Event Notification Report for January 03, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/02/2019 - 01/03/2019
Power Reactor
Event Number: 53813
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: JACOB MILLIKEN
HQ OPS Officer: JEFFREY WHITED
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: JACOB MILLIKEN
HQ OPS Officer: JEFFREY WHITED
Notification Date: 01/03/2019
Notification Time: 23:57 [ET]
Event Date: 01/03/2019
Event Time: 20:28 [EST]
Last Update Date: 01/04/2019
Notification Time: 23:57 [ET]
Event Date: 01/03/2019
Event Time: 20:28 [EST]
Last Update Date: 01/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ERIC DUNCAN (R3DO)
ERIC DUNCAN (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 85 | Power Operation | 0 | Hot Standby |
REACTOR TRIP DUE TO CYCLING OF TURBINE GOVERNOR VALVE
"At 2028 [EST] on January 3, 2019, with the reactor at 85% power, the reactor was manually tripped due to cycling of Turbine Governor Valve #4. The trip was uncomplicated with all systems responding normally following the trip. Investigation of the cause of the valve cycling is ongoing.
"All full-length control rods inserted fully. Auxiliary Feedwater System actuated as designed in response to low steam generator water levels. Operations stabilized the plant in Mode 3 (hot standby). Decay heat is being removed by atmospheric dump valves.
"This condition has no impact to the health and safety of the public.
"The licensee notified the NRC Senior Resident Inspector.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A)."
"At 2028 [EST] on January 3, 2019, with the reactor at 85% power, the reactor was manually tripped due to cycling of Turbine Governor Valve #4. The trip was uncomplicated with all systems responding normally following the trip. Investigation of the cause of the valve cycling is ongoing.
"All full-length control rods inserted fully. Auxiliary Feedwater System actuated as designed in response to low steam generator water levels. Operations stabilized the plant in Mode 3 (hot standby). Decay heat is being removed by atmospheric dump valves.
"This condition has no impact to the health and safety of the public.
"The licensee notified the NRC Senior Resident Inspector.
"This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A)."
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 53814
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: MAXWELL AMURAO
HQ OPS Officer: DONALD NORWOOD
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: MAXWELL AMURAO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/04/2019
Notification Time: 12:15 [ET]
Event Date: 01/03/2019
Event Time: 16:00 [CST]
Last Update Date: 01/14/2019
Notification Time: 12:15 [ET]
Event Date: 01/03/2019
Event Time: 16:00 [CST]
Last Update Date: 01/14/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ERIC DUNCAN (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT
A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead.
The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.
* * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *
The following was received via email from the licensee:
"As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, [the licensee radiation safety officer] is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive."
Notified R3DO (PELKE) and NMSS vis email.
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.
A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead.
The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.
* * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *
The following was received via email from the licensee:
"As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, [the licensee radiation safety officer] is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive."
Notified R3DO (PELKE) and NMSS vis email.
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.