Event Notification Report for July 14, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/13/2015 - 07/14/2015
Agreement State
Event Number: 51233
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY HOSPITALS OF CLEVELAND
Region: 3
City: CLEVELAND State: OH
County: CUYAHOGA
License #: OH-0211018007
Agreement: Y
Docket:
NRC Notified By: KARL VAN AHN
HQ OPS Officer: VINCE KLCO
Licensee: UNIVERSITY HOSPITALS OF CLEVELAND
Region: 3
City: CLEVELAND State: OH
County: CUYAHOGA
License #: OH-0211018007
Agreement: Y
Docket:
NRC Notified By: KARL VAN AHN
HQ OPS Officer: VINCE KLCO
Notification Date: 07/15/2015
Notification Time: 10:50 [ET]
Event Date: 07/14/2015
Event Time: 10:30 [EDT]
Last Update Date: 07/15/2015
Notification Time: 10:50 [ET]
Event Date: 07/14/2015
Event Time: 10:30 [EDT]
Last Update Date: 07/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICA
AGREEMENT STATE REPORT - DOSE TO IMPROPER TREATMENT SITE
The following information was received by the State of Ohio via email:
"On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]."
Ohio Report: OH150007
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 by the State of Ohio via email:
"On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]."
Ohio Report: OH150007
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: 51231
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MICHAEL BROOKS
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MICHAEL BROOKS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/14/2015
Notification Time: 22:59 [ET]
Event Date: 07/14/2015
Event Time: 17:15 [CDT]
Last Update Date: 07/14/2015
Notification Time: 22:59 [ET]
Event Date: 07/14/2015
Event Time: 17:15 [CDT]
Last Update Date: 07/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
GERALD MCCOY (R2DO)
SCOTT MORRIS (NRR)
WILLIAM GOTT (IRD)
GERALD MCCOY (R2DO)
SCOTT MORRIS (NRR)
WILLIAM GOTT (IRD)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 99 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 99 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 99 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
"At 1810 (Central Daylight Time) on July 14, 2015, Browns Ferry Units 1, 2, and 3 initiated actions to commence a reactor shutdown to comply with TS [Technical Specifications] LCO 3.0.3. TS LCO 3.0.3 was entered at 1715 (Central Daylight Time) due to concurrent losses of the A and B Control Bay Chillers. This resulted in a loss of cooling to the U1 and U2 4kV Shutdown Board Rooms. Required actions for the loss of cooling to the U1 and U2 4kV Shutdown Board Rooms are to declare the electrical equipment in the 4kV Shutdown Board Rooms inoperable. The declaration of inoperability of the equipment supported by the U1 and U2 4kV Shutdown Boards resulted in TS LCO 3.0.3 for Units 1, 2, and 3. TS LCO 3.0.3 requires actions to be initiated within one hour to place the affected units in MODE 2 within 10 hours; MODE 3 within 13 hours; and MODE 4 within 37 hours.
"This event requires a 4-hour report in accordance with 50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.'
"The NRC Resident Inspector has been notified.
"Condition Report #1056829 has been initiated in the Corrective Action Program."
The 4kV shutdown electrical boards are required in all modes of operation.
"At 1810 (Central Daylight Time) on July 14, 2015, Browns Ferry Units 1, 2, and 3 initiated actions to commence a reactor shutdown to comply with TS [Technical Specifications] LCO 3.0.3. TS LCO 3.0.3 was entered at 1715 (Central Daylight Time) due to concurrent losses of the A and B Control Bay Chillers. This resulted in a loss of cooling to the U1 and U2 4kV Shutdown Board Rooms. Required actions for the loss of cooling to the U1 and U2 4kV Shutdown Board Rooms are to declare the electrical equipment in the 4kV Shutdown Board Rooms inoperable. The declaration of inoperability of the equipment supported by the U1 and U2 4kV Shutdown Boards resulted in TS LCO 3.0.3 for Units 1, 2, and 3. TS LCO 3.0.3 requires actions to be initiated within one hour to place the affected units in MODE 2 within 10 hours; MODE 3 within 13 hours; and MODE 4 within 37 hours.
"This event requires a 4-hour report in accordance with 50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.'
"The NRC Resident Inspector has been notified.
"Condition Report #1056829 has been initiated in the Corrective Action Program."
The 4kV shutdown electrical boards are required in all modes of operation.