Event Notification Report for August 30, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/29/2023 - 08/30/2023
Agreement State
Event Number: 56703
Rep Org: Kentucky Dept of Radiation Control
Licensee: Univ of Kentucky Broadscope Medical
Region: 1
City: Lexington State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Karen Cotton-Gross
Licensee: Univ of Kentucky Broadscope Medical
Region: 1
City: Lexington State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/31/2023
Notification Time: 08:22 [ET]
Event Date: 08/30/2023
Event Time: 10:00 [CDT]
Last Update Date: 01/02/2024
Notification Time: 08:22 [ET]
Event Date: 08/30/2023
Event Time: 10:00 [CDT]
Last Update Date: 01/02/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 1/3/2024
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on 8/30/2023, at 1700 CDT, by a representative from University of Kentucky Broadscope Medical, of an underdose of a patient during a lutetium 177 (Lu-177) treatment. The underdosing was due to a leakage in the administration line.
"The underdosing was considered more than 20 percent. There was no harm to the patient. A separate report will be submitted once all the facts are gathered."
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.
* * * UPDATE FROM RUSSELL HESTAND TO BRIAN P. SMITH AT 1229 EST ON JANUARY 2, 2024 * * *
The following summary of information was provided by the Kentucky Department of Public Health and Safety, Radiation Health Branch (KY RHB) via email and phone:
Further pertinent information regarding the medical event on Wednesday, August 30, 2023 at Chandler Hospital was identified per KY RHB's 15 day report. The event involved an administration of 200 mCi of Lutathera (Lu-177) via syringe pump where a leak was identified during the infusion. At approximately 20 minutes into the infusion the patient reported a wet feeling on their hand. The infusion was halted immediately. It was identified that a small volume of radioactive liquid was present on the patient's hand having dripped down onto it. The site of the leak was identified to be the connection between the syringe pump apparatus and the patient. Bedding and materials adjacent to the patient were found to have absorbed the majority of the leaked material, though some had also leaked onto the floor coverings. Spill response procedures were immediately initiated as well as notification to the authorized user (AU). Approximately 1/3 of the prescribed activity remained in the syringe. The AU elected to have a new connection established and administer the remainder to the patient.
The licensee estimated the administered activity based on volume of the drug administered, measurements of the contaminated bedding materials, and patient dose rate measurements post infusion (corrected for BMI). These estimates all suggest that this incident resulted in an underdose of approximately 25 percent to 30 percent due to the lost material from the leak. The skin dose to the patient's hand was estimated to conservatively be less than 10 rem (100 mSv). This is well below the level at which any tissue reaction is expected to occur.
Notified R1DO (Bickett), NMSS (Rivera-Capella), NMSS Events Notification (email)
NMED Event Number: 230360
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on 8/30/2023, at 1700 CDT, by a representative from University of Kentucky Broadscope Medical, of an underdose of a patient during a lutetium 177 (Lu-177) treatment. The underdosing was due to a leakage in the administration line.
"The underdosing was considered more than 20 percent. There was no harm to the patient. A separate report will be submitted once all the facts are gathered."
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.
* * * UPDATE FROM RUSSELL HESTAND TO BRIAN P. SMITH AT 1229 EST ON JANUARY 2, 2024 * * *
The following summary of information was provided by the Kentucky Department of Public Health and Safety, Radiation Health Branch (KY RHB) via email and phone:
Further pertinent information regarding the medical event on Wednesday, August 30, 2023 at Chandler Hospital was identified per KY RHB's 15 day report. The event involved an administration of 200 mCi of Lutathera (Lu-177) via syringe pump where a leak was identified during the infusion. At approximately 20 minutes into the infusion the patient reported a wet feeling on their hand. The infusion was halted immediately. It was identified that a small volume of radioactive liquid was present on the patient's hand having dripped down onto it. The site of the leak was identified to be the connection between the syringe pump apparatus and the patient. Bedding and materials adjacent to the patient were found to have absorbed the majority of the leaked material, though some had also leaked onto the floor coverings. Spill response procedures were immediately initiated as well as notification to the authorized user (AU). Approximately 1/3 of the prescribed activity remained in the syringe. The AU elected to have a new connection established and administer the remainder to the patient.
The licensee estimated the administered activity based on volume of the drug administered, measurements of the contaminated bedding materials, and patient dose rate measurements post infusion (corrected for BMI). These estimates all suggest that this incident resulted in an underdose of approximately 25 percent to 30 percent due to the lost material from the leak. The skin dose to the patient's hand was estimated to conservatively be less than 10 rem (100 mSv). This is well below the level at which any tissue reaction is expected to occur.
Notified R1DO (Bickett), NMSS (Rivera-Capella), NMSS Events Notification (email)
NMED Event Number: 230360
Part 21
Event Number: 56821
Rep Org: Curtiss Wright Flow Control Co.
Licensee:
Region: 4
City: Brea State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Loretta Anaya
HQ OPS Officer: Lawrence Criscione
Licensee:
Region: 4
City: Brea State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Loretta Anaya
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/27/2023
Notification Time: 20:57 [ET]
Event Date: 08/30/2023
Event Time: 00:00 [PDT]
Last Update Date: 12/07/2023
Notification Time: 20:57 [ET]
Event Date: 08/30/2023
Event Time: 00:00 [PDT]
Last Update Date: 12/07/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Deese, Rick (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
Deese, Rick (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 12/8/2023
EN Revision Text: PART 21 - INCONSISTENT POTENTIOMETER RESISTANCE VALUES
The following is a synopsis of information that was provided by Curtiss-Wright via fax:
On August 30, 2023, Enertech (a division of Curtiss-Wright) determined a potential defect for potentiometer part number D2060S based on the inspection of a returned items from Korea Hydro and Electro Power in Korea. A number of returned potentiometers exhibited inconsistent resistance values at certain stroke positions. The potentiometers are used in modulating actuators.
A shorter wiper was used in the manufacture of the potentiometers that introduced the possibility of intermittent separation between the wiper (sliding contact) and the coil at certain stroke positions, resulting in momentary signal interruptions.
The evaluation at Enertech is also ongoing regarding the potential effects of wiper separation on the functionality of the modulating actuator and will not be completed within 60 days. The expected date of completion is December 20, 2023.
South Texas Project Electric Generating Station (Operator: STP Nuclear Operating Company) purchased defective modulating actuators on four occasions.
Questions should be directed to Loretta Anaya, Quality Assurance Manager, Enertech, at 714-982-1856.
Known potentially affected plant(s): South Texas Project
* * * UPDATE ON 12/7 AT 1807 EST FROM SANDRA VALDIVIA TO ERNEST WEST * * *
Enertech has completed their evaluation of the deviation described in their interim report submitted on 27 October, 2023, and concluded that the deviation does not potentially create a substantial safety hazard.
Notified R4DO (Dixon) and Part 21 Group (Email)
EN Revision Text: PART 21 - INCONSISTENT POTENTIOMETER RESISTANCE VALUES
The following is a synopsis of information that was provided by Curtiss-Wright via fax:
On August 30, 2023, Enertech (a division of Curtiss-Wright) determined a potential defect for potentiometer part number D2060S based on the inspection of a returned items from Korea Hydro and Electro Power in Korea. A number of returned potentiometers exhibited inconsistent resistance values at certain stroke positions. The potentiometers are used in modulating actuators.
A shorter wiper was used in the manufacture of the potentiometers that introduced the possibility of intermittent separation between the wiper (sliding contact) and the coil at certain stroke positions, resulting in momentary signal interruptions.
The evaluation at Enertech is also ongoing regarding the potential effects of wiper separation on the functionality of the modulating actuator and will not be completed within 60 days. The expected date of completion is December 20, 2023.
South Texas Project Electric Generating Station (Operator: STP Nuclear Operating Company) purchased defective modulating actuators on four occasions.
Questions should be directed to Loretta Anaya, Quality Assurance Manager, Enertech, at 714-982-1856.
Known potentially affected plant(s): South Texas Project
* * * UPDATE ON 12/7 AT 1807 EST FROM SANDRA VALDIVIA TO ERNEST WEST * * *
Enertech has completed their evaluation of the deviation described in their interim report submitted on 27 October, 2023, and concluded that the deviation does not potentially create a substantial safety hazard.
Notified R4DO (Dixon) and Part 21 Group (Email)
Agreement State
Event Number: 56772
Rep Org: Louisiana DEQ
Licensee: Union Carbide Corp
Region: 4
City: Taft State: LA
County:
License #: LA-2163-L01, Amendment Number 55
Agreement: Y
Docket:
NRC Notified By: Russell Clark
HQ OPS Officer: Thomas Herrity
Licensee: Union Carbide Corp
Region: 4
City: Taft State: LA
County:
License #: LA-2163-L01, Amendment Number 55
Agreement: Y
Docket:
NRC Notified By: Russell Clark
HQ OPS Officer: Thomas Herrity
Notification Date: 10/02/2023
Notification Time: 17:09 [ET]
Event Date: 08/30/2023
Event Time: 09:00 [CDT]
Last Update Date: 10/02/2023
Notification Time: 17:09 [ET]
Event Date: 08/30/2023
Event Time: 09:00 [CDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTER
The following report was received from the Louisiana Department of Environmental Quality (LDEQ) via email:
"On August 30, 2023, at approximately 0900 [CDT], an Ohmart Model SH-F1-0 level/density gauge experienced a shutter malfunction during a routine semiannual shutter test. The gauge was installed on the Reactor 3, West Production vessel within the Poly Process Unit. The gauge possesses a nominal 500 millicurie sealed source of Cs-137. The above gauge was undergoing a routine semiannual shutter test when the malfunction was observed. The gauge sealed source serial number is: 1560CO. The device serial number has not been provided by the licensee. The gauge containing source number 1560CO, is mounted on the Reactor 3, West Production Chamber vessel in the polyethylene unit. On the above date, the Radiation Safety Officer (RSO) for Union Carbide Corporation contacted BBP Sales (BBP), radioactive material license LA-10799-L01. BBP arrived on site on that day to repair the stuck shutter. After several unsuccessful attempts to break the shutter free, the licensee and the BBP service engineer decided the best course of action would be to order a rotor replacement kit and the BBP service engineer should return on site to replace it. BBP is currently awaiting delivery of the new rotor kit.
"On October 2, 2023, at 0824, Union Carbide RSO notified the LDEQ concerning this equipment malfunction. According to RSO, the gauge rotor bracket broke due to corrosion, which prevented the gauge shutter from closing fully. The gauge is under the licensee's control. There were no exposures to members of the public approaching regulatory limits. Currently, the shutter on the gauge remains in the open position as the gauge source is needed to operate process control equipment. The gauge cannot be locked out in its current state. No entry to the vessel will be conducted until the gauge is repaired by BBP. The licensee will continue to monitor the gauge until repaired. The licensee stated they will keep the LDEQ updated on the progress of repairs."
Louisiana Event Report ID No.: LA230011
The following report was received from the Louisiana Department of Environmental Quality (LDEQ) via email:
"On August 30, 2023, at approximately 0900 [CDT], an Ohmart Model SH-F1-0 level/density gauge experienced a shutter malfunction during a routine semiannual shutter test. The gauge was installed on the Reactor 3, West Production vessel within the Poly Process Unit. The gauge possesses a nominal 500 millicurie sealed source of Cs-137. The above gauge was undergoing a routine semiannual shutter test when the malfunction was observed. The gauge sealed source serial number is: 1560CO. The device serial number has not been provided by the licensee. The gauge containing source number 1560CO, is mounted on the Reactor 3, West Production Chamber vessel in the polyethylene unit. On the above date, the Radiation Safety Officer (RSO) for Union Carbide Corporation contacted BBP Sales (BBP), radioactive material license LA-10799-L01. BBP arrived on site on that day to repair the stuck shutter. After several unsuccessful attempts to break the shutter free, the licensee and the BBP service engineer decided the best course of action would be to order a rotor replacement kit and the BBP service engineer should return on site to replace it. BBP is currently awaiting delivery of the new rotor kit.
"On October 2, 2023, at 0824, Union Carbide RSO notified the LDEQ concerning this equipment malfunction. According to RSO, the gauge rotor bracket broke due to corrosion, which prevented the gauge shutter from closing fully. The gauge is under the licensee's control. There were no exposures to members of the public approaching regulatory limits. Currently, the shutter on the gauge remains in the open position as the gauge source is needed to operate process control equipment. The gauge cannot be locked out in its current state. No entry to the vessel will be conducted until the gauge is repaired by BBP. The licensee will continue to monitor the gauge until repaired. The licensee stated they will keep the LDEQ updated on the progress of repairs."
Louisiana Event Report ID No.: LA230011