Event Notification Report for July 18, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/17/2008 - 07/18/2008
Power Reactor
Event Number: 44355
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: SUSAN GARDNER
HQ OPS Officer: BILL HUFFMAN
Region: 4 State: CA
Unit: [] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: SUSAN GARDNER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/18/2008
Notification Time: 19:36 [ET]
Event Date: 07/18/2008
Event Time: 08:00 [PDT]
Last Update Date: 07/19/2008
Notification Time: 19:36 [ET]
Event Date: 07/18/2008
Event Time: 08:00 [PDT]
Last Update Date: 07/19/2008
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):
CLAUDE JOHNSON (R4)
CLAUDE JOHNSON (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 98 | Power Operation | 98 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
EMERGENCY OPERATIONS FACILITY INOPERABLE FOR MAINTENANCE WORK
"Southern California Edison (SCE) has scheduled maintenance for the electrical system of the San Onofre Emergency Operations Facility (EOF), for Saturday, July 19, 2008. While the maintenance is being performed, the EOF will be inoperable. The EOF outage is expected to begin at 0800 PDT and last approximately 4 hours.
"The alternate EOF, located in Irvine, CA, will be available should SCE need to respond to an Emergency Event.
"The Emergency Recall System, which is housed in the EOF, will be out of service while the maintenance is performed. Should recall of the Emergency Response Organization (ERO) be necessary during the EOF outage, SCE will utilize alternate methods (contained in existing site procedures) for activating the ERO.
"This planned EOF outage is being reported in accordance with 10CFR50.72(b)(3)(xiii).
"At the time of this report, Unit 2 and Unit 3 were operating at about 98 per cent and 100 per cent, respectively.
"The NRC Resident Inspector has been notified of this report and will be provided a copy."
* * * UPDATE PROVIDED BY SUSAN GARDNER TO JASON KOZAL ON 7/19/08 AT 1705 * * *
"The Emergency Operations Facility was returned to service on July 19, 2008 at 1240 PDT.
"The NRC Resident Inspector will be notified of this occurrence and will be provided with a copy of this report."
Notified R4DO (Johnson).
"Southern California Edison (SCE) has scheduled maintenance for the electrical system of the San Onofre Emergency Operations Facility (EOF), for Saturday, July 19, 2008. While the maintenance is being performed, the EOF will be inoperable. The EOF outage is expected to begin at 0800 PDT and last approximately 4 hours.
"The alternate EOF, located in Irvine, CA, will be available should SCE need to respond to an Emergency Event.
"The Emergency Recall System, which is housed in the EOF, will be out of service while the maintenance is performed. Should recall of the Emergency Response Organization (ERO) be necessary during the EOF outage, SCE will utilize alternate methods (contained in existing site procedures) for activating the ERO.
"This planned EOF outage is being reported in accordance with 10CFR50.72(b)(3)(xiii).
"At the time of this report, Unit 2 and Unit 3 were operating at about 98 per cent and 100 per cent, respectively.
"The NRC Resident Inspector has been notified of this report and will be provided a copy."
* * * UPDATE PROVIDED BY SUSAN GARDNER TO JASON KOZAL ON 7/19/08 AT 1705 * * *
"The Emergency Operations Facility was returned to service on July 19, 2008 at 1240 PDT.
"The NRC Resident Inspector will be notified of this occurrence and will be provided with a copy of this report."
Notified R4DO (Johnson).
Other Nuclear Material
Event Number: 44371
Rep Org: MEMORIAL HOSPITAL - SHERIDAN, WY
Licensee: MEMORIAL HOSPITAL - SHERIDAN, WY
Region: 4
City: SHERIDAN State: WY
County:
License #: 49-10982-02
Agreement: N
Docket:
NRC Notified By: THOMAS NANCE
HQ OPS Officer: JEFF ROTTON
Licensee: MEMORIAL HOSPITAL - SHERIDAN, WY
Region: 4
City: SHERIDAN State: WY
County:
License #: 49-10982-02
Agreement: N
Docket:
NRC Notified By: THOMAS NANCE
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/28/2008
Notification Time: 14:26 [ET]
Event Date: 07/18/2008
Event Time: 10:00 [MDT]
Last Update Date: 07/28/2008
Notification Time: 14:26 [ET]
Event Date: 07/18/2008
Event Time: 10:00 [MDT]
Last Update Date: 07/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)
NEIL O'KEEFE (R4)
MICHELE BURGESS (FSME)
MEDICAL ERROR - WRONG CHEMICAL USED IN PATIENT TREATMENT
On the date described [07/18/08] an outpatient reported to the Nuclear Medicine Department for a Nuclear Medicine whole body bone scan. The technician drew up and injected the patient with 24.3 mCi mTc99 Sestamibi, I.V. instead of the proper cold kit which would have been Medronate. The error was not discovered until the patient returned 3 hours later for scanning and it was observed that the isotope was not properly tagged. Upon investigation, the reason for the poor tag was discovered. The patient was informed as well as the Department Manager, and the on-duty staff Radiologist. It was agreed by all that the patient would return on 07/21/08 to perform the study properly. According to the Radiation Absorbed Dose Table, the patient received the following:
Gallbladder Wall - 1.6 Rads, Small Intestine - 2.4 Rads, Upper Large Intestine Wall - 4.32 Rads, Lower Large Intestine Wall - 3.12 Rads, Stomach Wall - 0.48 Rads, Heart Wall - 0.40 Rads, Kidneys - 1.6 Rads, Liver - 0.48 Rads, Lungs - 0.24 Rads, Bone Surfaces - 0.56 Rads, Thyroid - 0.56, Testes - 0.24 Rads, Red Marrow - 0.40 Rads, Urinary Bladder Wall - 1.6 Rads, Total Body - 0.40 Rads.
It is believed that there was no ill effect on the patient. The technician has been re-instructed on the extreme importance of checking all the labels previous to preparing, drawing up and delivering any radioisotopes.
The licensee is still in the process of confirming that the ordering physician has been notified of this incident.
On the date described [07/18/08] an outpatient reported to the Nuclear Medicine Department for a Nuclear Medicine whole body bone scan. The technician drew up and injected the patient with 24.3 mCi mTc99 Sestamibi, I.V. instead of the proper cold kit which would have been Medronate. The error was not discovered until the patient returned 3 hours later for scanning and it was observed that the isotope was not properly tagged. Upon investigation, the reason for the poor tag was discovered. The patient was informed as well as the Department Manager, and the on-duty staff Radiologist. It was agreed by all that the patient would return on 07/21/08 to perform the study properly. According to the Radiation Absorbed Dose Table, the patient received the following:
Gallbladder Wall - 1.6 Rads, Small Intestine - 2.4 Rads, Upper Large Intestine Wall - 4.32 Rads, Lower Large Intestine Wall - 3.12 Rads, Stomach Wall - 0.48 Rads, Heart Wall - 0.40 Rads, Kidneys - 1.6 Rads, Liver - 0.48 Rads, Lungs - 0.24 Rads, Bone Surfaces - 0.56 Rads, Thyroid - 0.56, Testes - 0.24 Rads, Red Marrow - 0.40 Rads, Urinary Bladder Wall - 1.6 Rads, Total Body - 0.40 Rads.
It is believed that there was no ill effect on the patient. The technician has been re-instructed on the extreme importance of checking all the labels previous to preparing, drawing up and delivering any radioisotopes.
The licensee is still in the process of confirming that the ordering physician has been notified of this incident.