Event Notification Report for October 31, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/30/2023 - 10/31/2023
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 56825
Facility: River Bend
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Miah Navarro
HQ OPS Officer: Dan Livermore
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Miah Navarro
HQ OPS Officer: Dan Livermore
Notification Date: 10/31/2023
Notification Time: 14:20 [ET]
Event Date: 10/31/2023
Event Time: 08:00 [CDT]
Last Update Date: 11/02/2023
Notification Time: 14:20 [ET]
Event Date: 10/31/2023
Event Time: 08:00 [CDT]
Last Update Date: 11/02/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Roldan-Otero, Lizette (R4DO)
FFD Group, (EMAIL)
Roldan-Otero, Lizette (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
EN Revision Imported Date: 11/3/2023
EN Revision Text: FALSE NEGATIVE ON BLIND PERFORMANCE SAMPLE
The following information was provided by the licensee via phone call and email:
"On October 31, 2023, at 0800 CDT, River Bend Station discovered that the results of a blind performance sample provided to an Health and Human Services (HHS)-certified testing facility were inaccurate (false negative). This report is being made in accordance with 10 CFR 26.719(c)(3). The HHS-certified testing facility has been informed of the error."
The licensee notified the NRC resident inspector.
* * * RETRACTION AT 0946 EDT ON NOVEMBER 2, 2023 FROM MICAH NAVARRO TO SAMUEL COLVARD * * *
"On November 1, 2023, River Bend Station personnel were informed by the HHS-certified testing facility that the cut-off levels used for analysis of the performance testing sample in question were the correct (higher) cut-off levels currently being used by the licensee. This resulted in a correct negative test.
"The performance testing sample sent to the HHS-certified testing facility was purchased for use based on the new lower cut-off levels in accordance with the new fit for duty (FFD) rule being implemented by the licensee on November 6, 2023. Because the higher confirmatory cut-off levels were used at the HHS-certified testing facility, the results provided were correct.
"The NRC Resident Inspector has been notified."
Notified R1DO (Eve) and FFD Group (email)
EN Revision Text: FALSE NEGATIVE ON BLIND PERFORMANCE SAMPLE
The following information was provided by the licensee via phone call and email:
"On October 31, 2023, at 0800 CDT, River Bend Station discovered that the results of a blind performance sample provided to an Health and Human Services (HHS)-certified testing facility were inaccurate (false negative). This report is being made in accordance with 10 CFR 26.719(c)(3). The HHS-certified testing facility has been informed of the error."
The licensee notified the NRC resident inspector.
* * * RETRACTION AT 0946 EDT ON NOVEMBER 2, 2023 FROM MICAH NAVARRO TO SAMUEL COLVARD * * *
"On November 1, 2023, River Bend Station personnel were informed by the HHS-certified testing facility that the cut-off levels used for analysis of the performance testing sample in question were the correct (higher) cut-off levels currently being used by the licensee. This resulted in a correct negative test.
"The performance testing sample sent to the HHS-certified testing facility was purchased for use based on the new lower cut-off levels in accordance with the new fit for duty (FFD) rule being implemented by the licensee on November 6, 2023. Because the higher confirmatory cut-off levels were used at the HHS-certified testing facility, the results provided were correct.
"The NRC Resident Inspector has been notified."
Notified R1DO (Eve) and FFD Group (email)
Agreement State
Event Number: 56828
Rep Org: WA Office of Radiation Protection
Licensee: Multi-Care Health System Auburn Event
Region: 4
City: Auburn State: WA
County:
License #: WN-M017
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Thomas Herrity
Licensee: Multi-Care Health System Auburn Event
Region: 4
City: Auburn State: WA
County:
License #: WN-M017
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Thomas Herrity
Notification Date: 11/02/2023
Notification Time: 11:03 [ET]
Event Date: 10/31/2023
Event Time: 09:00 [PDT]
Last Update Date: 11/16/2023
Notification Time: 11:03 [ET]
Event Date: 10/31/2023
Event Time: 09:00 [PDT]
Last Update Date: 11/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 11/16/2023
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES
The following information was received from the Washington State Department of Health via email:
"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.
"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."
Washington Incident Number: WA-23-029
* * * UPDATE ON 11/15/23 AT 1855 EST FROM BORIS TSENOV TO ERIC SIMPSON * * *
The following information was received from the Washington State Department of Health via email:
"Attached is the final report for the reported medical event # WA-23-029.
"We are also reviewing the event closely and are available to provide further information if needed."
Notified R4DO (Vossmar) and NMSS Events 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: AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES
The following information was received from the Washington State Department of Health via email:
"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.
"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."
Washington Incident Number: WA-23-029
* * * UPDATE ON 11/15/23 AT 1855 EST FROM BORIS TSENOV TO ERIC SIMPSON * * *
The following information was received from the Washington State Department of Health via email:
"Attached is the final report for the reported medical event # WA-23-029.
"We are also reviewing the event closely and are available to provide further information if needed."
Notified R4DO (Vossmar) and NMSS Events 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.