Event Notification Report for August 13, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/12/2012 - 08/13/2012
Power Reactor
Event Number: 48185
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TONY COOK
HQ OPS Officer: JOHN KNOKE
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TONY COOK
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/13/2012
Notification Time: 19:10 [ET]
Event Date: 08/13/2012
Event Time: 16:30 [EDT]
Last Update Date: 08/13/2012
Notification Time: 19:10 [ET]
Event Date: 08/13/2012
Event Time: 16:30 [EDT]
Last Update Date: 08/13/2012
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):
DANIEL RICH (R2DO)
DANIEL RICH (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 |
OFFSITE NOTIFICATION TO THE NORTH CAROLINA WILDLIFE RESOURCES COMMISSION
"Duke Energy notified the NC Wildlife Resource Commission of dead catfish in the vicinity of the McGuire low level intake. Notification was made on 8/13/12 at 1630 EDT. In addition, the NC Dept. of Environment and Natural Resources will be notified.
"The dead fish are suspected to have been caused by increasing lake temperature and decreased oxygen levels, which is common during the late summer."
The NRC Resident Inspector will be notified.
"Duke Energy notified the NC Wildlife Resource Commission of dead catfish in the vicinity of the McGuire low level intake. Notification was made on 8/13/12 at 1630 EDT. In addition, the NC Dept. of Environment and Natural Resources will be notified.
"The dead fish are suspected to have been caused by increasing lake temperature and decreased oxygen levels, which is common during the late summer."
The NRC Resident Inspector will be notified.
Agreement State
Event Number: 48207
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket: 12-0677
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN SHOEMAKER
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket: 12-0677
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/20/2012
Notification Time: 13:26 [ET]
Event Date: 08/13/2012
Event Time: 00:00 [PDT]
Last Update Date: 08/20/2012
Notification Time: 13:26 [ET]
Event Date: 08/13/2012
Event Time: 00:00 [PDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
FSME_EVENTS RESOURCE (EMAI)
MICHAEL HAY (R4DO)
FSME_EVENTS RESOURCE (EMAI)
AGREEMENT STATE - MEDICAL EVENT INVOLVING DELIVERY OF UNDERDOSAGE
The following information was received from the State of Oregon via email:
"[The licensee reported] a misadministration on Monday, August 13, 2012, during a treatment with [Y-90] TheraSpheres. The misadministration was due to a malfunction of the syringe plunger of the delivery device, and is the first time that this problem has occurred at Oregon Health & Science University.
"This was a two-vial treatment, and the malfunction occurred with the first delivery set. (The activity from the second vial, and with a new delivery set, was administered with no difficulty. Delivery sets are single-use.). The nurse who was setting up the system, and who routinely sets up the systems, noticed a stiffness when she was snapping the plunger into position through the vial septum. She was not able to retract the needles (the plunger is designed not to be removable), and it appeared to be placed properly.
"The physician was informed of the 'stickiness'. The patient's catheter was correctly hooked up to the delivery device, and the catheter in the patient was in the desired position. As soon as the administration was started, blood backed up into the catheter, which was unusual. Normal attempts to administer the activity by pushing saline into the vial resulted in fluid running into the over-pressure vial. The treating physician ended the attempt to deliver the activity, and the system was removed in the normal way by placing the used items in the waste container.
"The second delivery set and the second dose vial were placed in position, the patient catheter hooked up, and the delivery of the activity went smoothly.
"The patient was notified of the problem and of the possibility of a retreat. The Oregon Department of Health Radiation Protection are waiting for the Nordion technical adviser to call mid-day today.
"The Y-90 TheraSphere treatment consisted of:
Vial 1 - Script 66 Gray, Administered 12 Gray, 81.8 % Error of 54 Gray
Vial 2 - Script 55 Gray, Administered 50.2 Gray, 8.7 % Error of 4.8 Gray
Treatment Total - Script 121 Gray, Administered 62.2 Gray, 48.5 % Error of 58.8 Gray"
Oregon Incident # - 12-0031
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 Oregon via email:
"[The licensee reported] a misadministration on Monday, August 13, 2012, during a treatment with [Y-90] TheraSpheres. The misadministration was due to a malfunction of the syringe plunger of the delivery device, and is the first time that this problem has occurred at Oregon Health & Science University.
"This was a two-vial treatment, and the malfunction occurred with the first delivery set. (The activity from the second vial, and with a new delivery set, was administered with no difficulty. Delivery sets are single-use.). The nurse who was setting up the system, and who routinely sets up the systems, noticed a stiffness when she was snapping the plunger into position through the vial septum. She was not able to retract the needles (the plunger is designed not to be removable), and it appeared to be placed properly.
"The physician was informed of the 'stickiness'. The patient's catheter was correctly hooked up to the delivery device, and the catheter in the patient was in the desired position. As soon as the administration was started, blood backed up into the catheter, which was unusual. Normal attempts to administer the activity by pushing saline into the vial resulted in fluid running into the over-pressure vial. The treating physician ended the attempt to deliver the activity, and the system was removed in the normal way by placing the used items in the waste container.
"The second delivery set and the second dose vial were placed in position, the patient catheter hooked up, and the delivery of the activity went smoothly.
"The patient was notified of the problem and of the possibility of a retreat. The Oregon Department of Health Radiation Protection are waiting for the Nordion technical adviser to call mid-day today.
"The Y-90 TheraSphere treatment consisted of:
Vial 1 - Script 66 Gray, Administered 12 Gray, 81.8 % Error of 54 Gray
Vial 2 - Script 55 Gray, Administered 50.2 Gray, 8.7 % Error of 4.8 Gray
Treatment Total - Script 121 Gray, Administered 62.2 Gray, 48.5 % Error of 58.8 Gray"
Oregon Incident # - 12-0031
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.