO
HQ OPS Officer: OSSY FONT
Licensee: HOLCIM (US), INC.
Region: 1
City: WHITEHALL State: PA
County:
License #: PA-1336
Agreement: Y
Docket:
NRC Notified By: JOHN S. CHIPPO
HQ OPS Officer: OSSY FONT
Notification Date: 03/01/2019
Notification Time: 13:56 [ET]
Event Date: 02/28/2019
Event Time: 00:00 [EST]
Last Update Date: 03/01/2019
Notification Time: 13:56 [ET]
Event Date: 02/28/2019
Event Time: 00:00 [EST]
Last Update Date: 03/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - MISSING ANALYZER SOURCE
The following was received via fax from the Pennsylvania Department of Environmental Protection:
"On March 1, 2019, a manufacturer's technician from Sabia Inc. (PA-R0124) notified the Department [Pennsylvania Department of Environmental Protection] of a missing 0.9 microgram (0.5 mCi) Californium-252 source from a Sabia XL5000 analyzer at the Holcim (US), Inc. Whitehall Cement Plant (PA-1336). The manufacturer was performing replenishment of two of seven sources [on February 28, 2019]. It was discovered that the analyzer only contained six sources. The analyzer was removed and disassembled, destroying the unit, in efforts to locate the missing source but it was not located. The manufacturer technician surveyed the unit and the area multiple times and did not find the source. The remaining sources have been packaged in a drum for safe storage until shipping can be arranged.
"The Department will perform a reactive inspection. More information will be provided upon receipt."
Pennsylvania Event Report ID No: PA190006
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 was received via fax from the Pennsylvania Department of Environmental Protection:
"On March 1, 2019, a manufacturer's technician from Sabia Inc. (PA-R0124) notified the Department [Pennsylvania Department of Environmental Protection] of a missing 0.9 microgram (0.5 mCi) Californium-252 source from a Sabia XL5000 analyzer at the Holcim (US), Inc. Whitehall Cement Plant (PA-1336). The manufacturer was performing replenishment of two of seven sources [on February 28, 2019]. It was discovered that the analyzer only contained six sources. The analyzer was removed and disassembled, destroying the unit, in efforts to locate the missing source but it was not located. The manufacturer technician surveyed the unit and the area multiple times and did not find the source. The remaining sources have been packaged in a drum for safe storage until shipping can be arranged.
"The Department will perform a reactive inspection. More information will be provided upon receipt."
Pennsylvania Event Report ID No: PA190006
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
Agreement State
Event Number: 53901
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. ANTHONY HOSPITAL - CENTURA HEALTH
Region: 4
City: LAKEWOOD State: CO
County:
License #: CO152-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: OSSY FONT
Licensee: ST. ANTHONY HOSPITAL - CENTURA HEALTH
Region: 4
City: LAKEWOOD State: CO
County:
License #: CO152-01
Agreement: Y
Docket:
NRC Notified By: RAMON LI
HQ OPS Officer: OSSY FONT
Notification Date: 02/28/2019
Notification Time: 17:15 [ET]
Event Date: 02/28/2019
Event Time: 13:00 [MST]
Last Update Date: 02/28/2019
Notification Time: 17:15 [ET]
Event Date: 02/28/2019
Event Time: 13:00 [MST]
Last Update Date: 02/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following was received via email from the state of Colorado:
"At approximately 1438 MST on February 28, 2019 the RSO [Radiation Safety Officer] for CO 152-01, St. Anthony Hospital - Centura Health, notified the Department [Colorado Department of Public Health and Environment] of a Y-90 SIR-Sphere misadministration. The procedure occurred at approximately 1300 MST and it was determined that 65 percent of the prescribed dose was delivered to the patient. The RSO noted that during the procedure there were issues with the delivering catheter. During the procedure, the catheter was replaced.
"A department investigation will occur in the near future. A written report per section 7.21.4 is expected within 15 days."
Colorado Event Report ID No.: CO190003
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 Colorado:
"At approximately 1438 MST on February 28, 2019 the RSO [Radiation Safety Officer] for CO 152-01, St. Anthony Hospital - Centura Health, notified the Department [Colorado Department of Public Health and Environment] of a Y-90 SIR-Sphere misadministration. The procedure occurred at approximately 1300 MST and it was determined that 65 percent of the prescribed dose was delivered to the patient. The RSO noted that during the procedure there were issues with the delivering catheter. During the procedure, the catheter was replaced.
"A department investigation will occur in the near future. A written report per section 7.21.4 is expected within 15 days."
Colorado Event Report ID No.: CO190003
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.
Power Reactor
Event Number: 53903
Facility: LASALLE
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: WAYNE CLAYTON
HQ OPS Officer: JOANNA BRIDGE
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: WAYNE CLAYTON
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 03/01/2019
Notification Time: 04:03 [ET]
Event Date: 02/28/2019
Event Time: 22:17 [CST]
Last Update Date: 03/01/2019
Notification Time: 04:03 [ET]
Event Date: 02/28/2019
Event Time: 22:17 [CST]
Last Update Date: 03/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN HANNA (R3DO)
JOHN HANNA (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
SPECIFIED SYSTEM ACTUATION - TRIP OF SAFETY RELATED BUS
"On February 28, 2019, at 2217 CST, LaSalle Unit 2 experienced a trip of the 241Y Safety Related Bus during surveillance testing resulting in a valid undervoltage actuation signal to the Common Emergency Diesel Generator ('O' EDG), causing it to start and load to Bus 241Y. The purpose of the surveillance testing was to demonstrate the operability of the breakers necessary to provide the second off site source to Unit 2. This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A), as an event that results in a valid actuation of the emergency AC electrical power system. In addition to the 241Y bus trip and 'O' EDG actuation signal, the following plant responses occurred as designed due to the momentary loss of this AC Bus: "A" RPS de-energized due to the loss of the 2A Reactor Protection System Motor-Generator Set, and the running Unit 2 Fuel Pool Cooling pump tripped. The Non-Safety Related Bus 241X de-energized resulting in a trip of the Unit 2 Station Air Compressor. All systems have been restored and troubleshooting is currently in progress. Unit 1 remained in MODE 1 during this event.
"The NRC Senior Resident Inspector has been notified."
"On February 28, 2019, at 2217 CST, LaSalle Unit 2 experienced a trip of the 241Y Safety Related Bus during surveillance testing resulting in a valid undervoltage actuation signal to the Common Emergency Diesel Generator ('O' EDG), causing it to start and load to Bus 241Y. The purpose of the surveillance testing was to demonstrate the operability of the breakers necessary to provide the second off site source to Unit 2. This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A), as an event that results in a valid actuation of the emergency AC electrical power system. In addition to the 241Y bus trip and 'O' EDG actuation signal, the following plant responses occurred as designed due to the momentary loss of this AC Bus: "A" RPS de-energized due to the loss of the 2A Reactor Protection System Motor-Generator Set, and the running Unit 2 Fuel Pool Cooling pump tripped. The Non-Safety Related Bus 241X de-energized resulting in a trip of the Unit 2 Station Air Compressor. All systems have been restored and troubleshooting is currently in progress. Unit 1 remained in MODE 1 during this event.
"The NRC Senior Resident Inspector has been notified."