Event Notification Report for January 17, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/16/2008 - 01/17/2008
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 43917
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 1
City: BOSTON State: MA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: JASON KOZAL
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 1
City: BOSTON State: MA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: JASON KOZAL
Notification Date: 01/18/2008
Notification Time: 15:20 [ET]
Event Date: 01/17/2008
Event Time: 00:00 [EST]
Last Update Date: 03/12/2008
Notification Time: 15:20 [ET]
Event Date: 01/17/2008
Event Time: 00:00 [EST]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
EUGENE COBEY (R1)
HIRONORI PETERSON (R3)
KEITH McCONNELL (FSME)
EUGENE COBEY (R1)
HIRONORI PETERSON (R3)
KEITH McCONNELL (FSME)
POTENTIAL OVEREXPOSURE
"The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts.
"The possible medical event occurred on January 17, 2008, and was discovered the same day. The basis for the possible medical event is under 10 CFR 35.3045(a)(2) and involved administration of radiopharmaceutical that might have resulted in more than 50 rem to tissue and involved a wrong route of administration.
"Specifically, a F-18 FDG injection of approximately 3.6 millicuries was infiltrated into a patient's arm.
"The Department of Veterans Affairs and permittee are reviewing the possible medical event circumstances and the dose calculation methods.
"The permittee informed the patient and referring physician."
* * * RETRACTION FROM THOMAS HUSTON TO HOWIE CROUCH ON 3/12/08 @ 1430 HRS. * * *
"The basis for retracting the event is that infiltration is not considered to be a wrong route of administration. This basis was communicated to NHPP [National Health Physics Program] in a phone call received from our NRC Region III Project Manager (Cassandra Frazier) on March 7, 2008 at 4:40 pm."
Notified R1DO (Lorson), R3DO (Ring), and FSME (Burgess).
"The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts.
"The possible medical event occurred on January 17, 2008, and was discovered the same day. The basis for the possible medical event is under 10 CFR 35.3045(a)(2) and involved administration of radiopharmaceutical that might have resulted in more than 50 rem to tissue and involved a wrong route of administration.
"Specifically, a F-18 FDG injection of approximately 3.6 millicuries was infiltrated into a patient's arm.
"The Department of Veterans Affairs and permittee are reviewing the possible medical event circumstances and the dose calculation methods.
"The permittee informed the patient and referring physician."
* * * RETRACTION FROM THOMAS HUSTON TO HOWIE CROUCH ON 3/12/08 @ 1430 HRS. * * *
"The basis for retracting the event is that infiltration is not considered to be a wrong route of administration. This basis was communicated to NHPP [National Health Physics Program] in a phone call received from our NRC Region III Project Manager (Cassandra Frazier) on March 7, 2008 at 4:40 pm."
Notified R1DO (Lorson), R3DO (Ring), and FSME (Burgess).
Power Reactor
Event Number: 43914
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CECIL WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CECIL WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/17/2008
Notification Time: 23:48 [ET]
Event Date: 01/17/2008
Event Time: 18:00 [EST]
Last Update Date: 01/18/2008
Notification Time: 23:48 [ET]
Event Date: 01/17/2008
Event Time: 18:00 [EST]
Last Update Date: 01/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES MOORMAN (R2)
JIM WHITNEY (ILTA)
JAMES MOORMAN (R2)
JIM WHITNEY (ILTA)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 97 | Power Operation | 97 | Power Operation |
| 2 | N | Y | 98 | Power Operation | 98 | Power Operation |
CONTROLLED SUBSTANCE FOUND IN LOCATION OUTSIDE PROTECTED AREA
"At approximately 1800 EST, a controlled substance and paraphernalia were discovered by a supplemental employee, who then reported the discovery to his supervision. Plant Security was contacted, who then notified Local Law Enforcement. All supplemental personnel who were in-processing in the area at the time of discovery were interviewed and sent for FFD testing. All immediate results were negative; lab results are still pending. A drug detection dog was brought in by the Local Law Enforcement Agency to clear the area where the substance was found and nothing additional was found. This notification is being made as a courtesy as a result of the potential newsworthiness of the event."
The licensee will notify the NRC Resident Inspector.
* * * UPDATE FROM LICENSEE (POPE) TO NRC (HUFFMAN) AT 0925 EST ON 01/18/08 * * *
"The building in which the substance was found was located outside the Plant Vogtle Protected Area."
The licensee notified the NRC Resident Inspector. R2DO (Moorman) notified.
"At approximately 1800 EST, a controlled substance and paraphernalia were discovered by a supplemental employee, who then reported the discovery to his supervision. Plant Security was contacted, who then notified Local Law Enforcement. All supplemental personnel who were in-processing in the area at the time of discovery were interviewed and sent for FFD testing. All immediate results were negative; lab results are still pending. A drug detection dog was brought in by the Local Law Enforcement Agency to clear the area where the substance was found and nothing additional was found. This notification is being made as a courtesy as a result of the potential newsworthiness of the event."
The licensee will notify the NRC Resident Inspector.
* * * UPDATE FROM LICENSEE (POPE) TO NRC (HUFFMAN) AT 0925 EST ON 01/18/08 * * *
"The building in which the substance was found was located outside the Plant Vogtle Protected Area."
The licensee notified the NRC Resident Inspector. R2DO (Moorman) notified.
Power Reactor
Event Number: 43911
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: TIM SCHENK
HQ OPS Officer: STEVE SANDIN
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: TIM SCHENK
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/17/2008
Notification Time: 10:21 [ET]
Event Date: 01/17/2008
Event Time: 09:17 [CST]
Last Update Date: 01/17/2008
Notification Time: 10:21 [ET]
Event Date: 01/17/2008
Event Time: 09:17 [CST]
Last Update Date: 01/17/2008
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):
BLAIR SPITZBERG (R4)
BLAIR SPITZBERG (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
CONTROL ROOM ANNUNCIATORS REMOVED FROM SERVICE FOR PLANNED MAINTENANCE
"At 0917 CST on 1/17/2008, the Main Control Room annunciator system has been removed from service to support maintenance at River Bend Station. The duration of the work is expected to be completed in less than one (1) hour.
"During this time, other Main Control Room indications and alternate methods will be available to implement the Emergency Plan. Since the Main Control Room annunciator system will be unavailable, this is considered a Loss of Emergency Assessment Capability and is reportable under 10CFR50.72(b)(3)(xiii).
"A follow-up notification will be made to the NRC after the Main Control Room annunciator system is returned to service.
"The licensee notified the NRC Resident Inspector."
* * * UPDATE FROM SCHENK TO SANDIN AT 1120 EST ON 01/17/08 * * *
At 1015 CST on 1/17/08, the licensee restored the main control room annunciator system to service. The NRC Resident has been notified. R4DO (Spitzberg) notified.
"At 0917 CST on 1/17/2008, the Main Control Room annunciator system has been removed from service to support maintenance at River Bend Station. The duration of the work is expected to be completed in less than one (1) hour.
"During this time, other Main Control Room indications and alternate methods will be available to implement the Emergency Plan. Since the Main Control Room annunciator system will be unavailable, this is considered a Loss of Emergency Assessment Capability and is reportable under 10CFR50.72(b)(3)(xiii).
"A follow-up notification will be made to the NRC after the Main Control Room annunciator system is returned to service.
"The licensee notified the NRC Resident Inspector."
* * * UPDATE FROM SCHENK TO SANDIN AT 1120 EST ON 01/17/08 * * *
At 1015 CST on 1/17/08, the licensee restored the main control room annunciator system to service. The NRC Resident has been notified. R4DO (Spitzberg) notified.