Event Notification Report for April 14, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/13/2020 - 04/14/2020
EVENT NUMBERS
54665546665466854941
Agreement State
Event Number: 54665
Rep Org: COLORADO DEPT OF HEALTH
Licensee: LA QUINTA INN
Region: 4
City: LOUISVILLE State: CO
County:
License #: GL000263
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: DONALD NORWOOD
Licensee: LA QUINTA INN
Region: 4
City: LOUISVILLE State: CO
County:
License #: GL000263
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/14/2020
Notification Time: 17:29 [ET]
Event Date: 04/14/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/14/2020
Notification Time: 17:29 [ET]
Event Date: 04/14/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/14/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS
The following information was received via E-mail:
21 tritium exit signs, each containing 9.21 Ci, are unaccounted for. There has been no response for annual general license registrations since 2015.
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 information was received via E-mail:
21 tritium exit signs, each containing 9.21 Ci, are unaccounted for. There has been no response for annual general license registrations since 2015.
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
Power Reactor
Event Number: 54666
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: WILLIAM MURREY
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: WILLIAM MURREY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/14/2020
Notification Time: 23:36 [ET]
Event Date: 04/14/2020
Event Time: 16:45 [CDT]
Last Update Date: 04/14/2020
Notification Time: 23:36 [ET]
Event Date: 04/14/2020
Event Time: 16:45 [CDT]
Last Update Date: 04/14/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
MICHAEL KUNOWSKI (R3DO)
| 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 | 15 | Power Operation | 15 | Power Operation |
CONTROL ROOM EMERGENCY VENTILATION SYSTEM INOPERABLE
"On April 14, 2020 at 1645 CDT, the Control Room Emergency Ventilation Air Conditioning (CREV AC) system was declared inoperable when the electrical feed breaker to the Refrigeration Compressor Unit (RCU) was found in a tripped condition. As a result, both units entered Technical Specification 3.7.5 Condition A. Investigation is in progress to determine the cause and corrective actions of the RCU feed breaker trip.
"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.
"This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D) because the CREV system is a single train system, and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident."
"On April 14, 2020 at 1645 CDT, the Control Room Emergency Ventilation Air Conditioning (CREV AC) system was declared inoperable when the electrical feed breaker to the Refrigeration Compressor Unit (RCU) was found in a tripped condition. As a result, both units entered Technical Specification 3.7.5 Condition A. Investigation is in progress to determine the cause and corrective actions of the RCU feed breaker trip.
"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.
"This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D) because the CREV system is a single train system, and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident."
Agreement State
Event Number: 54668
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: BRIAN P. SMITH
Licensee: UNIVERSITY OF LOUISVILLE HOSPITAL
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 04/15/2020
Notification Time: 10:12 [ET]
Event Date: 04/14/2020
Event Time: 13:15 [EDT]
Last Update Date: 04/15/2020
Notification Time: 10:12 [ET]
Event Date: 04/14/2020
Event Time: 13:15 [EDT]
Last Update Date: 04/15/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EVENT OF Y-90 SIRTEX
The following is a summary of an email received from the Kentucky Department of Radiation:
At the University of Louisville Hospital on April 14, 2020, a patient received two doses (each dose was 0.4 GBq) of Y-90 Sirtex. The first dose was given at 1130 EDT and the second dose started at 1315 EDT. The second dose was started to be administered when a problem developed. While pushing saline into the dose V-vial, pressure built and vented out the top of the vial rather than pushing the spheres via the tubing to the patent as normal. Liquid, and presumably spheres, vented either from the side of the septum or around the needle at this time which is unknown. The administration box contained the leakage and prevented wider contamination. The second dose was not delivered to the patient so the patient received 0.4 GBq of a planned 0.8 GBq treatment. The manufacturer was contacted and the administration was stopped. Most of the intended dose remained in the plexiglass box that is used for shielding during administration. To prevent any contamination everything was kept and confined to the box.
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 is a summary of an email received from the Kentucky Department of Radiation:
At the University of Louisville Hospital on April 14, 2020, a patient received two doses (each dose was 0.4 GBq) of Y-90 Sirtex. The first dose was given at 1130 EDT and the second dose started at 1315 EDT. The second dose was started to be administered when a problem developed. While pushing saline into the dose V-vial, pressure built and vented out the top of the vial rather than pushing the spheres via the tubing to the patent as normal. Liquid, and presumably spheres, vented either from the side of the septum or around the needle at this time which is unknown. The administration box contained the leakage and prevented wider contamination. The second dose was not delivered to the patient so the patient received 0.4 GBq of a planned 0.8 GBq treatment. The manufacturer was contacted and the administration was stopped. Most of the intended dose remained in the plexiglass box that is used for shielding during administration. To prevent any contamination everything was kept and confined to the box.
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: 54941
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: Roswell Park Cancer Institute Corp.
Region: 1
City: Buffalo State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Donald Norwood
Licensee: Roswell Park Cancer Institute Corp.
Region: 1
City: Buffalo State: NY
County:
License #: 2923
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Donald Norwood
Notification Date: 10/09/2020
Notification Time: 13:42 [ET]
Event Date: 04/14/2020
Event Time: 00:00 [EDT]
Last Update Date: 10/09/2020
Notification Time: 13:42 [ET]
Event Date: 04/14/2020
Event Time: 00:00 [EDT]
Last Update Date: 10/09/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MISSING IODINE-125 SEED
The following information was received via facsimile:
"On April 29, 2020, the Department [New York State Department of Health, Bureau of Environmental Radiation Protection] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 220 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.
"In this incident, two seeds were placed into a patient on 4/10/2020 and removed on 4/14/2020. One of the two seeds was lost by the attending surgeon. An extensive survey of the patient was performed to verify that the seed was not in the patient and the Nuclear Medicine Department was notified. A survey of the operating room (OR) suite was conducted and the seed was not recovered. The Radiation Safety Office was notified, another survey of the OR was performed, again the seed was not recovered. The patient also had a lymphoscintigraphy with Tc-99m so the surgical trash that was still in the room was sequestered. After three days, the trash was surveyed and examined but the seed was not recovered.
"Searches and surveys were performed in surgery, pathology, radiation safety and environmental service areas. Trash and regulated medical waste were also surveyed and inspected.
"Ultimate disposition of the source is unknown and it is possible that the source may still be recovered."
New York State Event Report ID No.: NYDOH - 20-05
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 information was received via facsimile:
"On April 29, 2020, the Department [New York State Department of Health, Bureau of Environmental Radiation Protection] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 220 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.
"In this incident, two seeds were placed into a patient on 4/10/2020 and removed on 4/14/2020. One of the two seeds was lost by the attending surgeon. An extensive survey of the patient was performed to verify that the seed was not in the patient and the Nuclear Medicine Department was notified. A survey of the operating room (OR) suite was conducted and the seed was not recovered. The Radiation Safety Office was notified, another survey of the OR was performed, again the seed was not recovered. The patient also had a lymphoscintigraphy with Tc-99m so the surgical trash that was still in the room was sequestered. After three days, the trash was surveyed and examined but the seed was not recovered.
"Searches and surveys were performed in surgery, pathology, radiation safety and environmental service areas. Trash and regulated medical waste were also surveyed and inspected.
"Ultimate disposition of the source is unknown and it is possible that the source may still be recovered."
New York State Event Report ID No.: NYDOH - 20-05
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