Event Notification Report for June 04, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
6/3/2019 - 6/4/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State	Event Number: 54084
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH Licensee: UNIVERSITY OF IOWA HOSPITAL Region: 3 City: IOWA CITY State: IA County: License #: 0037-1-52-AAB Agreement: Y Docket: NRC Notified By: STUART JORDAN HQ OPS Officer: HOWIE CROUCH	Notification Date: 05/24/2019 Notification Time: 12:01 [ET] Event Date: 05/22/2019 Event Time: 12:52 [CDT] Last Update Date: 05/30/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMNES CAMERON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 THERASPHERE TREATMENT

The following information was obtained from the state of Iowa via email:

"The University of Iowa Radiation Safety Officer notified the Iowa Department of Public Health (IDPH) on May 23, 2019, of a possible medical event that had occurred at the University of Iowa Hospital on May 22, 2019. The event occurred during a therapeutic Yttrium-90 (Y-90) microsphere (TheraSphere) administration to the liver. The signed written directive from the authorized user was 1.37 GBq (37.03 milliCuries). During the administration, it appeared that the spheres were being administered without incident until the point at which the flow of spheres ceased. The interventional radiologist determined that stasis had been reached, which prevented the remainder of the prescribed dose from being administered and appeared to be the only explanation for what happened. Based on the final survey reading of the source vial and tubing in the waste container, the initial determined dose was 0.586 GBq (15.84 milliCuries) which is 42% of the written directive.

"The following morning, May 23, 2019, routine imaging of the patient indicated no Y-90 activity in the patient's liver or abdominal areas. A second whole-body scan to determine any migration of activity was also negative for Y-90. The University of Iowa Radiation Safety Staff initiated an investigation into the location of the remainder of activity that was not remaining in the dose vial by surveying the procedure room and patient's room which were background levels and verified correct imaging protocol for the patient. The dose vial was re-surveyed and was found to contain all the original activity and no Y-90 TheraSpheres.

"The licensee's preliminary probable cause is an occluded needle in the vial that could have prevented either the flow of saline into the source vial, or the flow of microspheres out of the vial to the patient. The authorized user, the interventional radiologist, and the patient have been informed of the issue with this administration. No direct harm to the patient has occurred because no radioactivity had been delivered to the patient.

"This is a preliminary report and IDPH will be conducting an investigation to provide additional updated information. Items to initially get resolved include but are not limited to the licensee's issue with how dosages are measured before and after the procedure, independently verifying that no dose had been delivered to the patient, examine the integrity of the tubing and needles used in the procedure, and communication with the manufacturer about the circumstances surrounding this event and if they or the NRC are aware of any similar events."

NMED Report No.: IA190001

* * * RETRACTION AT 1641 EDT ON 5/30/19 FROM STUART JORDAN TO JEFF HERRERA * * *

The following retraction was received from the Iowa Bureau of Radiological Health via email:

"The Iowa Department of Public Health requests to retract the NRC Event Notification No. 54084 (Item No. IA190001) that was transmitted to the NRC Operations Center on May 24, 2019. After conversations with the licensee's radiation safety officer and review of information provided by the licensee we have determined that no detectable amount of Y-90 TheraSpheres was administered to the patient, and therefore no dose was delivered. Based on a discussion with NRC Region III Office, we have determined that the circumstances surrounding this incident do not meet the reportable medical event described in 10 CFR 35.3045."

Notified the R3DO (Daley), 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.

Non-Agreement State	Event Number: 54086
Rep Org: TRACERCO Licensee: TRACERCO Region: 4 City: PASADENA State: TX County: License #: 07-28386-01 Agreement: Y Docket: NRC Notified By: MONTY POPE HQ OPS Officer: CATY NOLAN	Notification Date: 05/24/2019 Notification Time: 16:22 [ET] Event Date: 05/22/2019 Event Time: 00:00 [CDT] Last Update Date: 05/25/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X	Person (Organization): FRANK ARNER (R1DO) HEATHER GEPFORD (R4DO) ILTAB (EMAIL) NMSS_EVENTS_NOTIFICATION (EMAIL) - CNSNS (MEXICO) (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST SOURCE DURING SHIPMENT

The following is a synopsis of an event received via phone call:

During a shipment from Pasadena, TX to Billings, MT, a 4 milliCurie Cobalt-60 (Co-60) source was lost in transit. The last known location was Memphis, TN. It was shipped on May 17, 2019 and was identified lost on May 22, 2019. The shipper and the common carrier are investigating.

* * * UPDATE ON 05/25/2019 AT 1045 EDT FROM MONTY POPE TO JOANNA BRIDGE * * *

The following is a summary of a phone call with Mr. Pope:

On May 24, 2019, the source that was misplaced by the common carrier was able to be located. New shipping documents are being generated.

Notified R1RDO (Arner), R4RDO (GEPFORD), ILTAB (e-mail), NMSS Events (e-mail) and CNSNS Mexico (email).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.p

Agreement State	Event Number: 54088
Rep Org: VIRGINIA RAD MATERIALS PROGRAM Licensee: FROEHLING & ROBERTSON, INC. Region: 1 City: CHESAPEAKE State: VA County: License #: 087-096-2 Agreement: Y Docket: NRC Notified By: CHARLES COLEMAN HQ OPS Officer: HOWIE CROUCH	Notification Date: 05/24/2019 Notification Time: 17:43 [ET] Event Date: 05/24/2019 Event Time: 00:00 [EDT] Last Update Date: 05/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE ON MOISTURE DENSITY GAUGE

The following information was obtained from the Commonwealth of Virginia via email:

"On May 24, 2019, the Radiation Safety Office for the licensee made a preliminary report of an incident which occurred earlier on that day. The technician extended the source rod while using a portable moisture density gauge but was unable to retract it. The technician placed the gauge, with source rod extended, in the bed of his truck and drove back to his office, approximately 15 miles.

"When he arrived at his office, the other technicians were able to retract the source. A radiation survey confirmed the source was secured in its shield.

The Virginia Office of Radiological Health will perform a reactive inspection to investigate this incident. This notification will be updated with additional information determined during the inspection."

Virginia Event Report ID: VA 19-001

Power Reactor	Event Number: 54098
Facility: LIMERICK Region: 1 State: PA Unit: [] [2] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: STEVEN BARCZYK HQ OPS Officer: OSSY FONT	Notification Date: 06/04/2019 Notification Time: 04:10 [ET] Event Date: 06/04/2019 Event Time: 01:45 [EDT] Last Update Date: 06/04/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL	Person (Organization): ERIN CARFANG (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

100

Power Operation

Hot Shutdown

Event Text

MANUAL SCRAM DURING RAPID PLANT SHUTDOWN

"At 0145 EDT, on 6/4/19, Unit 2 was manually scrammed during a Rapid Plant Shutdown. At 64 percent reactor power, a Rapid Plant Shutdown was initiated due to lowering Main Condenser vacuum as a result of the loss of a plant electrical panel that powers Offgas System controls.

"The shutdown was normal and the plant is stable in Hot Shutdown with normal pressure control via the Main Turbine Bypass Valves to the Main Condenser and normal level control using Feedwater and Condensate. Main Condenser Vacuum has been restored."

The licensee notified the NRC Resident Inspector. Additionally, state and local government agencies were notified.

Prior to restarting Unit 2, an evaluation needs to be done due to the Unit 1 Diesel currently out of service for maintenance. The Unit 1 Diesel is a power supply for some of the common systems under the Unit 2 Technical Specifications and therefore required.

Page Last Reviewed/Updated Wednesday, March 24, 2021