Event Notification Report for January 19, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/18/2011 - 01/19/2011
EVENT NUMBERS
4655846551465524655346548465554655646567
Power Reactor
Event Number: 46558
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: JIM DAVIS
HQ OPS Officer: JOHN KNOKE
Region: 2 State: GA
Unit: [3] [4] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: JIM DAVIS
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/20/2011
Notification Time: 15:25 [ET]
Event Date: 01/19/2011
Event Time: 19:00 [EST]
Last Update Date: 01/20/2011
Notification Time: 15:25 [ET]
Event Date: 01/19/2011
Event Time: 19:00 [EST]
Last Update Date: 01/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
MARVIN SYKES (R2DO)
ALAN BLAMEY (R2)
MARVIN SYKES (R2DO)
ALAN BLAMEY (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Under Construction | 0 | Under Construction |
| 4 | N | N | 0 | 0 |
FITNESS FOR DUTY REPORT INVOLVING FFD PROGRAM VULNERABILITY
A discovered vulnerability in the Fitness-For-Duty (FFD) program has resulted in contractor personnel being granted unescorted access to Vogtle 3&4 construction site without meeting all the requirements of the FFD Program. Contact the Headquarters Operations Officer for more details.
The NRC Resident Inspector has been notified.
A discovered vulnerability in the Fitness-For-Duty (FFD) program has resulted in contractor personnel being granted unescorted access to Vogtle 3&4 construction site without meeting all the requirements of the FFD Program. Contact the Headquarters Operations Officer for more details.
The NRC Resident Inspector has been notified.
Power Reactor
Event Number: 46551
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: TOM PHILLIPS
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: TOM PHILLIPS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/19/2011
Notification Time: 03:10 [ET]
Event Date: 01/19/2011
Event Time: 02:32 [EST]
Last Update Date: 01/19/2011
Notification Time: 03:10 [ET]
Event Date: 01/19/2011
Event Time: 02:32 [EST]
Last Update Date: 01/19/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
TAMARA BLOOMER (R3DO)
WILLIAM GOTT (IRD)
MARK SATORIUS (R3)
BRUCE BOGER (NRR)
TRIPP STRINGFIELD (DHS)
TAMARA BLOOMER (R3DO)
WILLIAM GOTT (IRD)
MARK SATORIUS (R3)
BRUCE BOGER (NRR)
TRIPP STRINGFIELD (DHS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION OF UNUSUAL EVENT DUE TO A FIRE AND EXPLOSIONS IN THE PROTECTED AREA
"An electrical fire and explosions were reported near the Containment Access Facility construction area. An Unusual Event was declared based on HU4. Temporary electrical power at service disconnect DSLM3-3 was isolated. The fire was out at 0243 EST. The fire was extinguished using dry chemical. The fire was reported at 0232 EST on 1/19/11. The cause of the fire has not been determined at this time."
The fire and explosions were initially reported by site security personnel. The licensee declared the NOUE at 0243 EST based on criteria HU4. The licensee initially called for offsite assistance in putting out the fire, however, the fire was extinguished by plant personnel and the offsite assistance was turned back. The licensee posted a reflash watch. The fire reportedly involved temporary cables and possibly a transformer supplying power to the construction area which is located inside the protected area outside the auxiliary building.
The licensee notified the NRC Resident Inspector.
* * * UPDATE FROM TOM PHILLIPS TO DONALD NORWOOD AT 0405 EST ON 1/19/2011 * * *
The licensee terminated the Notification of Unusual Event at 0358 EST. No additional information is available at this time.
Notified R3DO (Bloomer), NRR EO (Skeen), IRD (Gott), DHS (Stringfield), and FEMA (Casto).
"An electrical fire and explosions were reported near the Containment Access Facility construction area. An Unusual Event was declared based on HU4. Temporary electrical power at service disconnect DSLM3-3 was isolated. The fire was out at 0243 EST. The fire was extinguished using dry chemical. The fire was reported at 0232 EST on 1/19/11. The cause of the fire has not been determined at this time."
The fire and explosions were initially reported by site security personnel. The licensee declared the NOUE at 0243 EST based on criteria HU4. The licensee initially called for offsite assistance in putting out the fire, however, the fire was extinguished by plant personnel and the offsite assistance was turned back. The licensee posted a reflash watch. The fire reportedly involved temporary cables and possibly a transformer supplying power to the construction area which is located inside the protected area outside the auxiliary building.
The licensee notified the NRC Resident Inspector.
* * * UPDATE FROM TOM PHILLIPS TO DONALD NORWOOD AT 0405 EST ON 1/19/2011 * * *
The licensee terminated the Notification of Unusual Event at 0358 EST. No additional information is available at this time.
Notified R3DO (Bloomer), NRR EO (Skeen), IRD (Gott), DHS (Stringfield), and FEMA (Casto).
Agreement State
Event Number: 46552
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: GENERAL MILLS CORPORATION
Region: 1
City: MOONACHIE State: NJ
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: ALLEN JACOBSEN
HQ OPS Officer: HOWIE CROUCH
Licensee: GENERAL MILLS CORPORATION
Region: 1
City: MOONACHIE State: NJ
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: ALLEN JACOBSEN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/19/2011
Notification Time: 10:29 [ET]
Event Date: 01/19/2011
Event Time: 00:00 [EST]
Last Update Date: 01/25/2011
Notification Time: 10:29 [ET]
Event Date: 01/19/2011
Event Time: 00:00 [EST]
Last Update Date: 01/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TODD JACKSON (R1DO)
GLENDA VILLAMAR (FSME)
TODD JACKSON (R1DO)
GLENDA VILLAMAR (FSME)
AGREEMENT STATE REPORT - INDUSTRIAL GAUGES INADVERTENTLY SENT TO SCRAP MATERIAL RECYCLER
General Mills Company in Moonachie, New Jersey notified Terrapin Recycling of Baltimore, Maryland that they inadvertently sent three industrial gauges to Terrapin in a load of scrap material. General Mills has contracted Clym Environmental Services, LLC of Frederick, MD to locate and recover the gauges.
The gauges are Peco Controls Corporation Industrial gauges and each of them contain 100 mCi of Am-241.
The State of Maryland has notified the State of New Jersey.
* * * UPDATE BY ALAN JACOBSON TO VINCE KLCO ON 1/25/2011 AT 1138 EST * * *
The following information was received from the State of Maryland by email:
"After searching approximately 800 tons of scrap metal on Friday, January 21, 2011, two of the three devices were located and retrieved from compressed bails. Leak tests were conducted. Results revealed no contamination. The two sources remain secured at Terrapin, pending transportation to an authorized recipient. The search for the third device continues. The State of New Jersey was notified on January 19, 2011."
Notified the R1DO (Newport) and FSME (McIntosh).
General Mills Company in Moonachie, New Jersey notified Terrapin Recycling of Baltimore, Maryland that they inadvertently sent three industrial gauges to Terrapin in a load of scrap material. General Mills has contracted Clym Environmental Services, LLC of Frederick, MD to locate and recover the gauges.
The gauges are Peco Controls Corporation Industrial gauges and each of them contain 100 mCi of Am-241.
The State of Maryland has notified the State of New Jersey.
* * * UPDATE BY ALAN JACOBSON TO VINCE KLCO ON 1/25/2011 AT 1138 EST * * *
The following information was received from the State of Maryland by email:
"After searching approximately 800 tons of scrap metal on Friday, January 21, 2011, two of the three devices were located and retrieved from compressed bails. Leak tests were conducted. Results revealed no contamination. The two sources remain secured at Terrapin, pending transportation to an authorized recipient. The search for the third device continues. The State of New Jersey was notified on January 19, 2011."
Notified the R1DO (Newport) and FSME (McIntosh).
Hospital
Event Number: 46553
Rep Org: BOTSFORD CANCER CENTER
Licensee: BOTSFORD CANCER CENTER
Region: 3
City: FARMINGTON HILLS State: MI
County:
License #: 21-08892-01
Agreement: N
Docket:
NRC Notified By: MARGARET SYRIAN
HQ OPS Officer: BILL HUFFMAN
Licensee: BOTSFORD CANCER CENTER
Region: 3
City: FARMINGTON HILLS State: MI
County:
License #: 21-08892-01
Agreement: N
Docket:
NRC Notified By: MARGARET SYRIAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/19/2011
Notification Time: 17:25 [ET]
Event Date: 01/19/2011
Event Time: 09:40 [EST]
Last Update Date: 01/19/2011
Notification Time: 17:25 [ET]
Event Date: 01/19/2011
Event Time: 09:40 [EST]
Last Update Date: 01/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
TAMARA BLOOMER (R3DO)
BILL VON TILL (FSME)
TAMARA BLOOMER (R3DO)
BILL VON TILL (FSME)
DOSE TO NON-RADIATION WORKER DURING MEDICAL TREATMENT
The licensee reported an event that occurred while using a HDR Afterloader brachytherapy device for prostate treatment with a 8.3 curie Ir-192 source. Following setup of the HDR Afterloader, the medical staff exited the treatment room and commenced the prostate irradiation. 1.8 minutes after the start of the treatment, the anesthesiologist technician was observed exiting the treatment room. The staff physicist completed the patient treatment and then conducted a review of the circumstances of the event. The anesthesiologist technician was unaware that the treatment was beginning and was crouched down and not visible when the rest of the staff left the treatment room. The technician was not wearing dosimetry (and not required to) so his exposure was estimated based on recreation of the event. His calculated exposure is believed to be approximately 5.6 millirem. The licensee is still evaluating corrective actions.
The licensee reported an event that occurred while using a HDR Afterloader brachytherapy device for prostate treatment with a 8.3 curie Ir-192 source. Following setup of the HDR Afterloader, the medical staff exited the treatment room and commenced the prostate irradiation. 1.8 minutes after the start of the treatment, the anesthesiologist technician was observed exiting the treatment room. The staff physicist completed the patient treatment and then conducted a review of the circumstances of the event. The anesthesiologist technician was unaware that the treatment was beginning and was crouched down and not visible when the rest of the staff left the treatment room. The technician was not wearing dosimetry (and not required to) so his exposure was estimated based on recreation of the event. His calculated exposure is believed to be approximately 5.6 millirem. The licensee is still evaluating corrective actions.
Power Reactor
Event Number: 46548
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: BRAD BISHOP
HQ OPS Officer: HOWIE CROUCH
Region: 2 State: FL
Unit: [1] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: BRAD BISHOP
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2011
Notification Time: 10:48 [ET]
Event Date: 01/19/2011
Event Time: 02:00 [EST]
Last Update Date: 03/24/2011
Notification Time: 10:48 [ET]
Event Date: 01/19/2011
Event Time: 02:00 [EST]
Last Update Date: 03/24/2011
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):
MARVIN SYKES (R2DO)
MARVIN SYKES (R2DO)
| 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 | N | 0 | Refueling | 0 | Refueling |
EMERGENCY RESPONSE DATA ACQUISITION AND DISPLAY SYSTEM (ERDADS) REMOVED FROM SERVICE FOR MAINTENANCE
"On 1/19/11, St Lucie Unit 1 and Unit 2 will lose the computer trains associated with Emergency Response Data Acquisition and Display System (ERDADS). Unit 1 will be removed for corrective maintenance, and Unit 2 will be removed for system modification. It is expected that Unit 1 will be restored by 1/21/11, and Unit 2 will be returned to a functional status prior to core reload and fully operational by March 20, 2011. Further, neither Unit 1 nor Unit 2 ERDADS will be removed from service until Unit 2 has defueled (currently scheduled for 1/19/2011 at 0200). This is an advance notification of a planned loss of emergency assessment capability, which will be reportable under 10CFR50.72(b)(3)(xiii). Other means to monitor critical data exists. Notification will be made when each unit is restored to available status."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM REESE KILIAN TO HOWIE CROUCH @ 0952 EST ON 1/19/11 * * *
"Unit 1 and 2 ERDADS have been removed from service at 0955 [EST]."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM TIMOTHY KUDO TO JOHN SHOEMAKER @ 1527 EST ON 01/20/11 * * *
Unit 1 ERDADS has been returned to available status as of 1520 EST on 01/20/11. Unit 2 ERDADS remains out of service.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM BISHOP TO HUFFMAN AT 2013 EDT ON 3/24/11 * * *
Unit 1 and Unit 2 ERDADS have both been restored to service as of 1600 EDT on 3/24/11.
The licensee has notified the NRC Resident Inspector. R2DO (Rich) notified.
"On 1/19/11, St Lucie Unit 1 and Unit 2 will lose the computer trains associated with Emergency Response Data Acquisition and Display System (ERDADS). Unit 1 will be removed for corrective maintenance, and Unit 2 will be removed for system modification. It is expected that Unit 1 will be restored by 1/21/11, and Unit 2 will be returned to a functional status prior to core reload and fully operational by March 20, 2011. Further, neither Unit 1 nor Unit 2 ERDADS will be removed from service until Unit 2 has defueled (currently scheduled for 1/19/2011 at 0200). This is an advance notification of a planned loss of emergency assessment capability, which will be reportable under 10CFR50.72(b)(3)(xiii). Other means to monitor critical data exists. Notification will be made when each unit is restored to available status."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM REESE KILIAN TO HOWIE CROUCH @ 0952 EST ON 1/19/11 * * *
"Unit 1 and 2 ERDADS have been removed from service at 0955 [EST]."
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM TIMOTHY KUDO TO JOHN SHOEMAKER @ 1527 EST ON 01/20/11 * * *
Unit 1 ERDADS has been returned to available status as of 1520 EST on 01/20/11. Unit 2 ERDADS remains out of service.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM BISHOP TO HUFFMAN AT 2013 EDT ON 3/24/11 * * *
Unit 1 and Unit 2 ERDADS have both been restored to service as of 1600 EDT on 3/24/11.
The licensee has notified the NRC Resident Inspector. R2DO (Rich) notified.
Power Reactor
Event Number: 46555
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: ALBERT MARTIN
HQ OPS Officer: JOE O'HARA
Region: 4 State: AR
Unit: [1] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: ALBERT MARTIN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/19/2011
Notification Time: 22:50 [ET]
Event Date: 01/19/2011
Event Time: 20:58 [CST]
Last Update Date: 01/19/2011
Notification Time: 22:50 [ET]
Event Date: 01/19/2011
Event Time: 20:58 [CST]
Last Update Date: 01/19/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
NEIL OKEEFE (R4DO)
WILLIAM GOTT (IRD)
LAURA PEARSON (ILTA)
DAVID SKEEN (NRR)
ELMO COLLINS (RA)
NEIL OKEEFE (R4DO)
WILLIAM GOTT (IRD)
LAURA PEARSON (ILTA)
DAVID SKEEN (NRR)
ELMO COLLINS (RA)
| 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 |
NOTICE OF UNUSUAL EVENT (NOUE) DUE TO A SECURITY EVENT
The licensee declared an unusual event based upon a potential security incident at the site. Contact the Headquarters Operations Officer for additional details. The NRC Resident Inspector has been notified. The licensee terminated the NOUE at 2150 CST.
The licensee declared an unusual event based upon a potential security incident at the site. Contact the Headquarters Operations Officer for additional details. The NRC Resident Inspector has been notified. The licensee terminated the NOUE at 2150 CST.
Power Reactor
Event Number: 46556
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROB WARNER
HQ OPS Officer: DONALD NORWOOD
Region: 4 State: AZ
Unit: [] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROB WARNER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/20/2011
Notification Time: 00:08 [ET]
Event Date: 01/19/2011
Event Time: 18:41 [MST]
Last Update Date: 01/20/2011
Notification Time: 00:08 [ET]
Event Date: 01/19/2011
Event Time: 18:41 [MST]
Last Update Date: 01/20/2011
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):
NEIL OKEEFE (R4DO)
NEIL OKEEFE (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
REACTOR TRIP DUE TO MAIN FEEDWATER PUMP TRIP
"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On January 19, 2011, at approximately 1840 Mountain Standard Time (MST), Palo Verde Unit 3 received a Reactor Power Cutback (RPCB) due to the 'B' Main Feedwater Pump (MFP) tripping on low suction pressure in response to the 'A' MFP mini-flow valve failing open. Reactor power lowered to approximately 60% in response to the RPCB. Steam Generator levels continued to decrease and a Reactor Trip occurred on Low Steam Generator #1 level at 18:41. Unit 3 was at normal operating temperature and pressure prior to the trip. Following the automatic reactor trip all CEAs [Control Element Assemblies] inserted fully into the reactor core. No emergency classification was required per the Emergency Plan. An AFAS-2 [Auxiliary Feedwater Actuation Signal] occurred at 1844 on low Steam Generator #2 level. Safety related busses remained energized during and following the reactor trip. The Emergency Diesel Generators started in response to the AFAS-2 actuation but did not energize the class 4.16kV buses as they remained energized from off-site power. The offsite power grid is stable. No major equipment was inoperable prior to the event that contributed to the event.
"Unit 3 is stable at normal operating temperature and pressure in Mode 3 feeding the steam generators with Auxiliary Feedwater pump 'B'. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.
"The [NRC] Senior Resident Inspector was informed of the Unit 3 reactor trip."
Unit 3 is in a normal post-trip electrical lineup. Decay heat is being removed via the turbine bypass valves to the main condenser. No safety valves on the secondary or primary side opened.
"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On January 19, 2011, at approximately 1840 Mountain Standard Time (MST), Palo Verde Unit 3 received a Reactor Power Cutback (RPCB) due to the 'B' Main Feedwater Pump (MFP) tripping on low suction pressure in response to the 'A' MFP mini-flow valve failing open. Reactor power lowered to approximately 60% in response to the RPCB. Steam Generator levels continued to decrease and a Reactor Trip occurred on Low Steam Generator #1 level at 18:41. Unit 3 was at normal operating temperature and pressure prior to the trip. Following the automatic reactor trip all CEAs [Control Element Assemblies] inserted fully into the reactor core. No emergency classification was required per the Emergency Plan. An AFAS-2 [Auxiliary Feedwater Actuation Signal] occurred at 1844 on low Steam Generator #2 level. Safety related busses remained energized during and following the reactor trip. The Emergency Diesel Generators started in response to the AFAS-2 actuation but did not energize the class 4.16kV buses as they remained energized from off-site power. The offsite power grid is stable. No major equipment was inoperable prior to the event that contributed to the event.
"Unit 3 is stable at normal operating temperature and pressure in Mode 3 feeding the steam generators with Auxiliary Feedwater pump 'B'. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.
"The [NRC] Senior Resident Inspector was informed of the Unit 3 reactor trip."
Unit 3 is in a normal post-trip electrical lineup. Decay heat is being removed via the turbine bypass valves to the main condenser. No safety valves on the secondary or primary side opened.
Agreement State
Event Number: 46567
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: EASTERN REGIONAL MEDICAL CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0980
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: VINCE KLCO
Licensee: EASTERN REGIONAL MEDICAL CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0980
Agreement: Y
Docket:
NRC Notified By: DAVID J. ALLARD
HQ OPS Officer: VINCE KLCO
Notification Date: 01/24/2011
Notification Time: 17:03 [ET]
Event Date: 01/19/2011
Event Time: 00:00 [EST]
Last Update Date: 01/24/2011
Notification Time: 17:03 [ET]
Event Date: 01/19/2011
Event Time: 00:00 [EST]
Last Update Date: 01/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
BILL VON TILL (FSME)
CHRISTOPHER NEWPORT (R1DO)
BILL VON TILL (FSME)
AGREEMENT STATE REPORT - POTENTIAL DOSAGE DIFFERENT THAN INTENDED DOSE
The following information was received from the state by facsimile:
"The licensee called the PaDEP [Pennsylvania Department Bureau of Radiation Protection] South East Region at 1600 [EST] on January 20, 2011 to provide a 24-hour verbal notice of a medical event involving a dosage that differs from the intended dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(1)(i). PaDEP Central Office was notified on 1/21/2011.
"During a formal review immediately following a second Yttrium-90 (Y90) TheraSphere radiation treatment on January 19, 2011, CTCA [Cancer Treatment Centers of America] noticed that the activity of microspheres delivered was different than the activity that was prescribed by the doctor. The patient was first treated with 10 GBq (about 0.27 Ci) of TheraSphere Y-90 beads for the right lobe of the liver. A second treatment of 3 GBq (about 0.081 Ci) was prescribed for the left lobe, however the activity ordered remained unchanged on the second order form, resulting in 10 GBq (about 0.27 Ci) being delivered to the patient.
"Cause of the Event: Human Error.
"The Department [Pennsylvania Department Bureau of Radiation Protection] has a call into the Radiation Safety Officer regarding the estimated organ dose to the liver, and will be obtaining more event details. At this time DEP plans to send regional staff to conduct a reactive inspection on 1/25/2011. Final event details will be communicated in a NMED and any other required report."
Pennsylvania Event Report: PA110001
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 was received from the state by facsimile:
"The licensee called the PaDEP [Pennsylvania Department Bureau of Radiation Protection] South East Region at 1600 [EST] on January 20, 2011 to provide a 24-hour verbal notice of a medical event involving a dosage that differs from the intended dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(1)(i). PaDEP Central Office was notified on 1/21/2011.
"During a formal review immediately following a second Yttrium-90 (Y90) TheraSphere radiation treatment on January 19, 2011, CTCA [Cancer Treatment Centers of America] noticed that the activity of microspheres delivered was different than the activity that was prescribed by the doctor. The patient was first treated with 10 GBq (about 0.27 Ci) of TheraSphere Y-90 beads for the right lobe of the liver. A second treatment of 3 GBq (about 0.081 Ci) was prescribed for the left lobe, however the activity ordered remained unchanged on the second order form, resulting in 10 GBq (about 0.27 Ci) being delivered to the patient.
"Cause of the Event: Human Error.
"The Department [Pennsylvania Department Bureau of Radiation Protection] has a call into the Radiation Safety Officer regarding the estimated organ dose to the liver, and will be obtaining more event details. At this time DEP plans to send regional staff to conduct a reactive inspection on 1/25/2011. Final event details will be communicated in a NMED and any other required report."
Pennsylvania Event Report: PA110001
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.