Event Notification Report for January 18, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/17/2013 - 01/18/2013
Power Reactor
Event Number: 48681
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: LT. EARSLEY
HQ OPS Officer: PETE SNYDER
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: LT. EARSLEY
HQ OPS Officer: PETE SNYDER
Notification Date: 01/18/2013
Notification Time: 15:37 [ET]
Event Date: 01/18/2013
Event Time: 12:40 [CST]
Last Update Date: 01/18/2013
Notification Time: 15:37 [ET]
Event Date: 01/18/2013
Event Time: 12:40 [CST]
Last Update Date: 01/18/2013
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):
TAMARA BLOOMER (R3DO)
TAMARA BLOOMER (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 |
PANS SYSTEM FALSE ACTIVATION OF 58 SIRENS
There was a false activation signal applied for 3 seconds to site emergency sirens. The licensee notified the State of Minnesota and local government agencies.
The licensee will notify the NRC Resident Inspector.
There was a false activation signal applied for 3 seconds to site emergency sirens. The licensee notified the State of Minnesota and local government agencies.
The licensee will notify the NRC Resident Inspector.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 48784
Rep Org: ST JOSEPH REGIONAL MEDICAL CENTER
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 4
City: LEWISTON State: ID
County:
License #: 11-27371-01
Agreement: N
Docket:
NRC Notified By: DOUG HEIDORN
HQ OPS Officer: VINCE KLCO
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 4
City: LEWISTON State: ID
County:
License #: 11-27371-01
Agreement: N
Docket:
NRC Notified By: DOUG HEIDORN
HQ OPS Officer: VINCE KLCO
Notification Date: 02/26/2013
Notification Time: 12:42 [ET]
Event Date: 01/18/2013
Event Time: 00:00 [MST]
Last Update Date: 03/26/2013
Notification Time: 12:42 [ET]
Event Date: 01/18/2013
Event Time: 00:00 [MST]
Last Update Date: 03/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
DON ALLEN (R4DO)
FSME RESOURCE(email)
DON ALLEN (R4DO)
FSME RESOURCE(email)
UNPLANNED IODINE-131 DOSE TO AN EMBRYO
A female patient with a previously removed thyroid, was treated for remnant thyroid cancer on January 18, 2013. She received an I-131 therapy dose of 58 mCi. On February 21, 2013, the radiation oncologist was informed by the primary physician that the patient had tested positive on a pregnancy test. The patient received an ultrasound on February 25, 2013 and the conception date was determined to be January 14, 2013. Based on the patient therapy activity received, an embryo dose of 15 Rem was calculated. Physician review of the ultrasound was determined to be normal for the embryo. The radiation oncologist is in contact with the primary physician and the patient.
* * * RETRACTION FROM DOUGLAS HEIDORN TO DONALD NORWOOD AT 1324 EDT ON 3/26/2013 * * *
Based on a telephone notification made by Douglas Heidorn, Radiation Safety Officer (RSO) at 1950 EDT on 3/25/2013, it was agreed that a written justification for a retraction would be submitted. The following is a synopsis of what Dr. Heidorn submitted.
The Radiation Oncologist (Prescribing Physician) and RSO originally thought that the fetal dose was 14.6 rem, but upon further investigation, it was determined that the fetal dose was only 52 mrem. The discrepancy in the dose estimate was due to confusion about the exact conception date (fetal age).
The Prescribing Physician has been corresponding with a Professor of Pediatrics and Radiology (Expert Physician) regarding this issue. The Expert Physician believes that conception occurred between 1/27/2013 and 1/29/2013. Another obstetrician at SJRMC and the Referring Physician concur with the Expert Physician's date range for conception. The 52 mrem fetal dose rate is based on this conception date.
On 3/11/2013, a second ultrasound was performed that confirms the above information. Both ultrasound reports indicate the fetus is growing and has normal characteristics.
As a corrective action, the Radiation Department will immediately adopt a policy that requires any female aged 12-60 shall receive a pregnancy test 48 hours prior to an I-131 administration.
Notified R4DO (Pick) and FSME Event Resources (via E-mail).
A female patient with a previously removed thyroid, was treated for remnant thyroid cancer on January 18, 2013. She received an I-131 therapy dose of 58 mCi. On February 21, 2013, the radiation oncologist was informed by the primary physician that the patient had tested positive on a pregnancy test. The patient received an ultrasound on February 25, 2013 and the conception date was determined to be January 14, 2013. Based on the patient therapy activity received, an embryo dose of 15 Rem was calculated. Physician review of the ultrasound was determined to be normal for the embryo. The radiation oncologist is in contact with the primary physician and the patient.
* * * RETRACTION FROM DOUGLAS HEIDORN TO DONALD NORWOOD AT 1324 EDT ON 3/26/2013 * * *
Based on a telephone notification made by Douglas Heidorn, Radiation Safety Officer (RSO) at 1950 EDT on 3/25/2013, it was agreed that a written justification for a retraction would be submitted. The following is a synopsis of what Dr. Heidorn submitted.
The Radiation Oncologist (Prescribing Physician) and RSO originally thought that the fetal dose was 14.6 rem, but upon further investigation, it was determined that the fetal dose was only 52 mrem. The discrepancy in the dose estimate was due to confusion about the exact conception date (fetal age).
The Prescribing Physician has been corresponding with a Professor of Pediatrics and Radiology (Expert Physician) regarding this issue. The Expert Physician believes that conception occurred between 1/27/2013 and 1/29/2013. Another obstetrician at SJRMC and the Referring Physician concur with the Expert Physician's date range for conception. The 52 mrem fetal dose rate is based on this conception date.
On 3/11/2013, a second ultrasound was performed that confirms the above information. Both ultrasound reports indicate the fetus is growing and has normal characteristics.
As a corrective action, the Radiation Department will immediately adopt a policy that requires any female aged 12-60 shall receive a pregnancy test 48 hours prior to an I-131 administration.
Notified R4DO (Pick) and FSME Event Resources (via E-mail).