Event Notification Report for April 22, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/21/2015 - 04/22/2015
Power Reactor
Event Number: 51005
Facility: SUMMER
Region: 2 State: SC
Unit: [] [2] [3]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: APRIL RICE
HQ OPS Officer: DONG HWA PARK
Region: 2 State: SC
Unit: [] [2] [3]
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: APRIL RICE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/23/2015
Notification Time: 13:18 [ET]
Event Date: 04/22/2015
Event Time: 15:28 [EDT]
Last Update Date: 04/23/2015
Notification Time: 13:18 [ET]
Event Date: 04/22/2015
Event Time: 15:28 [EDT]
Last Update Date: 04/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ALAN BLAMEY (R2DO)
ALAN BLAMEY (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Under Construction | 0 | Under Construction |
| 3 | N | N | 0 | Under Construction | 0 | Under Construction |
VIOLATION OF THE FITNESS FOR DUTY PROGRAM
A contract employee supervisor willfully acted to avoid a random fitness-for-duty test. The individual left the construction site after the notification to report to the fitness-for-duty office. The employees access to the plant has been terminated.
The licensee has notified the NRC Resident Inspector.
A contract employee supervisor willfully acted to avoid a random fitness-for-duty test. The individual left the construction site after the notification to report to the fitness-for-duty office. The employees access to the plant has been terminated.
The licensee has notified the NRC Resident Inspector.
Agreement State
Event Number: 51009
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BAYSTATE HEALTH
Region: 1
City: SPRINGFIELD State: MA
County:
License #: 60-0095
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: VINCE KLCO
Licensee: BAYSTATE HEALTH
Region: 1
City: SPRINGFIELD State: MA
County:
License #: 60-0095
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: VINCE KLCO
Notification Date: 04/24/2015
Notification Time: 09:22 [ET]
Event Date: 04/22/2015
Event Time: 00:00 [EDT]
Last Update Date: 04/24/2015
Notification Time: 09:22 [ET]
Event Date: 04/22/2015
Event Time: 00:00 [EDT]
Last Update Date: 04/24/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
JAMES NOGGLE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
AGREEMENT STATE REPORT - BULK DOSE ADMINISTERED TO PATIENT
The following information was received from the Commonwealth of Massachusetts via email:
"The licensee's Radiation Safety Officer (RSO) reported on April 23, 2015 that, on the morning of April 22, 2015, the licensee mistakenly administered to a patient the wrong radioactive drug, a 118 mCi Tc-99m bulk dose instead of the prescribed 12.9 mCi Tc-99m Sestamibi dose, at the licensee's Baystate Franklin Medical Center facility.
"The wrong radioactive drug administered was reported by the licensee's RSO to have resulted in 5.6 rem effective dose equivalent to the patient, a reportable medical event in accordance with 105 CMR 120.594(A)(1)(b)1.
"The licensee's RSO reported that the patient and the referring physician have been notified and that the RSO did not expect any harm to the patient.
"The RSO reported the cause included that proper procedures were not followed.
"The Agency (Massachusetts Radiation Control Program) plans to perform a special inspection and considers this event to be open."
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 Commonwealth of Massachusetts via email:
"The licensee's Radiation Safety Officer (RSO) reported on April 23, 2015 that, on the morning of April 22, 2015, the licensee mistakenly administered to a patient the wrong radioactive drug, a 118 mCi Tc-99m bulk dose instead of the prescribed 12.9 mCi Tc-99m Sestamibi dose, at the licensee's Baystate Franklin Medical Center facility.
"The wrong radioactive drug administered was reported by the licensee's RSO to have resulted in 5.6 rem effective dose equivalent to the patient, a reportable medical event in accordance with 105 CMR 120.594(A)(1)(b)1.
"The licensee's RSO reported that the patient and the referring physician have been notified and that the RSO did not expect any harm to the patient.
"The RSO reported the cause included that proper procedures were not followed.
"The Agency (Massachusetts Radiation Control Program) plans to perform a special inspection and considers this event to be open."
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.