Event Notification Report for May 04, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/03/2020 - 05/04/2020
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 54693
Facility: LASALLE
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOE MESSINA
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOE MESSINA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/04/2020
Notification Time: 23:40 [ET]
Event Date: 05/04/2020
Event Time: 16:40 [CDT]
Last Update Date: 05/08/2020
Notification Time: 23:40 [ET]
Event Date: 05/04/2020
Event Time: 16:40 [CDT]
Last Update Date: 05/08/2020
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):
ANN MARIE STONE (R3DO)
ANN MARIE STONE (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 |
DIESEL GENERATOR COOLING WATER SYSTEM DECLARED INOPERABLE
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to mitigate the Consequences of an Accident. A through wall leak was found on piping connected to the Division 3 Diesel Generator (DG) Cooling Water Strainer. This condition has been evaluated and the Division 3 DG Cooling Water System has been declared inoperable. The Division 3 DG Cooling Water System is a support system for the Division 3 Emergency DG and the High Pressure Core Spray System (HPCS).
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON MAY 8, 2020 AT 1709 EDT FROM JOE MESSINA TO BRIAN LIN * * *
"This update retracts Event Notification #54693, which reported a condition that could have potentially prevented fulfillment of a safety function needed to mitigate the consequences of an accident.
"An evaluation of the flaw on the piping connected to the Unit 2 Division 3 Diesel Generator (DG) Cooling Water strainer concluded that the system would have remained operable. The High Pressure Core Spray system, supported by the operable DG Cooling Water system, remained operable and capable of performing its safety function.
"The NRC Resident Inspector has been notified."
Notified R3DO (Stone).
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to mitigate the Consequences of an Accident. A through wall leak was found on piping connected to the Division 3 Diesel Generator (DG) Cooling Water Strainer. This condition has been evaluated and the Division 3 DG Cooling Water System has been declared inoperable. The Division 3 DG Cooling Water System is a support system for the Division 3 Emergency DG and the High Pressure Core Spray System (HPCS).
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON MAY 8, 2020 AT 1709 EDT FROM JOE MESSINA TO BRIAN LIN * * *
"This update retracts Event Notification #54693, which reported a condition that could have potentially prevented fulfillment of a safety function needed to mitigate the consequences of an accident.
"An evaluation of the flaw on the piping connected to the Unit 2 Division 3 Diesel Generator (DG) Cooling Water strainer concluded that the system would have remained operable. The High Pressure Core Spray system, supported by the operable DG Cooling Water system, remained operable and capable of performing its safety function.
"The NRC Resident Inspector has been notified."
Notified R3DO (Stone).
Agreement State
Event Number: 54694
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT ATHENS REGIONAL MEDICAL CENTER
Region: 1
City: ATHENS State: GA
County:
License #: GA 4-1
Agreement: Y
Docket:
NRC Notified By: GREGORY REESE
HQ OPS Officer: BETHANY CECERE
Licensee: PIEDMONT ATHENS REGIONAL MEDICAL CENTER
Region: 1
City: ATHENS State: GA
County:
License #: GA 4-1
Agreement: Y
Docket:
NRC Notified By: GREGORY REESE
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/05/2020
Notification Time: 13:16 [ET]
Event Date: 05/04/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/05/2020
Notification Time: 13:16 [ET]
Event Date: 05/04/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/05/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following was received via email:
"On 5/4/20, Piedmont Athens Regional Medical Center (GA 4-1) experienced a misadministration of BTG's TheraSphere Y-90 product. The plan of treatment was for [the treating physician] to deliver 120 Gy to the patient's left hepatic lobe with 1.62 GBq (43.78 milliCuries) of Y-90. The treating physician positioned the microcatheter in the left hepatic artery and verified positioning with a left hepatic arteriogram. With the microcatheter in this position, the treating physician began administering the microspheres. However, only a portion of the dose was delivered as the catheter quickly became occluded. Because of the patient's tortuous hepatic vasculature, the assessment is that a kink in the microcatheter prevented the majority of the dose from being delivered.
"The delivered activity was calculated by comparing pre- and post-treatment survey meter measurements of the administration equipment as outlined in TheraSphere's administration procedure. The delivered activity to the patient was 0.28 GBq (7.52 milliCuries). The delivered activity is approximately 83 percent less than the prescribed activity. Post treatment surveys of all gowns, syringes, gloves, drapes, floor coverings, and trash revealed no contamination of the surgical suite. Post treatment planar imaging revealed no extrahepatic deposition of activity. The treating physician explained our inability to deliver the full dose with the patient and a plan was made for the patient to return on 6/5/20 for a second attempt at treating the left hepatic lobe."
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:
"On 5/4/20, Piedmont Athens Regional Medical Center (GA 4-1) experienced a misadministration of BTG's TheraSphere Y-90 product. The plan of treatment was for [the treating physician] to deliver 120 Gy to the patient's left hepatic lobe with 1.62 GBq (43.78 milliCuries) of Y-90. The treating physician positioned the microcatheter in the left hepatic artery and verified positioning with a left hepatic arteriogram. With the microcatheter in this position, the treating physician began administering the microspheres. However, only a portion of the dose was delivered as the catheter quickly became occluded. Because of the patient's tortuous hepatic vasculature, the assessment is that a kink in the microcatheter prevented the majority of the dose from being delivered.
"The delivered activity was calculated by comparing pre- and post-treatment survey meter measurements of the administration equipment as outlined in TheraSphere's administration procedure. The delivered activity to the patient was 0.28 GBq (7.52 milliCuries). The delivered activity is approximately 83 percent less than the prescribed activity. Post treatment surveys of all gowns, syringes, gloves, drapes, floor coverings, and trash revealed no contamination of the surgical suite. Post treatment planar imaging revealed no extrahepatic deposition of activity. The treating physician explained our inability to deliver the full dose with the patient and a plan was made for the patient to return on 6/5/20 for a second attempt at treating the left hepatic lobe."
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.