Event Notification Report for November 05, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/04/2015 - 11/05/2015
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 51520
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT 1800494
Agreement: Y
Docket:
NRC Notified By: MIKE GIVENS
HQ OPS Officer: JOHN SHOEMAKER
Licensee: INTERMOUNTAIN MEDICAL CENTER
Region: 4
City: MURRAY State: UT
County:
License #: UT 1800494
Agreement: Y
Docket:
NRC Notified By: MIKE GIVENS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/06/2015
Notification Time: 20:24 [ET]
Event Date: 11/05/2015
Event Time: 00:00 [MST]
Last Update Date: 01/26/2016
Notification Time: 20:24 [ET]
Event Date: 11/05/2015
Event Time: 00:00 [MST]
Last Update Date: 01/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following report was received from the State of Utah via email:
"On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma.
"It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.)
"The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation."
Utah Event Report No.: UT150005
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.
* * * EVENT RETRACTION FROM GYWN CALLOWAY TO JOHN SHOEMAKER AT 1919 EST ON 1/26/16 * * *
The State of Utah (Division of Waste Management) has received additional information, from the licensee, indicating that the actual underdose to the patient was < 5% and does not meet the reportability criteria. Therefore, this event is being retracted.
Notified the R4DO (Farnholtz) and NMSS Events Notification via email.
The following report was received from the State of Utah via email:
"On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma.
"It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.)
"The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation."
Utah Event Report No.: UT150005
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.
* * * EVENT RETRACTION FROM GYWN CALLOWAY TO JOHN SHOEMAKER AT 1919 EST ON 1/26/16 * * *
The State of Utah (Division of Waste Management) has received additional information, from the licensee, indicating that the actual underdose to the patient was < 5% and does not meet the reportability criteria. Therefore, this event is being retracted.
Notified the R4DO (Farnholtz) and NMSS Events Notification via email.
Power Reactor
Event Number: 51516
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/05/2015
Notification Time: 10:32 [ET]
Event Date: 11/05/2015
Event Time: 10:00 [EST]
Last Update Date: 11/05/2015
Notification Time: 10:32 [ET]
Event Date: 11/05/2015
Event Time: 10:00 [EST]
Last Update Date: 11/05/2015
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):
ROBERT ORLIKOWSKI (R3DO)
ROBERT ORLIKOWSKI (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
INTEGRATED PLANT COMPUTER SYSTEM REMOVED FROM SERVICE
"On November 5, 2015 at approximately 1000 EST, the Fermi 2 Integrated Plant Computer System (IPCS) was removed from service for planned maintenance on the Uninterruptible Power Supply (UPS) vital bus power supply. The Safety Parameter Display System (SPDS) resides on the IPCS platform and will be out of service and unavailable to Emergency Response Facilities (ERFs) during the time that IPCS is removed from service. The duration of work is expected to be approximately 48 hours. During this time dose assessment (Raddose) capability will only be available in the manual data input mode. The majority of the Control Room indications remain available to the plant staff and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS is completely restored, including SPDS to the Operational Support Center, the Technical Support Center, and alternate facilities. The plant is currently in Mode 5, and will remain in Mode 5, for the duration of the IPCS and SPDS unavailability. This 8-hour non-emergency notification is being made per the requirements of 10 CFR 50.72(b)(3)(xiii), as an event that results in a major loss of emergency assessment capability, as described in NEI 13-01.
"The NRC Resident Inspector has been notified."
"On November 5, 2015 at approximately 1000 EST, the Fermi 2 Integrated Plant Computer System (IPCS) was removed from service for planned maintenance on the Uninterruptible Power Supply (UPS) vital bus power supply. The Safety Parameter Display System (SPDS) resides on the IPCS platform and will be out of service and unavailable to Emergency Response Facilities (ERFs) during the time that IPCS is removed from service. The duration of work is expected to be approximately 48 hours. During this time dose assessment (Raddose) capability will only be available in the manual data input mode. The majority of the Control Room indications remain available to the plant staff and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS is completely restored, including SPDS to the Operational Support Center, the Technical Support Center, and alternate facilities. The plant is currently in Mode 5, and will remain in Mode 5, for the duration of the IPCS and SPDS unavailability. This 8-hour non-emergency notification is being made per the requirements of 10 CFR 50.72(b)(3)(xiii), as an event that results in a major loss of emergency assessment capability, as described in NEI 13-01.
"The NRC Resident Inspector has been notified."