Event Notification Report for August 18, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/17/2010 - 08/18/2010
Power Reactor
Event Number: 46188
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DELBERT ELKINTON
HQ OPS Officer: JOHN KNOKE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DELBERT ELKINTON
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/18/2010
Notification Time: 16:30 [ET]
Event Date: 08/18/2010
Event Time: 07:42 [MST]
Last Update Date: 08/19/2010
Notification Time: 16:30 [ET]
Event Date: 08/18/2010
Event Time: 07:42 [MST]
Last Update Date: 08/19/2010
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):
GEOFFREY MILLER (R4DO)
GEOFFREY MILLER (R4DO)
| 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 |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF SEVERAL PUBLIC WARNING SYSTEM SIRENS
"On August 18, 2010, at approximately 0742 Mountain Standard Time (MST), the Palo Verde Emergency Preparedness Department discovered that public warning system sirens Nos. 17, 23, and 34 were not responding, and therefore, were out of service. The loss of these sirens could potentially impact a population of approximately 1800 people in the 5-mile emergency planning zone (EPZ). Since the loss of these sirens could impair Arizona Public Service Company's ability to inform greater than 5% of the population within the EPZ, this notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii). If an event occurs while the sirens are out of service, the Palo Verde Emergency Plan has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area. The MCSO is prepared to implement this contingency should it become necessary. Troubleshooting to determine the cause of the failure has commenced.
"The NRC Resident Inspector has been notified of the out of service sirens and this ENS call.
"[At the time of the notification to the NRC], siren #23 was restored at 1316 MST. The out of service sirens are now Nos. 17 and 34 with an affected population of 1196 within the 5 mile EPZ."
* * * UPDATE FROM ELKINTON TO HUFFMAN AT 1104 EDT ON 8/19/10 * * *
The licensee restored siren #17 at 1647 MST on 8/18/10. The restoration of this siren provided coverage to all the population within the 5-mile EPZ. The licensee has notified the NRC Resident Inspector and will also notify State and local authorities. R4DO (Miller) notified.
"On August 18, 2010, at approximately 0742 Mountain Standard Time (MST), the Palo Verde Emergency Preparedness Department discovered that public warning system sirens Nos. 17, 23, and 34 were not responding, and therefore, were out of service. The loss of these sirens could potentially impact a population of approximately 1800 people in the 5-mile emergency planning zone (EPZ). Since the loss of these sirens could impair Arizona Public Service Company's ability to inform greater than 5% of the population within the EPZ, this notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii). If an event occurs while the sirens are out of service, the Palo Verde Emergency Plan has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area. The MCSO is prepared to implement this contingency should it become necessary. Troubleshooting to determine the cause of the failure has commenced.
"The NRC Resident Inspector has been notified of the out of service sirens and this ENS call.
"[At the time of the notification to the NRC], siren #23 was restored at 1316 MST. The out of service sirens are now Nos. 17 and 34 with an affected population of 1196 within the 5 mile EPZ."
* * * UPDATE FROM ELKINTON TO HUFFMAN AT 1104 EDT ON 8/19/10 * * *
The licensee restored siren #17 at 1647 MST on 8/18/10. The restoration of this siren provided coverage to all the population within the 5-mile EPZ. The licensee has notified the NRC Resident Inspector and will also notify State and local authorities. R4DO (Miller) notified.
General Information or Other
Event Number: 46189
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County: COOK
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Licensee: RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County: COOK
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2010
Notification Time: 16:56 [ET]
Event Date: 08/18/2010
Event Time: 00:00 [CDT]
Last Update Date: 08/19/2010
Notification Time: 16:56 [ET]
Event Date: 08/18/2010
Event Time: 00:00 [CDT]
Last Update Date: 08/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NICK VALOS (R3DO)
MARK DELLIGATTI (FSME)
NICK VALOS (R3DO)
MARK DELLIGATTI (FSME)
ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING YTTRIUM-90 UNDER DOSE
The following information was obtained from the State of Illinois via email:
"On the afternoon of August 18, [REDACTED], the licensee's Radiation Safety Officer [RSO] called the Agency [Illinois Emergency Management Agency] to report a medical event in accordance with 32 Ill. Adm. Code 336.1080. The licensee was conducting a treatment involving the use of colloidal Y-90 'SIR-Spheres' under consultation with the manufacturer's representative. A dose of 15.4 milliCi was prescribed by the authorized user and the entire volume of material appeared to be delivered without any unexpected complications, including a complete repeated flushing of the delivery line. However, measurements of the associated tubing, vial and other contaminated items in accordance with accepted procedures showed a notable quantity of Y-90 remained. It was subsequently determined that the dose received was less than 80% of the intended dose. [The RSO] contacted the Agency within the prescribed notification period after verifying the measurements and calculations. The Medical Center also notified the attending physician and the patient the same day. Estimates are that 72% [11.1 milliCi] of the intended dose was delivered.
"[The RSO] was advised of the regulatory reporting requirements and was beginning preparations for providing that information. Initially, it is believed that the underdose will not have any adverse effect on the patient. The prescribed treatment was intended as a palliative measure for liver tumors secondary to colon cancer. [The RSO] was asked to obtain the opinion of the manufacturer's rep as to the cause of the underdose and any recommended corrective actions the manufacturer suggests in these treatments. [The RSO] was also requested to provide the initial corrective action the hospital intends to take for this and subsequent treatments.
"A separate conversation was held with the authorized physician user [REDACTED] who attended and oversaw the patient treatment. [The physician] advised that there were no spills, leaks, adverse patient reactions or shunting of the dose outside of the hepatic artery that led to the underdose. Comments from all involved at the time of the treatment, including the manufacturer's representative, was that the administration of the palliative treatment was as good as could be expected and there were no visual indications that any anomalies were present in delivery of the dose. Patient will undergo PET and CT scans in 6 weeks and 12 weeks respectively to determine if any additional actions are warranted such as making up the difference in dose, conducting a repeat of the treatment or if taking no action at all is appropriate. The overriding issue will be the patient's general quality of life. At this point, preliminary indications are that no changes in procedures or processes are necessary and that general delivery system design, coupled with characteristics of material to be administered, resulted in the unintended coagulation and accumulation of microspheres either within the Sir-Sphere three way stopcock or the microcatheter despite routine agitation of the suspension delivery vial."
Illinois Case Number: IL10055
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 obtained from the State of Illinois via email:
"On the afternoon of August 18, [REDACTED], the licensee's Radiation Safety Officer [RSO] called the Agency [Illinois Emergency Management Agency] to report a medical event in accordance with 32 Ill. Adm. Code 336.1080. The licensee was conducting a treatment involving the use of colloidal Y-90 'SIR-Spheres' under consultation with the manufacturer's representative. A dose of 15.4 milliCi was prescribed by the authorized user and the entire volume of material appeared to be delivered without any unexpected complications, including a complete repeated flushing of the delivery line. However, measurements of the associated tubing, vial and other contaminated items in accordance with accepted procedures showed a notable quantity of Y-90 remained. It was subsequently determined that the dose received was less than 80% of the intended dose. [The RSO] contacted the Agency within the prescribed notification period after verifying the measurements and calculations. The Medical Center also notified the attending physician and the patient the same day. Estimates are that 72% [11.1 milliCi] of the intended dose was delivered.
"[The RSO] was advised of the regulatory reporting requirements and was beginning preparations for providing that information. Initially, it is believed that the underdose will not have any adverse effect on the patient. The prescribed treatment was intended as a palliative measure for liver tumors secondary to colon cancer. [The RSO] was asked to obtain the opinion of the manufacturer's rep as to the cause of the underdose and any recommended corrective actions the manufacturer suggests in these treatments. [The RSO] was also requested to provide the initial corrective action the hospital intends to take for this and subsequent treatments.
"A separate conversation was held with the authorized physician user [REDACTED] who attended and oversaw the patient treatment. [The physician] advised that there were no spills, leaks, adverse patient reactions or shunting of the dose outside of the hepatic artery that led to the underdose. Comments from all involved at the time of the treatment, including the manufacturer's representative, was that the administration of the palliative treatment was as good as could be expected and there were no visual indications that any anomalies were present in delivery of the dose. Patient will undergo PET and CT scans in 6 weeks and 12 weeks respectively to determine if any additional actions are warranted such as making up the difference in dose, conducting a repeat of the treatment or if taking no action at all is appropriate. The overriding issue will be the patient's general quality of life. At this point, preliminary indications are that no changes in procedures or processes are necessary and that general delivery system design, coupled with characteristics of material to be administered, resulted in the unintended coagulation and accumulation of microspheres either within the Sir-Sphere three way stopcock or the microcatheter despite routine agitation of the suspension delivery vial."
Illinois Case Number: IL10055
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.