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Event Notification Report for June 23, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/22/2005 - 06/23/2005

** EVENT NUMBERS **


41763 41787

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Hospital Event Number: 41763
Rep Org: EDWARD W. SPARROW REGIONAL CENTER
Licensee: EDWARD W. SPARROW REGIONAL CENTER
Region: 3
City: LANSING State: MI
County:
License #: 21-01430-01
Agreement: N
Docket:
NRC Notified By: TRACY MAUDRIE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/10/2005
Notification Time: 14:07 [ET]
Event Date: 06/10/2005
Event Time: [EDT]
Last Update Date: 06/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
TOM ESSIG (NMSS)

Event Text

FRACTIONAL DOSE DELIVERED DIFFERED FROM THE PRESCRIBED DOSE

"A hyperthyroid therapy patient received one of the intended two Nal-131 capsules sent by the radio pharmacy for the therapy. The patient received 10.2 mCi in one capsule instead of the intended 20.6 mCi in two capsules. Both capsules were received in one plastic vial inside of a lead shield. The entire vial was assayed and the assay of 20.6 mCi was within 10% of the prescribed dose of 20.0 mCi. The technologist failed to notice that there were two capsules in the vial because a desiccant inside the vial blocked the view of the second capsule and prevented the second capsule from leaving the vial. Normally, hyperthyroid therapy doses are received in one capsule. Therefore, the technologist was not expecting a second capsule.

"The radio pharmacy discovered the second capsule when the package was returned to the pharmacy the next day, June 10, 2005. They called the Nuclear Medicine department at 8:30 am on June 10, 2005. The prescribing physician was called and he requested that the patient receive the second capsule. The patient returned to the Nuclear Medicine department at 10:00 am on June 10, 2005 and received the second capsule, which assayed at 9.74 mCi at that time. The total dose the patient received was 19.94 mCi.

"Why the event occurred: Hyperthyroid therapy doses are normally received in one capsule. The technologist was not expecting a second capsule. The desiccant placed in the vial by the radio pharmacy obscured the second capsule from the technologist's sight. The desiccant also prevented the second capsule from coming out of the vial when the first capsule came out of the vial.

"Effect on the patient: The prescribing physician does not believe this event will have a negative effect on the patient as she received the remainder of the dose within 24 hours.

"To prevent recurrence of this action the licensee will assay all applicable capsule vials after the patient has received their dose, but before the patient leaves the department. This will ensure that no capsules remain in the vial.

"Certification that the licensee notified the individual: The patient was notified by telephone on June 10, 2005 and the patient returned to the hospital to receive the second capsule of 9.74 mCi Nal-131."

* * * RETRACTION ON 06/13/05 AT 1720 BY MARTY JOHNSON TO CHAUNCEY GOULD * * *

Based on a re-reading of Part 35 and a conversation with Region 3 Materials Inspection and Materials Licensing Branches it was determined that this is not a medical event and should be retracted.

Notified Reg 3 RDO (Patrick Louden) and NMSS (Patricia Holahan).

* * * UNRETRACTION ON 06/22/05 AT 0945 EDT BY MARTY JOHNSON TO HOWIE CROUCH * * *

Through discussions with Region 3, the licensee was informed that the NRC has determined this event is, in fact, a medical event therefore should not be retracted.

Notified R3DO (Burgess) and NMSS (Michelle Burgess).

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Power Reactor Event Number: 41787
Facility: LASALLE
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: JOHN WASHKO
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/22/2005
Notification Time: 05:56 [ET]
Event Date: 06/21/2005
Event Time: 23:40 [CDT]
Last Update Date: 06/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BRUCE BURGESS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

MULTIPLE SPECIFIED SYSTEMS ACTUATIONS DUE TO LOSS OF AC SAFETY RELATED BUSES

"At 23:40 CDST, LaSalle Unit 2 experienced a trip of the 4160 Volt AC feed breaker to 480 Volt AC Safety Related buses 235X & 235Y. As a result of this feed breaker trip, containment isolation valves closed in multiple systems. The systems which isolated included Containment Monitoring System, Drywell Floor Drains and Drywell Equipment Drains, Reactor Recirculation Flow Control Hydraulic System, Drywell Instrument Nitrogen System, Reactor Water Cleanup System, and Reactor Recirculation Sample System. This event is reportable under 10CFR50.72(b)(3)(iv)(A). In addition to the- above mentioned system isolations, the following plant responses occurred due to the loss of these 480 Volt AC buses: Reactor Building Ventilation was lost due to the closure of the secondary containment isolation dampers; Multiple Division 1 containment isolation valves lost their AC power source, a 1/2-SCRAM occurred due to the loss of the 2A Reactor Protection System Motor-Generator set, the DC charger feed to the Division 1 DC Battery/Bus was lost, and the battery is currently maintaining availability of DC power to the bus. Troubleshooting has determined that the cause of the breaker trip was due to a defective neutral ground current protective relay. This relay has been replaced and the buses have been re-energized. System restoration is currently in progress."

The licensee informed the NRC Resident Inspector.

* * * UPDATE FROM JEFF WILLIAMS TO GERRY WAIG AT 1217 EDT ON 06/22/05 * * *

"The following is an update to EN# 41787. Restoration of all required safety systems with the exception of the Reactor Core Isolation Cooling (RCIC) system has been completed. The associated ECCS systems were filled, vented and restored to an available status at 0630 CDST and full operability established at 0803 CDST. The Division 1 DC battery was fully recharged and returned to an operable status at 0803 CDST. Restoration of the RCIC system and investigation into the cause of the relay failure is currently in progress."

The licensee has notified the NRC Resident Inspector.

Notified R3DO (Bruce Burgess).

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Friday, March 30, 2012