Event Notification Report for January 30, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/27/2023 - 01/30/2023
Part 21
Event Number: 56252
Rep Org: Flowserve
Licensee:
Region: 2
City: Lynchburg State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Chris Shaffer
HQ OPS Officer: Ernest West
Notification Date: 12/01/2022
Notification Time: 14:45 [ET]
Event Date: 10/05/2022
Event Time: 00:00 [EST]
Last Update Date: 01/27/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Part 21/50.55 Reactors, - (EMAIL)
Vossmar, Patricia (R4DO)
Event Text
EN Revision Imported Date: 1/30/2023
EN Revision Text: PART 21 - DEVIATION TO QUALIFIED DESIGN
The following is a summary of information provided by Flowserve - Limitorque via email:
Entergy Waterford 3 informed Flowserve - Limitorque on 10/5/2022 that it discovered that a Peerless 125 volt, 25ft-lb, 56 frame direct current (DC) motor had two fasteners securing the brush holder ring assembly to the motor frame. However, the DC motor assembly used in the qualification test program was assembled with 4 fasteners. Therefore, the use of two fasteners is a deviation to the qualified design. Flowserve is submitting this report as an interim report and is evaluating this deviation to determine whether this condition could potentially affect the safety related function of DC powered Limitorque actuators.
Flowserve is continuing to work with the motor original equipment manufacturer (OEM) to refine the scope of potentially affected motors. Limitorque actuators equipped with Peerless - Winsmith DC electric motors with start torque ratings of 40 ft-lb and larger are not affected by this issue. Limitorque actuators equipped with alternating current (AC) powered electric motors are not affected by this issue.
The evaluation is expected to be completed by 01/27/2023. If there are questions, or addition information is required, please contact Chris Shaffer, Quality Assurance Manager, Flowserve Corporation, Ph: (434) 522-4136.
Known affected plant: Waterford 3 Nuclear Generating Station
* * * UPDATE ON 01/27/2023 AT 1011 EST FROM FLOWSERVE TO JOHN RUSSELL* * *
Flowserve provided an update to notify that the final evaluation of the safety consequence and reportability, primarily involving seismic qualification, will be delayed until 02/24/2023.
Notified R4DO (Agrawal) via phone and the Part 21 group via email.
Hospital
Event Number: 56318
Rep Org: Hartford Hospital
Licensee: Hartford Hospital
Region: 1
City: Hartford State: CT
County:
License #: 06-00253-04
Agreement: N
Docket:
NRC Notified By: Sandra Phillips
HQ OPS Officer: Kerby Scales
Notification Date: 01/20/2023
Notification Time: 09:18 [ET]
Event Date: 01/19/2023
Event Time: 10:00 [EST]
Last Update Date: 01/20/2023
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
POTENTIAL MEDICAL EVENT
The following is a summary of information provided by the licensee via email and phone:
A patient, accompanied by her daughter who is the patient's preferred translator, was receiving the first of four Lutathera infusions. The physician, registered nurse, nuclear medicine personnel and radiological safety team members were present for the infusion. The Lutathera infusion was performed per protocol without any issue. Post infusion it was determined through the patient's daughter that the patient had had a lanreotide injection last week on 1/12/23. Per protocol Lutathera is to be given four weeks after a lanreotide/octreotide injection has been administered.
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: 56319
Rep Org: PA Bureau of Radiation Protection
Licensee: Geisinger Health System
Region: 1
City: Danville State: PA
County:
License #: PA-0006
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Ian Howard
Notification Date: 01/20/2023
Notification Time: 15:46 [ET]
Event Date: 01/11/2023
Event Time: 00:00 [EST]
Last Update Date: 01/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department) via email:
"On January 20, 2023 the licensee informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable per 10 CFR 35.3045(a)(1).
"On January 11, 2023 an Authorized User (AU) in Interventional Radiology was attempting to treat a patient with 45.4 mCi of yttrium-90 TheraSphere. The AU could not get the spheres to infuse. After consultation with the manufacturer (Boston Scientific), they decided on aborting the procedure. It was determined the patient received zero activity and all the radioactivity from the spheres remained inside the treatment vial. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Event Report ID No: PA230005
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: 56320
Rep Org: Arizona Dept of Health Services
Licensee: Patient Care Infusion
Region: 4
City: Tempe State: AZ
County:
License #: 07-572
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Adam Koziol
Notification Date: 01/21/2023
Notification Time: 10:08 [ET]
Event Date: 01/21/2023
Event Time: 00:00 [MST]
Last Update Date: 01/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - OVEREXPOSURE
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee that an employee has received a total extremity dose of around 51,000 mRem for 2022. The Department has requested additional information and continues to investigate the event."