Event Notification Report for September 06, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/05/2013 - 09/06/2013
Agreement State
Event Number: 49331
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-213-27
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: PETE SNYDER
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-213-27
Agreement: Y
Docket:
NRC Notified By: SHERRIE FLAHERTY
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 14:29 [ET]
Event Date: 09/06/2013
Event Time: 00:00 [CDT]
Last Update Date: 09/06/2013
Notification Time: 14:29 [ET]
Event Date: 09/06/2013
Event Time: 00:00 [CDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)
MICHAEL KUNOWSKI (R3DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG SITE
The following information was received from the State of Minnesota via email:
"The planned/prescribed dose that was to be delivered to a patient's tumor volume was 400cGy (4Gy) on this fraction. Due to medical event, [approximately] 0cGy (0Gy) was delivered to the tumor volume during HDR treatment fraction #2 of 6. The prescribed fraction dose of 400cGy (4Gy) was unintentionally delivered 5.4cm superiorly to the tumor volume in the patient's small bowel/external bladder wall region.
"The HDR remote afterloader at Abbott-Northwestern being used/in use during this patient's treatment is a Nucletron/Elekta V2 mHDR, serial number 31823; mHDR Ir-192 source #D36E-6829. The Ir-192 source activity at time of above medical event was 6.407 Ci.
"Abbott-Northwestern Radiation Oncology is actively investigating the cause of the above medical event, corrective action(s) to implement to prevent such an event from happening in the future, and any medical follow-up/expected implications to the patient from the above medical event. These items will be detailed in Abbott-Northwestern's full written report to be submitted within 15 days of discovery.
"MDH [Minnesota Department of Health] will submit more information as it becomes available."
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 from the State of Minnesota via email:
"The planned/prescribed dose that was to be delivered to a patient's tumor volume was 400cGy (4Gy) on this fraction. Due to medical event, [approximately] 0cGy (0Gy) was delivered to the tumor volume during HDR treatment fraction #2 of 6. The prescribed fraction dose of 400cGy (4Gy) was unintentionally delivered 5.4cm superiorly to the tumor volume in the patient's small bowel/external bladder wall region.
"The HDR remote afterloader at Abbott-Northwestern being used/in use during this patient's treatment is a Nucletron/Elekta V2 mHDR, serial number 31823; mHDR Ir-192 source #D36E-6829. The Ir-192 source activity at time of above medical event was 6.407 Ci.
"Abbott-Northwestern Radiation Oncology is actively investigating the cause of the above medical event, corrective action(s) to implement to prevent such an event from happening in the future, and any medical follow-up/expected implications to the patient from the above medical event. These items will be detailed in Abbott-Northwestern's full written report to be submitted within 15 days of discovery.
"MDH [Minnesota Department of Health] will submit more information as it becomes available."
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.
Power Reactor
Event Number: 49328
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: GREG KNUDSON
HQ OPS Officer: PETE SNYDER
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: GREG KNUDSON
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2013
Notification Time: 14:47 [ET]
Event Date: 09/06/2013
Event Time: 06:07 [PDT]
Last Update Date: 09/06/2013
Notification Time: 14:47 [ET]
Event Date: 09/06/2013
Event Time: 06:07 [PDT]
Last Update Date: 09/06/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VINCENT GADDY (R4DO)
VINCENT GADDY (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
RADIATION MONITORING SAMPLE RACK DECLARED NON-FUNCTIONAL
"At 0607 hours PDT on September 6, 2013, the Radwaste Building process radiation monitoring sample rack was declared non-functional due to a loss of power to the sample rack. The cause of the loss of power is under investigation.
"At 0945 hours PDT, auxiliary sampling equipment was installed to collect samples from the associated effluent release pathway.
"To compensate for the loss of assessment capability while the Radwaste Building process radiation monitoring sample rack is non-functional, field team survey results will be used if required.
"This event is being reported as a loss of emergency assessment capability in accordance with 10CFR50.72(b)(3)(xiii).
"The licensee has notified the NRC Resident Inspector."
* * * UPDATE FROM QUOC VO TO VINCE KLCO ON 9/6/13 AT 2251 EDT * * *
"Repairs have been completed and the Radwaste Building process radiation monitoring sample rack has been returned to service and declared functional at 1631 hours PDT.
"The licensee has notified the NRC Resident Inspector."
Notified the R4DO (Gaddy).
"At 0607 hours PDT on September 6, 2013, the Radwaste Building process radiation monitoring sample rack was declared non-functional due to a loss of power to the sample rack. The cause of the loss of power is under investigation.
"At 0945 hours PDT, auxiliary sampling equipment was installed to collect samples from the associated effluent release pathway.
"To compensate for the loss of assessment capability while the Radwaste Building process radiation monitoring sample rack is non-functional, field team survey results will be used if required.
"This event is being reported as a loss of emergency assessment capability in accordance with 10CFR50.72(b)(3)(xiii).
"The licensee has notified the NRC Resident Inspector."
* * * UPDATE FROM QUOC VO TO VINCE KLCO ON 9/6/13 AT 2251 EDT * * *
"Repairs have been completed and the Radwaste Building process radiation monitoring sample rack has been returned to service and declared functional at 1631 hours PDT.
"The licensee has notified the NRC Resident Inspector."
Notified the R4DO (Gaddy).