Event Notification Report for November 17, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/16/2022 - 11/17/2022
Hospital
Event Number: 56227
Rep Org: Defense Health Agency (DHA)
Licensee: Defense Health Agency (DHA)
Region: 1
City: Falls Church State: VA
County:
License #: 45-35423-01
Agreement: Y
Docket:
NRC Notified By: Ricardo Reyes
HQ OPS Officer: Brian P. Smith
Licensee: Defense Health Agency (DHA)
Region: 1
City: Falls Church State: VA
County:
License #: 45-35423-01
Agreement: Y
Docket:
NRC Notified By: Ricardo Reyes
HQ OPS Officer: Brian P. Smith
Notification Date: 11/17/2022
Notification Time: 16:30 [ET]
Event Date: 11/17/2022
Event Time: 13:00 [EST]
Last Update Date: 12/02/2022
Notification Time: 16:30 [ET]
Event Date: 11/17/2022
Event Time: 13:00 [EST]
Last Update Date: 12/02/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 12/5/2022
EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE
The following information was provided by the licensee via email:
"During an SIR [Selective Internal Radiation] Spheres treatment on November 17, 2022, a patient was to receive 10.8 milliCuries of Y-90 [Yttrium-90]. A measurement of the residue radiological waste from the procedure indicated that the patient only received 38 percent of the intended dose or 4.33 milliCuries. The total dose delivered differs from the prescribed dose by 20 percent or more.
"The doctor drew up a dose of 11.4 milliCuries for the procedure. Static readings on the vial averaged 0.205 mR/hr. Post procedure readings averaged 0.127 mR/hr. These readings resulted in the fraction delivered of 38 percent or a total of 4.33 milliCuries. Corrective action is pending."
* * * UPDATE ON 12/2/2022 AT 1257 EST FROM THE DEFENSE HEALTH AGENCY TO BILL GOTT * * *
"Following administration of Y-90 Sir Spheres on November 17, 2022, the treatment team determined that the faction of the assayed dose delivered to the patient was only 38 percent. The remaining 62 percent of the assayed dose of 11.4 mCi remained within the delivery system. This represents a delivery of 40 percent of the prescribed dose of 10.8 mCi. The microcatheter used was size 2.4F, which was appropriate for the clinical situation. The vascular access to the treatment location was unusually torturous. Two representatives from Sirtex advised during the procedure, rotating out part way through the procedure so one was present at all times, with no noted deviations from the recommended protocols.
"The event likely occurred due to microsphere blockage in the microcatheter, resulting from a torturous path to the delivery point required by the patient's vascular anatomy. Sirtex indicated that the spheres must have attached to the catheter walls due to a torturous path (excessive bends in the line)."
Notified R1DO (Cahill) and NMSS Events Notification via email.
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: MEDICAL EVENT - PATIENT UNDERDOSE
The following information was provided by the licensee via email:
"During an SIR [Selective Internal Radiation] Spheres treatment on November 17, 2022, a patient was to receive 10.8 milliCuries of Y-90 [Yttrium-90]. A measurement of the residue radiological waste from the procedure indicated that the patient only received 38 percent of the intended dose or 4.33 milliCuries. The total dose delivered differs from the prescribed dose by 20 percent or more.
"The doctor drew up a dose of 11.4 milliCuries for the procedure. Static readings on the vial averaged 0.205 mR/hr. Post procedure readings averaged 0.127 mR/hr. These readings resulted in the fraction delivered of 38 percent or a total of 4.33 milliCuries. Corrective action is pending."
* * * UPDATE ON 12/2/2022 AT 1257 EST FROM THE DEFENSE HEALTH AGENCY TO BILL GOTT * * *
"Following administration of Y-90 Sir Spheres on November 17, 2022, the treatment team determined that the faction of the assayed dose delivered to the patient was only 38 percent. The remaining 62 percent of the assayed dose of 11.4 mCi remained within the delivery system. This represents a delivery of 40 percent of the prescribed dose of 10.8 mCi. The microcatheter used was size 2.4F, which was appropriate for the clinical situation. The vascular access to the treatment location was unusually torturous. Two representatives from Sirtex advised during the procedure, rotating out part way through the procedure so one was present at all times, with no noted deviations from the recommended protocols.
"The event likely occurred due to microsphere blockage in the microcatheter, resulting from a torturous path to the delivery point required by the patient's vascular anatomy. Sirtex indicated that the spheres must have attached to the catheter walls due to a torturous path (excessive bends in the line)."
Notified R1DO (Cahill) and NMSS Events Notification via email.
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: 56231
Facility: Vogtle
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Taylor Joseph
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Taylor Joseph
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/17/2022
Notification Time: 20:23 [ET]
Event Date: 11/17/2022
Event Time: 10:09 [EST]
Last Update Date: 11/17/2022
Notification Time: 20:23 [ET]
Event Date: 11/17/2022
Event Time: 10:09 [EST]
Last Update Date: 11/17/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Miller, Mark (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
| 4 | N | N | 0 | Defueled | 0 | Defueled |
FITNESS FOR DUTY REPORT
A contract supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
A contract supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Fuel Cycle Facility
Event Number: 56232
Facility: Westinghouse Electric Corporation
Region: 2 State: SC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion (Uf6 To Uo2)
Commercial Lwr Fuel
NRC Notified By: Patrick Donnelly
HQ OPS Officer: Brian Lin
Region: 2 State: SC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion (Uf6 To Uo2)
Commercial Lwr Fuel
NRC Notified By: Patrick Donnelly
HQ OPS Officer: Brian Lin
Notification Date: 11/18/2022
Notification Time: 10:35 [ET]
Event Date: 11/17/2022
Event Time: 11:50 [EST]
Last Update Date: 11/18/2022
Notification Time: 10:35 [ET]
Event Date: 11/17/2022
Event Time: 11:50 [EST]
Last Update Date: 11/18/2022
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
OFFSITE NOTIFICATION DUE TO INJURED EMPLOYEE BEING ADMITTED TO HOSPITAL
The following information was provided by the licensee via email:
"SCOSHA [South Carolina Occupational Safety and Health Administration] was called due to CFFF [Columbia Fuel Fabrication Facility] an employee breaking their left ankle while descending stairs in the administration building. The employee was admitted to the hospital overnight and surgery was performed the morning of 11/18/2022.
"An in-patient hospitalization is required to be reported within 24 hours to SCOSHA. The event was reported on 11/18/2022 at 0838 EST through the online portal (SCOSHA-AR-2022-11-18-16433)."
The following information was provided by the licensee via email:
"SCOSHA [South Carolina Occupational Safety and Health Administration] was called due to CFFF [Columbia Fuel Fabrication Facility] an employee breaking their left ankle while descending stairs in the administration building. The employee was admitted to the hospital overnight and surgery was performed the morning of 11/18/2022.
"An in-patient hospitalization is required to be reported within 24 hours to SCOSHA. The event was reported on 11/18/2022 at 0838 EST through the online portal (SCOSHA-AR-2022-11-18-16433)."