Event Notification Report for August 11, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/10/2021 - 08/11/2021
Agreement State
Event Number: 55393
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Loyola University Medical Center
Region: 3
City: Maywood State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Bethany Cecere
Licensee: Loyola University Medical Center
Region: 3
City: Maywood State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Bethany Cecere
Notification Date: 08/03/2021
Notification Time: 09:12 [ET]
Event Date: 08/02/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/03/2021
Notification Time: 09:12 [ET]
Event Date: 08/02/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/03/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAK, LAURA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAK, LAURA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/11/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EXCEEDING 20 PERCENT
The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:
"Loyola University Medical Center (IL-01131-02), contacted the Agency on August 3, 2021, to advise that an administration of Y-90 resulted in an underdose exceeding 20 percent. The incident occurred yesterday, August 2, 2021. No untoward medical impact was expected to the patient.
"The licensee's Radiation Safety Officer contacted [the Agency] to advise that a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 71 percent of the dose prescribed in the written directive. The licensee's Radiation Safety Officer is reviewing the device today as well as the specifics of the administration to determine root cause. The licensee suspects a problem with a connector but is currently investigating. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. Agency inspectors will perform a reactionary inspection, tentatively within a week, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."
Illinois NMED report number: IL210023
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 - MEDICAL UNDERDOSE EXCEEDING 20 PERCENT
The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:
"Loyola University Medical Center (IL-01131-02), contacted the Agency on August 3, 2021, to advise that an administration of Y-90 resulted in an underdose exceeding 20 percent. The incident occurred yesterday, August 2, 2021. No untoward medical impact was expected to the patient.
"The licensee's Radiation Safety Officer contacted [the Agency] to advise that a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 71 percent of the dose prescribed in the written directive. The licensee's Radiation Safety Officer is reviewing the device today as well as the specifics of the administration to determine root cause. The licensee suspects a problem with a connector but is currently investigating. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. Agency inspectors will perform a reactionary inspection, tentatively within a week, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."
Illinois NMED report number: IL210023
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: 55397
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Total Petrochemicals & Refining USA, Inc.
Region: 4
City: Port Arthur State: TX
County:
License #: L 03498
Agreement: Y
Docket:
NRC Notified By: Matt Kennington
HQ OPS Officer: Thomas Kendzia
Licensee: Total Petrochemicals & Refining USA, Inc.
Region: 4
City: Port Arthur State: TX
County:
License #: L 03498
Agreement: Y
Docket:
NRC Notified By: Matt Kennington
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/05/2021
Notification Time: 11:39 [ET]
Event Date: 08/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/05/2021
Notification Time: 11:39 [ET]
Event Date: 08/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GEPFORD, HEATHER (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
GEPFORD, HEATHER (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/12/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Texas Department of State Health Services (Agency) via email:
"On August 4, 2021, a consultant for the licensee reported to the Agency a stuck shutter on a VEGA SHLG-2 fixed gauge with a 5 Ci Cs-137 source. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located at the top of a ladder and does not pose an increased risk of exposure due to the malfunction. The licensee has contacted the manufacturer for repair."
Texas incident number: I-9872
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Texas Department of State Health Services (Agency) via email:
"On August 4, 2021, a consultant for the licensee reported to the Agency a stuck shutter on a VEGA SHLG-2 fixed gauge with a 5 Ci Cs-137 source. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located at the top of a ladder and does not pose an increased risk of exposure due to the malfunction. The licensee has contacted the manufacturer for repair."
Texas incident number: I-9872
Power Reactor
Event Number: 55403
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Levi Smith
HQ OPS Officer: Lloyd Desotell
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Levi Smith
HQ OPS Officer: Lloyd Desotell
Notification Date: 08/11/2021
Notification Time: 11:32 [ET]
Event Date: 08/11/2021
Event Time: 06:34 [EDT]
Last Update Date: 08/11/2021
Notification Time: 11:32 [ET]
Event Date: 08/11/2021
Event Time: 06:34 [EDT]
Last Update Date: 08/11/2021
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):
SKOKOWSKI, RICHARD (R3)
SKOKOWSKI, RICHARD (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
HPCI INOPERABILITY
"At 0634 EDT on August 11, 2021 [high pressure coolant injection] HPCI was declared inoperable due to a pump flow controller problem. The cause of the controller problem is unknown at this time and is under investigation.
"[Reactor core isolation cooling] RCIC was verified operable per Tech Spec 3.5.1 E.1.
"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
"At 0634 EDT on August 11, 2021 [high pressure coolant injection] HPCI was declared inoperable due to a pump flow controller problem. The cause of the controller problem is unknown at this time and is under investigation.
"[Reactor core isolation cooling] RCIC was verified operable per Tech Spec 3.5.1 E.1.
"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."