Event Notification Report for February 13, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/12/2020 - 02/13/2020
Power Reactor
Event Number: 54524
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN WHETSLER
HQ OPS Officer: KERBY SCALES
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN WHETSLER
HQ OPS Officer: KERBY SCALES
Notification Date: 02/13/2020
Notification Time: 17:17 [ET]
Event Date: 02/13/2020
Event Time: 10:25 [PST]
Last Update Date: 02/13/2020
Notification Time: 17:17 [ET]
Event Date: 02/13/2020
Event Time: 10:25 [PST]
Last Update Date: 02/13/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RAY AZUA (R4DO)
RAY AZUA (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | Y | 100 | Power Operation | 51 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
"On February 13, 2020, at 1025 hours [PST], during the performance of the quarterly control rod exercise surveillance test, Shutdown Bank 'B' Group 1 became misaligned greater than 12 steps from its group demand position. In accordance with Technical Specification 3.1.4, 'Rod Group Alignment Limits,' Action D, a Unit 2 shutdown to Mode 3 was commenced at 1233 hours. Investigation into the cause of the rod bank misalignment is in progress.
"There is no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
"On February 13, 2020, at 1025 hours [PST], during the performance of the quarterly control rod exercise surveillance test, Shutdown Bank 'B' Group 1 became misaligned greater than 12 steps from its group demand position. In accordance with Technical Specification 3.1.4, 'Rod Group Alignment Limits,' Action D, a Unit 2 shutdown to Mode 3 was commenced at 1233 hours. Investigation into the cause of the rod bank misalignment is in progress.
"There is no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 54526
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: Boston State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: HOWIE CROUCH
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: Boston State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2020
Notification Time: 16:01 [ET]
Event Date: 02/13/2020
Event Time: 13:45 [EST]
Last Update Date: 08/11/2020
Notification Time: 16:01 [ET]
Event Date: 02/13/2020
Event Time: 13:45 [EST]
Last Update Date: 08/11/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date : 8/12/2020
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT
"A medical event was reported to the Massachusetts Radiation Control Program on Friday, February 14, 2020. A patient receiving a therapeutic radiation dose to the right lobe of the liver using Y-90 Theraspheres in 2 fractionated doses was intended to receive 135 Grays for each fraction. The patient was administered 45.5 Grays for the first fraction and 129.4 Grays for the second. The first fraction underdosed the right lobe of the liver by greater than 50 percent and differed from the prescribed dose by greater than 0.5 Sv (50 rem) effective dose equivalent. The actual underdose for the first fraction was 8,950 rads. This exceeds the reporting limits of 10 CFR 35.3045(a)(1)(i)(c), 'Report and Notification of a Medical Event,' and 105 CMR 120.594(A)(1)(a)(3).
"The licensee is investigating the cause of the event and will be reporting the results to the Massachusetts Radiation Control Program.
"
* * * UPDATE ON 8/11/2020 AT 1715 EDT FROM SZYMON MUDREWICZ TO BETHANY CECERE * * *
"Medical event no. 14-4085 was reported to the Massachusetts Radiation Control Program (hereafter, 'Agency') by Massachusetts General Hospital (hereafter, 'licensee') on 02/14/2020 involving administration of TheraSphere Y-90 microspheres to a patient for liver cancer treatment. The patient was scheduled to receive two doses on 02/13/2020 to the right lobe and segment 4 of the liver; 1.59 GBq and 0.29 GBq, respectively. Administration of both doses went accordingly and no unusual signs were observed by the authorized used conducting the administration. There were no problems with the flow of liquid through the microcatheter, no excessive pressure was needed to push the spheres, no leaks were observed, and there were no visual indicators that spheres were collecting at junctions in the tubing. The RADOS dosimeter, supplied with the delivery system, was reading 0.0 mR/hr at conclusion of each dose delivery indicating minimal residual activity inside the delivery system. After each dose the microcatheter and delivery system tubing are placed in a waste container - for storage to decay - where the dose is measured to calculate the activity of any residual microspheres that were not delivered. The calculations were performed the morning of 02/14/2020 and it was determined that only 0.512 GBq (33.7%) of the first dose was delivered to the target site, whereas as 0.273 GBq (95.9%) of the second was delivered to the target site. These calculations identified a possible occlusion in either the microcatheter or delivery set tubing and also identified a malfunctioning dosimeter. No physiological risk to patient health was identified.
"The Agency considers this event closed."
Notified R1DO (Gray) and NMSS Events Notification (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.
Agreement State
Event Number: 54610
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TOWN OF MEAD
Region: 4
City: MEAD State: CO
County:
License #: GL001806
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: KERBY SCALES
Licensee: TOWN OF MEAD
Region: 4
City: MEAD State: CO
County:
License #: GL001806
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: KERBY SCALES
Notification Date: 03/25/2020
Notification Time: 15:00 [ET]
Event Date: 02/13/2020
Event Time: 00:00 [MDT]
Last Update Date: 03/25/2020
Notification Time: 15:00 [ET]
Event Date: 02/13/2020
Event Time: 00:00 [MDT]
Last Update Date: 03/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN
The following was received from the state of Colorado via email.
"One tritium exit sign, containing 11.50 Ci, was determined lost. [The] tenant claims the exit sign was never delivered or installed.
"Initial date reported: 2/13/20
"Final Decision Material Lost Date: 2/13/20"
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 from the state of Colorado via email.
"One tritium exit sign, containing 11.50 Ci, was determined lost. [The] tenant claims the exit sign was never delivered or installed.
"Initial date reported: 2/13/20
"Final Decision Material Lost Date: 2/13/20"
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