Event Notification Report for September 16, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/15/2019 - 09/16/2019
Agreement State
Event Number: 54282
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/17/2019
Notification Time: 13:09 [ET]
Event Date: 09/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2019
Notification Time: 13:09 [ET]
Event Date: 09/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 09/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information is a summary of an email received from the state of North Carolina:
On September 16, 2019, a patient at Duke University Medical Center was prescribed 43.2 mCi of Y-90 Theraspheres to the liver, but received 89.6 mCi. While the cause of the misadministration is not clear at this time, it is known that the dose received was intended for a different patient. Both the patient and the authorized user have been informed of the incident.
An inspector has been dispatched to conduct a reactive inspection for this event.
North Carolina Tracking Number: 190032
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 is a summary of an email received from the state of North Carolina:
On September 16, 2019, a patient at Duke University Medical Center was prescribed 43.2 mCi of Y-90 Theraspheres to the liver, but received 89.6 mCi. While the cause of the misadministration is not clear at this time, it is known that the dose received was intended for a different patient. Both the patient and the authorized user have been informed of the incident.
An inspector has been dispatched to conduct a reactive inspection for this event.
North Carolina Tracking Number: 190032
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: 54281
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ROBERT RUSH
HQ OPS Officer: ANDREW WAUGH
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ROBERT RUSH
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/16/2019
Notification Time: 14:35 [ET]
Event Date: 09/16/2019
Event Time: 08:17 [CDT]
Last Update Date: 09/16/2019
Notification Time: 14:35 [ET]
Event Date: 09/16/2019
Event Time: 08:17 [CDT]
Last Update Date: 09/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILLY DICKSON (R3DO)
BILLY DICKSON (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
ACCIDENT MITIGATION
"On 9/16/19 at 0817 CDT, the Division 1 and Division 2 reactor water cleanup (RT) system differential flow instrumentation was declared inoperable due to failing downscale caused by flashing in the sensing lines that occurred during reactor cooldown for refueling outage C1R19. The Division 1 and Division 2 RT differential flow instrumentation were declared inoperable in accordance with Technical Specification 3.3.6.1 Conditions D and E which require restoring at least one division of instruments to operable status within one hour. This condition renders the leakage detection system incapable of performing its safety function, thus it is reportable under 10 CFR 50.72(b)(3)(v)(D).
"In response to the above, system alignment was changed to increase subcooling to restore indication. Division 1 and 2 Division RT differential flow instrumentation were declared operable at 0852 on 9/16/19.
"The NRC Resident Inspector has been notified."
"On 9/16/19 at 0817 CDT, the Division 1 and Division 2 reactor water cleanup (RT) system differential flow instrumentation was declared inoperable due to failing downscale caused by flashing in the sensing lines that occurred during reactor cooldown for refueling outage C1R19. The Division 1 and Division 2 RT differential flow instrumentation were declared inoperable in accordance with Technical Specification 3.3.6.1 Conditions D and E which require restoring at least one division of instruments to operable status within one hour. This condition renders the leakage detection system incapable of performing its safety function, thus it is reportable under 10 CFR 50.72(b)(3)(v)(D).
"In response to the above, system alignment was changed to increase subcooling to restore indication. Division 1 and 2 Division RT differential flow instrumentation were declared operable at 0852 on 9/16/19.
"The NRC Resident Inspector has been notified."