Event Notification Report for April 06, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/05/2022 - 04/06/2022
Agreement State
Event Number: 55830
Rep Org: California Radiation Control Prgm
Licensee: Loma Linda University Health
Region: 4
City: San Bernardino State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Thomas Herrity
Licensee: Loma Linda University Health
Region: 4
City: San Bernardino State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 21:09 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/08/2022
Notification Time: 21:09 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE TO PATIENT
The following was received from the State of California, Department of Public Health (RHB), via email:
"On April 6, 2022, Loma Linda University Health's (LLUH) Radiation Safety Officer was notified by a medical authorized user that a reportable medical event had occurred during a Y-90 Therasphere patient brachytherapy treatment on April 5, 2022.
"There were two patients scheduled for brachytherapy on the same day. Patient 1 had two tailored dose vials of Y-90 and Patient 2 had three tailored dose vials of Y-90 stored in the hot lab. A certified nuclear medical technologist mistakenly selected one of Patient 2's vials for Patient 1's treatment. The selected vial contained 4.0 GBq (108 milliCuries) with calibration date April 3, 2022 at 1200 PDT. It contained approximately 58.6 milliCuries at the time of administration.
"The two vials were taken to the therapy suite, where they were approved and used by the authorized user. The authorized user's written directive for Patient 1's liver segments 2 and 3 was to deliver a dose of 120 Gy. However, the mistake resulted in a dose of 750 Gy to the two liver segments. If the proper vial had been selected, the administered activity would have been 9.6 milliCuries.
"The error also resulted in the cancellation of Patient 2's treatment, as the Y-90 dose was no longer available. LLUH will be submitting a 15-day report to RHB. Abnormal Occurrence criteria for Medical Event's: Unplanned dose greater than or equal to 1000 rad to any other organ AND dose is greater than 150 percent of the prescribed dose."
California Event Number: 040622
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 - OVERDOSE TO PATIENT
The following was received from the State of California, Department of Public Health (RHB), via email:
"On April 6, 2022, Loma Linda University Health's (LLUH) Radiation Safety Officer was notified by a medical authorized user that a reportable medical event had occurred during a Y-90 Therasphere patient brachytherapy treatment on April 5, 2022.
"There were two patients scheduled for brachytherapy on the same day. Patient 1 had two tailored dose vials of Y-90 and Patient 2 had three tailored dose vials of Y-90 stored in the hot lab. A certified nuclear medical technologist mistakenly selected one of Patient 2's vials for Patient 1's treatment. The selected vial contained 4.0 GBq (108 milliCuries) with calibration date April 3, 2022 at 1200 PDT. It contained approximately 58.6 milliCuries at the time of administration.
"The two vials were taken to the therapy suite, where they were approved and used by the authorized user. The authorized user's written directive for Patient 1's liver segments 2 and 3 was to deliver a dose of 120 Gy. However, the mistake resulted in a dose of 750 Gy to the two liver segments. If the proper vial had been selected, the administered activity would have been 9.6 milliCuries.
"The error also resulted in the cancellation of Patient 2's treatment, as the Y-90 dose was no longer available. LLUH will be submitting a 15-day report to RHB. Abnormal Occurrence criteria for Medical Event's: Unplanned dose greater than or equal to 1000 rad to any other organ AND dose is greater than 150 percent of the prescribed dose."
California Event Number: 040622
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.
Part 21
Event Number: 55836
Rep Org: Westinghouse Electric Company
Licensee: Westinghouse Electric Company
Region: 1
City: Cranberry Township State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Camille Zozula
HQ OPS Officer: Mike Stafford
Licensee: Westinghouse Electric Company
Region: 1
City: Cranberry Township State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Camille Zozula
HQ OPS Officer: Mike Stafford
Notification Date: 04/11/2022
Notification Time: 21:01 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Notification Time: 21:01 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Cahill, Christopher (R1DO)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Cahill, Christopher (R1DO)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: PART 21 - WESTINGHOUSE ACTUATOR FULL VOLTAGE REVERSING CONTACTORS DEFICENCY REPORT
The following information was provided by the licensee via email:
"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard.
"Name and address of the individual informing the Commission:
Camille T. Zozula
Westinghouse Electric Company
1000 Westinghouse Drive
Cranberry Township, Pennsylvania 16066
(412) 374-2577
zozulact@westinghouse.com
"Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018.
"The [FVRs] are designed and qualified to open and close on demand. The FVR contactors sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position.
"Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related FVR contactors that are potentially affected between 2014 and 2022.
"Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022.
"Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding.
"Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available.
"Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts.
"Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022.
"The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event.
"Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."
EN Revision Text: PART 21 - WESTINGHOUSE ACTUATOR FULL VOLTAGE REVERSING CONTACTORS DEFICENCY REPORT
The following information was provided by the licensee via email:
"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard.
"Name and address of the individual informing the Commission:
Camille T. Zozula
Westinghouse Electric Company
1000 Westinghouse Drive
Cranberry Township, Pennsylvania 16066
(412) 374-2577
zozulact@westinghouse.com
"Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018.
"The [FVRs] are designed and qualified to open and close on demand. The FVR contactors sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position.
"Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related FVR contactors that are potentially affected between 2014 and 2022.
"Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022.
"Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding.
"Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available.
"Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts.
"Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022.
"The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event.
"Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."
Agreement State
Event Number: 55824
Rep Org: WA Office of Radiation Protection
Licensee: Nelson Geotechnical Asso
Region: 4
City: Trinidad State: WA
County:
License #: WN-I0421-1
Agreement: Y
Docket:
NRC Notified By: RAJ MAHARJAN
HQ OPS Officer: Lloyd Desotell
Licensee: Nelson Geotechnical Asso
Region: 4
City: Trinidad State: WA
County:
License #: WN-I0421-1
Agreement: Y
Docket:
NRC Notified By: RAJ MAHARJAN
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/07/2022
Notification Time: 12:31 [ET]
Event Date: 04/06/2022
Event Time: 09:00 [PDT]
Last Update Date: 04/07/2022
Notification Time: 12:31 [ET]
Event Date: 04/06/2022
Event Time: 09:00 [PDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:
"Washington State received a report of a portable gauge incident on 4/6/2022. The incident took place on the same day around 0900 PDT at Trinidad, WA. A Troxler 3440 portable gauge [containing 9 mCi Cs-137 and 44 mCi Am/Be-241 sources] was run over by a bulldozer at a construction site. The gauge was damaged. No over exposure or contamination [occurred]. The sources appear to be intact pending further report. Washington State will provide a detailed report once available within the required time frame."
Washington State Incident Number: WA-22-009.
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:
"Washington State received a report of a portable gauge incident on 4/6/2022. The incident took place on the same day around 0900 PDT at Trinidad, WA. A Troxler 3440 portable gauge [containing 9 mCi Cs-137 and 44 mCi Am/Be-241 sources] was run over by a bulldozer at a construction site. The gauge was damaged. No over exposure or contamination [occurred]. The sources appear to be intact pending further report. Washington State will provide a detailed report once available within the required time frame."
Washington State Incident Number: WA-22-009.
Agreement State
Event Number: 55825
Rep Org: New Mexico Rad Control Program
Licensee: Freeport-McMorin - Chino Mine
Region: 4
City: Vanadium State: NM
County:
License #: GA045-46
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Thomas Herrity
Licensee: Freeport-McMorin - Chino Mine
Region: 4
City: Vanadium State: NM
County:
License #: GA045-46
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 12:03 [ET]
Event Date: 04/06/2022
Event Time: 14:52 [MDT]
Last Update Date: 04/07/2022
Notification Time: 12:03 [ET]
Event Date: 04/06/2022
Event Time: 14:52 [MDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS
The following is a synopsis of a report received from the state of New Mexico via phone call:
The Chino Mine in Vanadium, NM has two Berthold model LB7440 gauge devices malfunctioning. Unit Serial Number 3175, with a 250 milliCi Cs-137 source, has a broken latch and cannot be held in the closed position. Unit Serial Number DZ256A, 150 milliCi Cs-137 source, is stuck in the open position. Open is the normal operating position for both units and the units will remain in service until the service contractor arrives in May 2022. Both units have been roped off to prevent personnel from exposure.
NM item number: N/A
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS
The following is a synopsis of a report received from the state of New Mexico via phone call:
The Chino Mine in Vanadium, NM has two Berthold model LB7440 gauge devices malfunctioning. Unit Serial Number 3175, with a 250 milliCi Cs-137 source, has a broken latch and cannot be held in the closed position. Unit Serial Number DZ256A, 150 milliCi Cs-137 source, is stuck in the open position. Open is the normal operating position for both units and the units will remain in service until the service contractor arrives in May 2022. Both units have been roped off to prevent personnel from exposure.
NM item number: N/A