Event Notification Report for June 07, 2004

MEDICAL EVENT

A 19 year old female was diagnosed with Grave's Disease of the thyroid. Consultation with an authorized user (a physician) was requested for consideration of Iodine-131 ablation of her thyroid gland.

After this consultation, the patient wished to undergo radioactive iodine ablation of her thyroid gland. The physician completed a prescription in which his written directive was an order for 12 microCuries of Iodine-131. The word "micro" was written using the Greek alphabet letter. The technologist ordered 12 milliCuries of Iodine-131. The technologist received 12.5 milliCuries and this amount was administered orally on 4/7/04. The licensee became aware of this misadministration on 6/7/04 during their quarterly quality maintenance review.

The licensee's review of this case with the physician revealed that his intent was to have ordered a 12 milliCurie dose. The physician wrote microCurie by mistake, as a microCurie dose would have been inappropriate for the clinical indication.

There were no untoward affects from this administration. At this time, it is not known if the patient has been notified. Licensee RSO will provide that information at a later time.

The licensee has reviewed this case and the sequence of events. The following action has been taken. The preprinted prescription form was modified such that after the blank where the authorized user enters the name of the isotope and the dose, the words "microCurie" and "milliCurie" will be written next to each other. The authorized user will need to circle one of the choices.

REACTOR TRIP DUE TO MAIN TURBINE ELECTRO-HYDRAULIC CONTROL SYSTEM FAILURE

"On June 7, 2004, at approximately 14:58 Mountain Standard Time (MST) while at 99% RTP [rated thermal power], Palo Verde Unit 3 experienced an apparent electro-hydraulic control (EHC) system fault resulting in Combined Intercept Valve (CIV) closure. This plant upset was followed by a Reactor Power Cutback System (RPCS) initiation. Several seconds later the Reactor automatically tripped on Lo DNBR from approximately 65% RTP. Unit 3 was at normal temperature and pressure prior to the trip. All CEAs [control rod assemblies] inserted fully into the reactor core. This was an uncomplicated reactor trip. No emergency classification was required per the Emergency Plan. No automatic ESF actuations occurred and none were required. Safety related buses remained energized during and following the reactor trip. The Emergency Diesel Generators did not start and were not required. The offsite power grid is stable. No significant LCOs have been entered as a result of this event. No major equipment was inoperable prior to the event that contributed to the event.

"Unit 3 is stabilized at normal temperature and pressure at approximately 565 degrees F and 2250 psia in Mode 3. The reactor coolant system remains in normal forced circulation with heat removal via the steam bypass control system to the condenser and feedwater from the non-essential auxiliary feedwater system. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"The Senior Resident Inspector was informed of the Unit 3 reactor trip and this notification. The Senior Resident Inspector was on-site at the time of the reactor trip."