Event Notification Report for January 20, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/19/2012 - 01/20/2012
EVENT NUMBERS
47611476124761447965
Power Reactor
Event Number: 47611
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: GREG RABALAIS
HQ OPS Officer: JOHN KNOKE
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: GREG RABALAIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/20/2012
Notification Time: 14:45 [ET]
Event Date: 01/20/2012
Event Time: 08:33 [EST]
Last Update Date: 01/20/2012
Notification Time: 14:45 [ET]
Event Date: 01/20/2012
Event Time: 08:33 [EST]
Last Update Date: 01/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
RONALD BELLAMY (R1DO)
RONALD BELLAMY (R1DO)
| 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 |
FITNESS FOR DUTY - CONFIRMED POSITIVE ALCOHOL TEST
A non-licensed, employee supervisor had a confirmed positive test for alcohol. The individual's unescorted access has been administratively withdrawn. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
A non-licensed, employee supervisor had a confirmed positive test for alcohol. The individual's unescorted access has been administratively withdrawn. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 47612
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/20/2012
Notification Time: 19:12 [ET]
Event Date: 01/20/2012
Event Time: 14:09 [EST]
Last Update Date: 01/20/2012
Notification Time: 19:12 [ET]
Event Date: 01/20/2012
Event Time: 14:09 [EST]
Last Update Date: 01/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)
RONALD BELLAMY (R1DO)
BRUCE WATSON (FSME)
AGREEMENT STATE REPORT - MISADMINISTRATION OF DOSE TO PATIENT
The following information was provided by the Commonwealth of Pennsylvania via facsimile:
"On January 20, 2012, at 1409 EST, the Department's [PA Bureau of Radiation Protection] southeast regional office received notification via phone call about this ME [Medical Event].
"On January 19, 2012, a worksheet was prepared for two patients who were to be treated on the same day, close in time. The worksheets were switched and each patient received the other patient's dose. The first patient reached stasis before receiving the full amount and received a dose 35% above the planned dose. The second patient received 55% less than what was planned.
"CAUSE OF THE EVENT: Human error.
"ACTIONS: No adverse effects are expected from the overdose to the first patient. The second patient will receive a higher dose than planned at their next schedule treatment. The licensee plans on modifying their current procedures to prevent this event from occurring again. The Department plans to do a reactive inspection."
Event Report 10 No: PA120005
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 provided by the Commonwealth of Pennsylvania via facsimile:
"On January 20, 2012, at 1409 EST, the Department's [PA Bureau of Radiation Protection] southeast regional office received notification via phone call about this ME [Medical Event].
"On January 19, 2012, a worksheet was prepared for two patients who were to be treated on the same day, close in time. The worksheets were switched and each patient received the other patient's dose. The first patient reached stasis before receiving the full amount and received a dose 35% above the planned dose. The second patient received 55% less than what was planned.
"CAUSE OF THE EVENT: Human error.
"ACTIONS: No adverse effects are expected from the overdose to the first patient. The second patient will receive a higher dose than planned at their next schedule treatment. The licensee plans on modifying their current procedures to prevent this event from occurring again. The Department plans to do a reactive inspection."
Event Report 10 No: PA120005
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: 47614
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: JOSEPH BRACKEN
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: JOSEPH BRACKEN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/21/2012
Notification Time: 04:00 [ET]
Event Date: 01/20/2012
Event Time: 22:37 [EST]
Last Update Date: 01/21/2012
Notification Time: 04:00 [ET]
Event Date: 01/20/2012
Event Time: 22:37 [EST]
Last Update Date: 01/21/2012
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):
RONALD BELLAMY (R1DO)
RONALD BELLAMY (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF ASSESSMENT CAPABILITY - SAFETY PARAMETER DISPLAY SYSTEM
"At 2237 EST on Friday, January 20, 2012, with the reactor at 100% core thermal power, the Pilgrim Nuclear Power Station (PNPS) determined that portions of the in-plant Safety Parameter Display System (SPDS) were not functioning as designed due to potential problems with the plant process computer. Specifically, the SPDS, which provides numerous plant parameters, some of which are credited for emergency assessment capability, are not currently available. The initial investigation has determined that the failure has not impacted the entire SPDS, but has the potential to impair the licensee's safety assessment capability at this time.
"Immediate actions are being taken to restore the system to functional status and applicable plant procedures have been entered to determine any further mitigating actions.
"This event had no impact on the health and/or safety of the public.
"The licensee has notified the NRC Resident Inspector.
"This notification is conservatively being made in accordance with 10 CFR 50.72 (b)(3)(xiii)."
There is no impact to plant operations. The licensee will be notifying the Commonwealth of Massachusetts.
"At 2237 EST on Friday, January 20, 2012, with the reactor at 100% core thermal power, the Pilgrim Nuclear Power Station (PNPS) determined that portions of the in-plant Safety Parameter Display System (SPDS) were not functioning as designed due to potential problems with the plant process computer. Specifically, the SPDS, which provides numerous plant parameters, some of which are credited for emergency assessment capability, are not currently available. The initial investigation has determined that the failure has not impacted the entire SPDS, but has the potential to impair the licensee's safety assessment capability at this time.
"Immediate actions are being taken to restore the system to functional status and applicable plant procedures have been entered to determine any further mitigating actions.
"This event had no impact on the health and/or safety of the public.
"The licensee has notified the NRC Resident Inspector.
"This notification is conservatively being made in accordance with 10 CFR 50.72 (b)(3)(xiii)."
There is no impact to plant operations. The licensee will be notifying the Commonwealth of Massachusetts.
Agreement State
Event Number: 47965
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CANONSBURG HOSPITAL
Region: 1
City: CANONSBURG State: PA
County:
License #: PA-0393
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Licensee: CANONSBURG HOSPITAL
Region: 1
City: CANONSBURG State: PA
County:
License #: PA-0393
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/25/2012
Notification Time: 14:19 [ET]
Event Date: 01/20/2012
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2012
Notification Time: 14:19 [ET]
Event Date: 01/20/2012
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1DO)
FSME VIA EMAIL
JAMES TRAPP (R1DO)
FSME VIA EMAIL
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING IODINE-125 PROSTATE SEEDS
The following information was obtained from the Commonwealth of Pennsylvania via fax:
"A patient was undergoing treatment with I-125 prostate seeds on January 20, 2012. The patient was prescribed to receive 110 Gy for a determined prostate volume of 21.08 cc. On March 16, 2012 the patient had a follow up CT scan where the prostate volume was determined to be 47 cc and the D90 to the prostate to be 75 Gy. The oncologist questioned the results and ordered an additional CT scan. On May 16, 2012, a second CT scan was performed to confirm the first CT scan. On May 21, 2012, the radiology oncologist calculated the prostate volume to be 33.59 cc and confirmed the D90 to be 75 Gy. The radiation oncologist has no explanation for the edema.
"Cause of the Event: Implant performed using ultrasound, post implant verification via CT.
"Actions: There will be a reactive inspection [by the Commonwealth of Pennsylvania]. The radiation oncologist ordered external beam radiation therapy and feels that the total dose is sufficient. Additional follow up with the patient will occur."
PA Report ID No.: PA120018
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 Commonwealth of Pennsylvania via fax:
"A patient was undergoing treatment with I-125 prostate seeds on January 20, 2012. The patient was prescribed to receive 110 Gy for a determined prostate volume of 21.08 cc. On March 16, 2012 the patient had a follow up CT scan where the prostate volume was determined to be 47 cc and the D90 to the prostate to be 75 Gy. The oncologist questioned the results and ordered an additional CT scan. On May 16, 2012, a second CT scan was performed to confirm the first CT scan. On May 21, 2012, the radiology oncologist calculated the prostate volume to be 33.59 cc and confirmed the D90 to be 75 Gy. The radiation oncologist has no explanation for the edema.
"Cause of the Event: Implant performed using ultrasound, post implant verification via CT.
"Actions: There will be a reactive inspection [by the Commonwealth of Pennsylvania]. The radiation oncologist ordered external beam radiation therapy and feels that the total dose is sufficient. Additional follow up with the patient will occur."
PA Report ID No.: PA120018
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.