Event Notification Report for March 12, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/11/2021 - 03/12/2021
Agreement State
Event Number: 55139
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: University of Pittsburgh
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Lloyd Desotell
Licensee: University of Pittsburgh
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/15/2021
Notification Time: 10:48 [ET]
Event Date: 03/12/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Notification Time: 10:48 [ET]
Event Date: 03/12/2021
Event Time: 00:00 [EST]
Last Update Date: 03/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE
The following was received via an email from the state of Pennsylvania:
"The Department [PA Bureau of Radiation Protection] received notification from a licensee on March 12, 2021 of medical event involving yttrium-90 TheraSphere [TM]. The licensee believes a patient received only 2 milliCurie of the 63.7 milliCurie prescribed dose. The connection piece between the Therasphere [TM] apparatus and the patient catheter failed when the injection started. All contamination was contained with absorbent pads that were located below the connection. The room, staff and patient were extensively surveyed and not found to be contaminated. The patient and the prescribing physician have been informed. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report ID No: PA210002
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.
EN Revision Text: AGREEMENT STATE REPORT - DOSE RECEIVED WAS LESS THAN PRESCRIBED DOSE
The following was received via an email from the state of Pennsylvania:
"The Department [PA Bureau of Radiation Protection] received notification from a licensee on March 12, 2021 of medical event involving yttrium-90 TheraSphere [TM]. The licensee believes a patient received only 2 milliCurie of the 63.7 milliCurie prescribed dose. The connection piece between the Therasphere [TM] apparatus and the patient catheter failed when the injection started. All contamination was contained with absorbent pads that were located below the connection. The room, staff and patient were extensively surveyed and not found to be contaminated. The patient and the prescribing physician have been informed. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report ID No: PA210002
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: 55136
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: University of Florida
Region: 1
City: Jacksonville State: FL
County:
License #: 0031-3
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Kerby Scales
Licensee: University of Florida
Region: 1
City: Jacksonville State: FL
County:
License #: 0031-3
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Kerby Scales
Notification Date: 03/12/2021
Notification Time: 16:49 [ET]
Event Date: 03/12/2021
Event Time: 09:48 [EST]
Last Update Date: 03/12/2021
Notification Time: 16:49 [ET]
Event Date: 03/12/2021
Event Time: 09:48 [EST]
Last Update Date: 03/12/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/12/2021
EN Revision Text: AGREEMENT STATE REPORT - PRESCRIBED UNDERDOSE
The following is a summary of an email from the state of Florida:
At 1600 [EST], the [Radiation Safety Officer] RSO called to report a radiation underdose. Following the procedure, the waste was collected and measured to calculate the actual activity delivered. The actual activity delivered was 0.76 GBq, 90 percent of the prescribed treatment dose. Post procedure, during the room survey, inside the Plexiglas Administration Box a high level of activity was detected. The box was placed in double bags and relocated to the waste storage area. An investigation into the event is ongoing to calculate the activity in the box following administration. No individuals were contaminated and there was no harm to the patient.
Florida Incident Number: FL21-038
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.
EN Revision Text: AGREEMENT STATE REPORT - PRESCRIBED UNDERDOSE
The following is a summary of an email from the state of Florida:
At 1600 [EST], the [Radiation Safety Officer] RSO called to report a radiation underdose. Following the procedure, the waste was collected and measured to calculate the actual activity delivered. The actual activity delivered was 0.76 GBq, 90 percent of the prescribed treatment dose. Post procedure, during the room survey, inside the Plexiglas Administration Box a high level of activity was detected. The box was placed in double bags and relocated to the waste storage area. An investigation into the event is ongoing to calculate the activity in the box following administration. No individuals were contaminated and there was no harm to the patient.
Florida Incident Number: FL21-038
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: 55137
Facility: Nine Mile Point
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Tyler Vincent
HQ OPS Officer: Joanna Bridge
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Tyler Vincent
HQ OPS Officer: Joanna Bridge
Notification Date: 03/13/2021
Notification Time: 01:11 [ET]
Event Date: 03/12/2021
Event Time: 21:02 [EST]
Last Update Date: 03/13/2021
Notification Time: 01:11 [ET]
Event Date: 03/12/2021
Event Time: 21:02 [EST]
Last Update Date: 03/13/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(A) - Pot Unable To Safe Sd
10 CFR Section:
50.72(b)(3)(v)(A) - Pot Unable To Safe Sd
Person (Organization):
GRAY, MEL (R1)
GRAY, MEL (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 98 | Power Operation | 93 | Power Operation |
EN Revision Imported Date: 4/12/2021
EN Revision Text: REACTOR RECIRCULATION PUMP TRIP
"On March 12, 2021, at 2102 (EST), Reactor Recirculation Pump (RRP) 13 tripped. The cause for the trip is under investigation.
"Following the RRP trip, the Average Power Ranger Monitors (APRMs) flow bias trips are inoperable due to reverse flow through RRP 13. The APRMs were restored to operable on March 12, 2021, at 2110 [EST] when the RRP 13 Discharge Blocking Valve was closed.
"This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(b)(3)(v)(A) which states: 'Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition.'
"The licensee has notified the NRC Resident Inspector."
EN Revision Text: REACTOR RECIRCULATION PUMP TRIP
"On March 12, 2021, at 2102 (EST), Reactor Recirculation Pump (RRP) 13 tripped. The cause for the trip is under investigation.
"Following the RRP trip, the Average Power Ranger Monitors (APRMs) flow bias trips are inoperable due to reverse flow through RRP 13. The APRMs were restored to operable on March 12, 2021, at 2110 [EST] when the RRP 13 Discharge Blocking Valve was closed.
"This 8-hour non-emergency report is being made based upon requirements of 10 CFR 50.72(b)(3)(v)(A) which states: 'Licensee shall notify the NRC of any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition.'
"The licensee has notified the NRC Resident Inspector."