Event Notification Report for July 21, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/20/2010 - 07/21/2010
EVENT NUMBERS
46119461134611446117
General Information or Other
Event Number: 46119
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: UNIVERSITY OF NEW MEXICO
Region: 4
City: ALBUQUERQUE State: NM
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL ORTIZ
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF NEW MEXICO
Region: 4
City: ALBUQUERQUE State: NM
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL ORTIZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/23/2010
Notification Time: 13:13 [ET]
Event Date: 07/21/2010
Event Time: 15:00 [MDT]
Last Update Date: 07/23/2010
Notification Time: 13:13 [ET]
Event Date: 07/21/2010
Event Time: 15:00 [MDT]
Last Update Date: 07/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
GLENDA VILLAMAR (FSME)
MICHAEL HAY (R4DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT INVOLVING LESS THAN PRESCRIBED DOSE
The following information was received from the State of New Mexico via email:
"Medical Event was reported 7/23/2010 at 8:39 am by the Radiation Safety Specialist, UNM Radiation Safety Office.
"Location: UNM Nuclear Medicine Department
1801 Tucker Avenue
Albuquerque, NM 87131
"Medical Event: 7/21/2010 at 3:00 pm, patient written directive order to receive Iodine-131 Therapy treatment 200 mCi (NaI), patient received 80 mCi.
"A detailed report will be supplied to State of New Mexico Radiation Control Bureau by UNM RSO within 15 days."
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 New Mexico via email:
"Medical Event was reported 7/23/2010 at 8:39 am by the Radiation Safety Specialist, UNM Radiation Safety Office.
"Location: UNM Nuclear Medicine Department
1801 Tucker Avenue
Albuquerque, NM 87131
"Medical Event: 7/21/2010 at 3:00 pm, patient written directive order to receive Iodine-131 Therapy treatment 200 mCi (NaI), patient received 80 mCi.
"A detailed report will be supplied to State of New Mexico Radiation Control Bureau by UNM RSO within 15 days."
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: 46113
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: BEN COOK
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: BEN COOK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/21/2010
Notification Time: 11:39 [ET]
Event Date: 07/21/2010
Event Time: 08:16 [CDT]
Last Update Date: 07/21/2010
Notification Time: 11:39 [ET]
Event Date: 07/21/2010
Event Time: 08:16 [CDT]
Last Update Date: 07/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANN MARIE STONE (R3DO)
ANN MARIE STONE (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
INADVERTENT MANUAL INITIATION OF EMERGENCY ALERT SIRENS
"At 0816 [CDT] on 7/21/2010, the Monticello Nuclear Power Generating Plant (MNGP) received a report from the Sherburne County Sheriff Dispatcher that there had been an inadvertent manual initiation of Emergency Preparedness sirens in the county while performing siren testing. All plant conditions/parameters are normal. A total of 48 emergency sirens were on for approximately 1 minute before being secured. The inadvertent initiation of the sirens was determined to be reportable under 10 CFR 50.72(b)(2)(xi), 'News Release or Notification of Other Government Agency.'
"Sherburne County, the State of Minnesota, and the site NRC Resident Inspector have been notified."
"At 0816 [CDT] on 7/21/2010, the Monticello Nuclear Power Generating Plant (MNGP) received a report from the Sherburne County Sheriff Dispatcher that there had been an inadvertent manual initiation of Emergency Preparedness sirens in the county while performing siren testing. All plant conditions/parameters are normal. A total of 48 emergency sirens were on for approximately 1 minute before being secured. The inadvertent initiation of the sirens was determined to be reportable under 10 CFR 50.72(b)(2)(xi), 'News Release or Notification of Other Government Agency.'
"Sherburne County, the State of Minnesota, and the site NRC Resident Inspector have been notified."
Power Reactor
Event Number: 46114
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD ELLIOT
HQ OPS Officer: PETE SNYDER
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD ELLIOT
HQ OPS Officer: PETE SNYDER
Notification Date: 07/21/2010
Notification Time: 19:48 [ET]
Event Date: 07/21/2010
Event Time: 17:30 [EDT]
Last Update Date: 07/21/2010
Notification Time: 19:48 [ET]
Event Date: 07/21/2010
Event Time: 17:30 [EDT]
Last Update Date: 07/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JONATHAN BARTLEY (R2DO)
JONATHAN BARTLEY (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION OF NORTH CAROLINA WILDLIFE RESOURCES DUE TO STRIPED BASS MORTALITY
"Duke Energy Scientific Services group notified the NC [North Carolina] Wildlife Resources Commission that we (McGuire Nuclear Station) were experiencing some Striper mortalities in and around the Cowan's Ford Dam.
"Since Monday (7/19/2010) of this week we have collected approximately 100 dead stripers. Some appear to have died from fishing related activities (catch and release) but some were also noted to be stressed from oxygen deprivation.
"[The Duke Energy Scientific Services group representative] also notified the NC Wildlife Resources Commission the McGuire Nuclear Station was operating their Low Level Intake [LLI] Pumps to support maintenance of their NPDES Permit 99 degree Fahrenheit average monthly temperature limit.
"July has been unusually hot and plant management has felt the need to run the LLI approximately 6 days to achieve compliance with our temperature limit. During the operation of the LLI pumps, Duke Energy's Scientific Services group is monitoring water quality and fish in the lake via the following activities:
"1) Daily hydroacoustic surveys of the Cowans Ford Dam forebay both immediate to the dam and also an approximately 2 mile run up the Catawba River channel.
"2) Around-the-clock monitoring of fish behavior in the immediate vicinity of the LLI. A DIDSON camera sits atop the LLI (25 meter deep) and is automated to record hourly video of areas both above the LLI and in front of the LLI using motorized rotators. These videos are monitored by [personnel] throughout the day and night.
"3) Every other day water quality monitoring including dissolved oxygen and temperature profiles at every meter to the bottom of the lake. These profiles occur in the forebay and at multiple locations up the channel.
"4) Daily surveys for dead striped bass by boat up the major tributaries of the lake. We will record lengths and condition of both dead and dying stripers before disposing of them.
"5) Hourly MNS discharge temperature monitoring.
"These activates will continue to be exercised until the pumps are turned off."
The licensee notified the NRC Resident Inspector.
"Duke Energy Scientific Services group notified the NC [North Carolina] Wildlife Resources Commission that we (McGuire Nuclear Station) were experiencing some Striper mortalities in and around the Cowan's Ford Dam.
"Since Monday (7/19/2010) of this week we have collected approximately 100 dead stripers. Some appear to have died from fishing related activities (catch and release) but some were also noted to be stressed from oxygen deprivation.
"[The Duke Energy Scientific Services group representative] also notified the NC Wildlife Resources Commission the McGuire Nuclear Station was operating their Low Level Intake [LLI] Pumps to support maintenance of their NPDES Permit 99 degree Fahrenheit average monthly temperature limit.
"July has been unusually hot and plant management has felt the need to run the LLI approximately 6 days to achieve compliance with our temperature limit. During the operation of the LLI pumps, Duke Energy's Scientific Services group is monitoring water quality and fish in the lake via the following activities:
"1) Daily hydroacoustic surveys of the Cowans Ford Dam forebay both immediate to the dam and also an approximately 2 mile run up the Catawba River channel.
"2) Around-the-clock monitoring of fish behavior in the immediate vicinity of the LLI. A DIDSON camera sits atop the LLI (25 meter deep) and is automated to record hourly video of areas both above the LLI and in front of the LLI using motorized rotators. These videos are monitored by [personnel] throughout the day and night.
"3) Every other day water quality monitoring including dissolved oxygen and temperature profiles at every meter to the bottom of the lake. These profiles occur in the forebay and at multiple locations up the channel.
"4) Daily surveys for dead striped bass by boat up the major tributaries of the lake. We will record lengths and condition of both dead and dying stripers before disposing of them.
"5) Hourly MNS discharge temperature monitoring.
"These activates will continue to be exercised until the pumps are turned off."
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 46117
Rep Org: NV DIV OF RAD HEALTH
Licensee: WEST VALLEY IMAGING
Region: 4
City: HENDERSON State: NV
County:
License #: 03-12-0384-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: STEVE SANDIN
Licensee: WEST VALLEY IMAGING
Region: 4
City: HENDERSON State: NV
County:
License #: 03-12-0384-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/22/2010
Notification Time: 13:30 [ET]
Event Date: 07/21/2010
Event Time: 12:00 [PDT]
Last Update Date: 07/22/2010
Notification Time: 13:30 [ET]
Event Date: 07/21/2010
Event Time: 12:00 [PDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)
MICHAEL HAY (R4DO)
TERRENCE REIS (FSME)
AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT
"Narrative: On 7/21/2010 at 12:00 p.m at the Hot Lab: 17 yr old patient came in for MIRALUMA study. STD dose is 25 mCi of Tc-99m MIRALUMA. Based on patient weight, (105 lbs), pediatric dose is calculated at 17.5 mCi. IV was started by mammography technician. Nuclear medicine technician went to physician to notify about pediatric dose. At this time, mammography technician assayed dose at 24.0 mCi and injected patient.
"Reported to the Nevada Radiation Control Program at around 3:00 p.m.
"The event is NRC reportable under 10CFR35.3045, since it is a dose different from the prescribed dose. Since 10 CFR 35 has been adopted by the state, it is reportable under state requirements too.
"Persons involved: Pediatric patient, mammography technician and nuclear medicine technician.
"Corrective Actions: Communication and cross-checking correct dosing especially during pediatric procedures.
"Root causes and contributing factors: Haste and the mammography technician not recognizing the fact that the patient was a pediatric patient.
"Isotope Details: Tc-99m: 24.0 mCi.
"Procedure administered: MIRALUMA study.
"Dose intended: 17.5 mCi of Tc-99m
"Dose Administered: 24.0 mCi of Tc-99m
"Target organ: Breast
"Patient Informed: N
"% Dose Exceeds Prescribed: 37
"Diagnostic Study: Breast (MIRALUMA study)
"Radiopharmaceutical: Tc-99m MIRALUMA
"Effect on Patient: UNKNOWN
"Source/Radioactive Material: UNSEALED SOURCE RADIOPHARM
"Manufacturer: Cardinal Health PSC
"Model Number: 190"
Nevada Report No.: NV100011
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.
"Narrative: On 7/21/2010 at 12:00 p.m at the Hot Lab: 17 yr old patient came in for MIRALUMA study. STD dose is 25 mCi of Tc-99m MIRALUMA. Based on patient weight, (105 lbs), pediatric dose is calculated at 17.5 mCi. IV was started by mammography technician. Nuclear medicine technician went to physician to notify about pediatric dose. At this time, mammography technician assayed dose at 24.0 mCi and injected patient.
"Reported to the Nevada Radiation Control Program at around 3:00 p.m.
"The event is NRC reportable under 10CFR35.3045, since it is a dose different from the prescribed dose. Since 10 CFR 35 has been adopted by the state, it is reportable under state requirements too.
"Persons involved: Pediatric patient, mammography technician and nuclear medicine technician.
"Corrective Actions: Communication and cross-checking correct dosing especially during pediatric procedures.
"Root causes and contributing factors: Haste and the mammography technician not recognizing the fact that the patient was a pediatric patient.
"Isotope Details: Tc-99m: 24.0 mCi.
"Procedure administered: MIRALUMA study.
"Dose intended: 17.5 mCi of Tc-99m
"Dose Administered: 24.0 mCi of Tc-99m
"Target organ: Breast
"Patient Informed: N
"% Dose Exceeds Prescribed: 37
"Diagnostic Study: Breast (MIRALUMA study)
"Radiopharmaceutical: Tc-99m MIRALUMA
"Effect on Patient: UNKNOWN
"Source/Radioactive Material: UNSEALED SOURCE RADIOPHARM
"Manufacturer: Cardinal Health PSC
"Model Number: 190"
Nevada Report No.: NV100011
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.