Event Notification Report for July 28, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/27/2020 - 07/28/2020
Power Reactor
Event Number: 54803
Facility: Prairie Island
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Logan Miller
HQ OPS Officer: Andrew Waugh
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Logan Miller
HQ OPS Officer: Andrew Waugh
Notification Date: 07/29/2020
Notification Time: 04:28 [ET]
Event Date: 07/28/2020
Event Time: 19:49 [CDT]
Last Update Date: 07/29/2020
Notification Time: 04:28 [ET]
Event Date: 07/28/2020
Event Time: 19:49 [CDT]
Last Update Date: 07/29/2020
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):
MICHAEL KUNOWSKI (R3DO)
MICHAEL KUNOWSKI (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FAILED RADIATION DETECTOR
"Radiation monitor RE-69, 'Guardhouse Area Radiation Detector' was found failed on operator rounds. RE-69 is a category A1 piece of equipment that provides the sole means of indication for a parameter used to directly assess emergency action level (EAL) RA3.1, 'dose rate greater than 15 mR/hr in either of the following areas: Control Room (R-1), Central Alarm Station (R-69).' A compensatory measure was subsequently established and the ability to assess EAL RA3.1 has been restored."
There was no impact on the health and safety of the public or plant personnel. The NRC Senior Resident Inspector has been notified.
"Radiation monitor RE-69, 'Guardhouse Area Radiation Detector' was found failed on operator rounds. RE-69 is a category A1 piece of equipment that provides the sole means of indication for a parameter used to directly assess emergency action level (EAL) RA3.1, 'dose rate greater than 15 mR/hr in either of the following areas: Control Room (R-1), Central Alarm Station (R-69).' A compensatory measure was subsequently established and the ability to assess EAL RA3.1 has been restored."
There was no impact on the health and safety of the public or plant personnel. The NRC Senior Resident Inspector has been notified.
Agreement State
Event Number: 54804
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: KishHealth System
Region: 3
City: Dekalb State: IL
County:
License #: IL-02097-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Thomas Herrity
Licensee: KishHealth System
Region: 3
City: Dekalb State: IL
County:
License #: IL-02097-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Thomas Herrity
Notification Date: 07/29/2020
Notification Time: 13:43 [ET]
Event Date: 07/28/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/29/2020
Notification Time: 13:43 [ET]
Event Date: 07/28/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/29/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT- PATIENT UNDERDOSE
The following was received from the Illinois Emergency Management Agency (IEMA) via email:
"KishHealth System in Dekalb, IL (d/b/a Kishwaukee Community Hospital) contacted the IEMA at approximately 1100 CDT on 7/29/20 to report a patient scheduled to receive Y-90 microsphere therapy for hepatocellular cancer received only 58% of the dose prescribed in the written directive. While investigation is ongoing, the reportable underdose is based on licensee's pre and post-administration measurements of the dose vial and waste container, respectively.
"IEMA staff have contacted the licensee and are seeking additional information on post-administration imaging, status of patient/referring AU notification, the nature of the written directive (i.e., was this a fractionated dose), and the members of the treatment team. These factors, among others, will determine regulatory compliance as well as patient impact. Therefore, this report will be updated as information becomes available. IEMA is dispatching staff today (7/29/20) for a reactionary inspection. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days."
Illinois item number: IL200013
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 was received from the Illinois Emergency Management Agency (IEMA) via email:
"KishHealth System in Dekalb, IL (d/b/a Kishwaukee Community Hospital) contacted the IEMA at approximately 1100 CDT on 7/29/20 to report a patient scheduled to receive Y-90 microsphere therapy for hepatocellular cancer received only 58% of the dose prescribed in the written directive. While investigation is ongoing, the reportable underdose is based on licensee's pre and post-administration measurements of the dose vial and waste container, respectively.
"IEMA staff have contacted the licensee and are seeking additional information on post-administration imaging, status of patient/referring AU notification, the nature of the written directive (i.e., was this a fractionated dose), and the members of the treatment team. These factors, among others, will determine regulatory compliance as well as patient impact. Therefore, this report will be updated as information becomes available. IEMA is dispatching staff today (7/29/20) for a reactionary inspection. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days."
Illinois item number: IL200013
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.