Event Notification Report for March 28, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/27/2007 - 03/28/2007
General Information or Other
Event Number: 43260
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 1319-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 1319-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Notification Date: 03/28/2007
Notification Time: 11:44 [ET]
Event Date: 03/28/2007
Event Time: 10:00 [EDT]
Last Update Date: 03/28/2007
Notification Time: 11:44 [ET]
Event Date: 03/28/2007
Event Time: 10:00 [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANTHONY DIMITRIADIS (R1)
GREG MORELL (FSME)
ANTHONY DIMITRIADIS (R1)
GREG MORELL (FSME)
AGREEMENT STATE REPORT - INCORRECT DOSE TO PATIENT DURING I-131 BEXXAR THERAPY
"Mis-administration while performing l-131 therapy. Procedure is called a [Bexxar] Therapy. 74 mCi was prescribed, but the patient received only 5 to 10 mCi. T connector to catheter was not properly fitted tight enough causing connector to come loose from tubing. Some 1-131 spilled on floor. Incident happened on 28-March-2007 at 10:00 am this office notified at 11:10 am. This incident is referred to Radioactive Materials for investigation."
The patient and the prescribing physician are aware of the dosing error. The licensee plans to conduct another procedure 3/30/07.
The state will follow up with the licensee on this incident. This incident is being tracked as Florida incident number FL07-054.
* * * UPDATE FROM FLANNERY (NRC/FSME) VIA E-MAIL TO HUFFMAN AT 1530 EDT ON 3/28/07 * * *
This event has been reviewed and determined to be a reportable medical event.
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.
"Mis-administration while performing l-131 therapy. Procedure is called a [Bexxar] Therapy. 74 mCi was prescribed, but the patient received only 5 to 10 mCi. T connector to catheter was not properly fitted tight enough causing connector to come loose from tubing. Some 1-131 spilled on floor. Incident happened on 28-March-2007 at 10:00 am this office notified at 11:10 am. This incident is referred to Radioactive Materials for investigation."
The patient and the prescribing physician are aware of the dosing error. The licensee plans to conduct another procedure 3/30/07.
The state will follow up with the licensee on this incident. This incident is being tracked as Florida incident number FL07-054.
* * * UPDATE FROM FLANNERY (NRC/FSME) VIA E-MAIL TO HUFFMAN AT 1530 EDT ON 3/28/07 * * *
This event has been reviewed and determined to be a reportable medical event.
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: 43262
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: WAYNE BENTLEY
HQ OPS Officer: JEFF ROTTON
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: WAYNE BENTLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/28/2007
Notification Time: 17:39 [ET]
Event Date: 03/28/2007
Event Time: 13:41 [CDT]
Last Update Date: 05/24/2007
Notification Time: 17:39 [ET]
Event Date: 03/28/2007
Event Time: 13:41 [CDT]
Last Update Date: 05/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)
JULIO LARA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 98 | Power Operation | 98 | Power Operation |
HPCI INOPERABLE DUE TO SURVEILLANCE TEST FAILURE
"During the running of the HPCI operability, STP 3.5.1-05, the discharge relief, PSV 2302, lifted and failed to reseat. The relief valve discharges to the Torus Area floor and was captured in the floor drain sump system. The STP was aborted and the HPCI system was declared inoperable.
The licensee notified the NRC Resident Inspector.
* * * RETRACTION ON 05/24/07 AT 1302 EDT BY ROBERT MURRELL TAKEN BY MACKINNON * * *
"The purpose of this notification is to retract a previous report made on 3/28/07 at 1739 (ET) (EN 43262). Notification of this issue to the NRC on 3/28/07 was initially made as a result of declaring HPCI inoperable during the running of the HPCI operability, Surveillance Test Procedure (STP) 3.5.1-05. HPCI was declared inoperable when the discharge relief, PSV 2302, lifted and failed to reseat. The relief valve discharges to the Torus Area floor and was capture in the floor drain sump system. The STP was aborted and HPCI system was declared inoperable.
"Since the initial report, Engineering had determined that the HPCI system was capable of performing its safety function.
"Engineering concluded that the stuck open HPCI discharge pressure relief valve would not have prevented HPCI from fulfilling its design function of providing adequate high pressure makeup to the reactor vessel. Existing operating procedure guidance would have ensured that HPCI injection would not have been terminated in the event it was needed under accident conditions, even with PSV2302 stuck open. Operating procedure guidance and Reactor Building floor drain sump pump capacity are adequate to prevent a flooding concern.
"This event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73."
The NRC Resident Inspector was notified of this retraction by the licensee. R3DO (Richard Skokowski) notified.
"During the running of the HPCI operability, STP 3.5.1-05, the discharge relief, PSV 2302, lifted and failed to reseat. The relief valve discharges to the Torus Area floor and was captured in the floor drain sump system. The STP was aborted and the HPCI system was declared inoperable.
The licensee notified the NRC Resident Inspector.
* * * RETRACTION ON 05/24/07 AT 1302 EDT BY ROBERT MURRELL TAKEN BY MACKINNON * * *
"The purpose of this notification is to retract a previous report made on 3/28/07 at 1739 (ET) (EN 43262). Notification of this issue to the NRC on 3/28/07 was initially made as a result of declaring HPCI inoperable during the running of the HPCI operability, Surveillance Test Procedure (STP) 3.5.1-05. HPCI was declared inoperable when the discharge relief, PSV 2302, lifted and failed to reseat. The relief valve discharges to the Torus Area floor and was capture in the floor drain sump system. The STP was aborted and HPCI system was declared inoperable.
"Since the initial report, Engineering had determined that the HPCI system was capable of performing its safety function.
"Engineering concluded that the stuck open HPCI discharge pressure relief valve would not have prevented HPCI from fulfilling its design function of providing adequate high pressure makeup to the reactor vessel. Existing operating procedure guidance would have ensured that HPCI injection would not have been terminated in the event it was needed under accident conditions, even with PSV2302 stuck open. Operating procedure guidance and Reactor Building floor drain sump pump capacity are adequate to prevent a flooding concern.
"This event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73."
The NRC Resident Inspector was notified of this retraction by the licensee. R3DO (Richard Skokowski) notified.