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Event Notification Report for July 03, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/2/2020 - 7/3/2020

** EVENT NUMBERS **


54755 54757 54761

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Agreement State Event Number: 54755
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Texas Oncology PA
Region: 4
City: Harlingen   State: TX
County:
License #: L 00154
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian Lin
Notification Date: 06/24/2020
Notification Time: 08:00 [ET]
Event Date: 06/23/2020
Event Time: 09:00 [CDT]
Last Update Date: 06/30/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - HIGH DOSE RATE TANDEM APPLICATOR BROKEN DURING TREATMENT

The following was received via E-mail from the State of Texas:

"On June 23, 2020, the licensee reported that at approximately 0900 CDT, a Medical Event occurred at its facility. The event involved a patient receiving an High Dose Rate (HDR) cervix treatment with a Nucletron Model microSelectron using a tandem and ring. The device contained a 5.191Curie Iridium-192 source. After the treatment was completed and the device was removed, it was discovered the tandem had broken into two pieces. The licensee stated it is unknown where the source was positioned during the treatment. The licensee reported no warnings or errors from the machine were recorded from either the check source or the treatment cable. The licensee stated the source was in the patient for a total of 564.7 seconds. The source was in the tandem a total of 355.2 seconds of that total time. The licensee stated the physician has been notified, but was not sure if the patient had been notified. The licensee stated they were still investigating what occurred and will provide more specific information as it is discovered. Additional information will be provided as it is received in accordance with SA300."

Texas Incident No.: 9774


* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 0902 EDT ON 6/30/2020 * * *

"The break in the tandem occurred about four inches from the end of the tandem. A picture provided by the licensee shows the break at the beginning of the bend in the tandem on the insertion end at the start of the ring. The licensee stated using the location of the guide wire, which they could track, it now appears that the source tracked next to the tandem and that the exposure occurred only to the intended tissue. The manufacture is investigating the event with the licensee. Additional information will be provided as it is received in accordance with SA300."

Notified R4DO (Silva) and NMSS Events Notification E-mail group.

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Agreement State Event Number: 54757
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: University of Oklahoma Health Science Center
Region: 4
City: Oklahoma City   State: OK
County:
License #: OK-03176-01
Agreement: Y
Docket:
NRC Notified By: Kevin Sampson
HQ OPS Officer: Bethany Cecere
Notification Date: 06/24/2020
Notification Time: 16:31 [ET]
Event Date: 06/23/2020
Event Time: 00:00 [CDT]
Last Update Date: 06/24/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SUSPECTED DOSE TO WRONG ORGAN

The following is a summary of email received from the Oklahoma Department of Environmental Quality (OK DEQ):

OK DEQ was just informed that yesterday, June 23, 2020, a medical event may have occurred involving a patient undergoing radiation therapy to the vagina. The treatment plan called for three (3) fractions delivered by a High Dose Rate (HDR) afterloader. After the first fraction was administered, the therapist noted the presence of fecal matter on the applicator. The licensee is assuming that the applicator was placed in the patient's rectum instead of the vagina. The treatment plan estimated a dose of 0.85 Sv to the rectum due to the procedure. The licensee estimates the actual dose delivered, assuming the applicator was in the rectum, to be 1.5 Sv. The licensee is the University of Oklahoma Health Science Center, OK-03176-01. This is a Type A medical broadscope license. OK DEQ will provide more information as it becomes available.


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.

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Power Reactor Event Number: 54761
Facility: Fermi
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Jeffrey Myers
HQ OPS Officer: Kerby Scales
Notification Date: 07/02/2020
Notification Time: 02:01 [ET]
Event Date: 07/01/2020
Event Time: 23:05 [EDT]
Last Update Date: 07/02/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
PATRICIA PELKE (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

LOSS OF OFFSITE POWER - AUTO INITIATION OF EMERGENCY DIESEL GENERATOR

"At 2305 EDT on July 1, 2020, while in Mode 5 for Refueling Outage 20 with no core alterations in progress, Fermi 2 experienced a loss of Division 2 offsite power (345 kV) which resulted in a valid automatic initiation of the Division 2 Emergency Diesel Generators (EDG) 13 and 14. EDG 13 and 14 started as expected to supply their associated busses. Division 1 offsite power remains operable and powering the Division 1 Residual Heat Removal (RHR) system in Shutdown Cooling (SDC) mode of operation. Division 1 EDGs 11 and 12 remain operable and available.

"The cause of the loss of Division 2 offsite power is under review and has preliminarily been determined to be caused by Mayfly accumulation in and around the Division 2 (345 kV) switchyard. Actions have been put in place to minimize and deter Mayflies from gathering near plant switchyards.

"All systems responded as expected for the loss of Division 2 offsite power and no loss of SDC occurred. There was no impact to the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified.

"The event is reportable pursuant to 10 CFR 50.72(b)(3)(iv)(A), as a valid specified system actuation."


Page Last Reviewed/Updated Friday, July 03, 2020
Friday, July 03, 2020