Event Notification Report for October 12, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/11/2017 - 10/12/2017
Power Reactor
Event Number: 53010
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JORGE RODRIGUEZ
HQ OPS Officer: RICHARD SMITH
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JORGE RODRIGUEZ
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/12/2017
Notification Time: 20:26 [ET]
Event Date: 10/12/2017
Event Time: 09:30 [MST]
Last Update Date: 10/12/2017
Notification Time: 20:26 [ET]
Event Date: 10/12/2017
Event Time: 09:30 [MST]
Last Update Date: 10/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
FFD GROUP (EMAI)
THOMAS HIPSCHMAN (R4DO)
FFD GROUP (EMAI)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
FITNESS FOR DUTY - POSITIVE FOR ILLEGAL DRUGS DURING INITIAL SCREENING
A contract employee supervisor had a confirmed positive for illegal drugs during an initial screening test. The individual's access to the plant has been terminated.
The NRC Resident Inspector has been notified by the Licensee.
A contract employee supervisor had a confirmed positive for illegal drugs during an initial screening test. The individual's access to the plant has been terminated.
The NRC Resident Inspector has been notified by the Licensee.
Agreement State
Event Number: 53011
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ADENA REGIONAL MEDICAL CENTER
Region: 3
City: CHILLICOTHE State: OH
County: ROSS
License #: 02120720000
Agreement: Y
Docket:
NRC Notified By: MICHAEL J. RUBADUE
HQ OPS Officer: RICHARD SMITH
Licensee: ADENA REGIONAL MEDICAL CENTER
Region: 3
City: CHILLICOTHE State: OH
County: ROSS
License #: 02120720000
Agreement: Y
Docket:
NRC Notified By: MICHAEL J. RUBADUE
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 13:45 [ET]
Event Date: 10/12/2017
Event Time: 11:05 [EDT]
Last Update Date: 10/13/2017
Notification Time: 13:45 [ET]
Event Date: 10/12/2017
Event Time: 11:05 [EDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED
The following information was received from the State of Ohio via email:
"On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. [EDT], the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination."
The patient was informed on the day of the event.
Ohio Item Number: OH170006
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 Ohio via email:
"On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. [EDT], the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination."
The patient was informed on the day of the event.
Ohio Item Number: OH170006
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.