Event Notification Report for November 02, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/01/2023 - 11/02/2023
Agreement State
Event Number: 56831
Rep Org: California Radiation Control Prgm
Licensee: Kaiser Permanente Med Care Program
Region: 4
City: Pasadena State: CA
County:
License #: 0372-19
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Donald Norwood
Licensee: Kaiser Permanente Med Care Program
Region: 4
City: Pasadena State: CA
County:
License #: 0372-19
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Donald Norwood
Notification Date: 11/03/2023
Notification Time: 19:01 [ET]
Event Date: 11/02/2023
Event Time: 00:00 [PDT]
Last Update Date: 11/03/2023
Notification Time: 19:01 [ET]
Event Date: 11/02/2023
Event Time: 00:00 [PDT]
Last Update Date: 11/03/2023
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)
AGREEMENT STATE REPORT - Y-90 UNDERDOSE
The following information was received via email:
"The Chief Physicist at Kaiser Permanente Medical Care Program of Southern California contacted the Radiologic Health Branch on November 2, 2023, at approximately 1757 PDT to report a medical event that occurred on the same day in Los Angeles, CA. The patient was underdosed during a radioembolization treatment for liver cancer that involved the administration of yttrium-90 (Y-90) TheraSpheres microspheres. The prescribed dose to the patient was 900 Gy, but the dose delivered to the patient was only 90.2 Gy due to a kink in the microcatheter used to deliver the Y-90.
"Kaiser Permanente will conduct an investigation to gain a better understanding of the details of the event."
CA event ID number: 110323
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.
The following information was received via email:
"The Chief Physicist at Kaiser Permanente Medical Care Program of Southern California contacted the Radiologic Health Branch on November 2, 2023, at approximately 1757 PDT to report a medical event that occurred on the same day in Los Angeles, CA. The patient was underdosed during a radioembolization treatment for liver cancer that involved the administration of yttrium-90 (Y-90) TheraSpheres microspheres. The prescribed dose to the patient was 900 Gy, but the dose delivered to the patient was only 90.2 Gy due to a kink in the microcatheter used to deliver the Y-90.
"Kaiser Permanente will conduct an investigation to gain a better understanding of the details of the event."
CA event ID number: 110323
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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 56829
Facility: Point Beach
Region: 3 State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Mary Sipiorski
HQ OPS Officer: Thomas Herrity
Region: 3 State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Mary Sipiorski
HQ OPS Officer: Thomas Herrity
Notification Date: 11/02/2023
Notification Time: 16:41 [ET]
Event Date: 11/02/2023
Event Time: 07:15 [CDT]
Last Update Date: 01/25/2024
Notification Time: 16:41 [ET]
Event Date: 11/02/2023
Event Time: 07:15 [CDT]
Last Update Date: 01/25/2024
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Ruiz, Robert (R3DO)
FFD Group, (EMAIL)
Ruiz, Robert (R3DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 38 | Power Operation | 38 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 1/26/2024
EN Revision Text: FALSE NEGATIVE AND POSITIVE ON BLIND PERFORMANCE SAMPLE
The following information was provided by the licensee via email:
"On November 2, 2023, at 0715 CDT, it was discovered that the results of a blind performance specimen provided to a Health & Human Services (HHS)-certified testing facility were not as expected. The blind specimen results indicated a false negative for MDA/MDMA and a false positive for amphetamines.
"Investigation is ongoing to determine if the results are accurate.
"This report is being made in accordance with 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3).
"The NRC Resident Inspector has been notified by the licensee."
* * * RETRACTION ON 1/25/24 AT 1139 EST FROM REX GUNDERSON TO THOMAS HERRITY * * *
"Follow-up investigation by an independent Health and Human Services laboratory confirmed that the blind specimen in question was analyzed correctly. The error is thought to have occurred during the preparation of the blind specimen, prior to delivery to the site.
"The NRC Resident Inspector has been notified by the licensee."
Notified R3DO (Orlikowski) and FFD Group (email).
EN Revision Text: FALSE NEGATIVE AND POSITIVE ON BLIND PERFORMANCE SAMPLE
The following information was provided by the licensee via email:
"On November 2, 2023, at 0715 CDT, it was discovered that the results of a blind performance specimen provided to a Health & Human Services (HHS)-certified testing facility were not as expected. The blind specimen results indicated a false negative for MDA/MDMA and a false positive for amphetamines.
"Investigation is ongoing to determine if the results are accurate.
"This report is being made in accordance with 10 CFR 26.719(c)(2) and 10 CFR 26.719(c)(3).
"The NRC Resident Inspector has been notified by the licensee."
* * * RETRACTION ON 1/25/24 AT 1139 EST FROM REX GUNDERSON TO THOMAS HERRITY * * *
"Follow-up investigation by an independent Health and Human Services laboratory confirmed that the blind specimen in question was analyzed correctly. The error is thought to have occurred during the preparation of the blind specimen, prior to delivery to the site.
"The NRC Resident Inspector has been notified by the licensee."
Notified R3DO (Orlikowski) and FFD Group (email).
Fuel Cycle Facility
Event Number: 56851
Facility: Framatome ANP Richland
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Ernest West
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Ernest West
Notification Date: 11/13/2023
Notification Time: 15:13 [ET]
Event Date: 11/02/2023
Event Time: 10:45 [PST]
Last Update Date: 11/13/2023
Notification Time: 15:13 [ET]
Event Date: 11/02/2023
Event Time: 10:45 [PST]
Last Update Date: 11/13/2023
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)
CONCURRENT REPORT FOR DEGRADED CONNECTOR
The following information was provided by the licensee via phone and email:
"Pursuant to 10 CFR 70 Appendix A (c), Framatome is making this concurrent report:
"On November 2, 2023, Framatome made a courtesy telephone call to the Washington Department of Health (WDOH) about a degraded flexible connector on an exhaust duct downstream of the final HEPA filter.
"On November 3, 2023, WDOH requested that Framatome submit a report within ten days regarding this notification. Framatome will be submitting the requested report today, [November 13, 2023]."
The following information was provided by the licensee via phone and email:
"Pursuant to 10 CFR 70 Appendix A (c), Framatome is making this concurrent report:
"On November 2, 2023, Framatome made a courtesy telephone call to the Washington Department of Health (WDOH) about a degraded flexible connector on an exhaust duct downstream of the final HEPA filter.
"On November 3, 2023, WDOH requested that Framatome submit a report within ten days regarding this notification. Framatome will be submitting the requested report today, [November 13, 2023]."