Event Notification Report for November 07, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/06/2014 - 11/07/2014
Agreement State
Event Number: 50647
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CEDARS SINAI MEDICAL CENTER
Region: 4
City: LOS ANGELES State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: JOSEPHINE ORTEGO
HQ OPS Officer: DONALD NORWOOD
Licensee: CEDARS SINAI MEDICAL CENTER
Region: 4
City: LOS ANGELES State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: JOSEPHINE ORTEGO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/02/2014
Notification Time: 17:15 [ET]
Event Date: 11/07/2014
Event Time: 00:00 [PST]
Last Update Date: 12/02/2014
Notification Time: 17:15 [ET]
Event Date: 11/07/2014
Event Time: 00:00 [PST]
Last Update Date: 12/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY KELLAR (R4DO)
NMSS EVENTS RESOURCE (EMAI)
RAY KELLAR (R4DO)
NMSS EVENTS RESOURCE (EMAI)
AGREEMENT STATE - MEDICAL EVENT INVOLVING UNDERDOSAGE TO PATIENT OF Y-90 SIR-SPHERES
The following is a synopsis of information received via E-mail:
The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center.
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 is a synopsis of information received via E-mail:
The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center.
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: 50601
Facility: PERRY
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CURTIS BRAY
HQ OPS Officer: JEFF ROTTON
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: CURTIS BRAY
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/07/2014
Notification Time: 11:13 [ET]
Event Date: 11/07/2014
Event Time: 08:47 [EST]
Last Update Date: 11/07/2014
Notification Time: 11:13 [ET]
Event Date: 11/07/2014
Event Time: 08:47 [EST]
Last Update Date: 11/07/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION 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)(A) - ECCS INJECTION 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMNES CAMERON (R3DO)
JAMNES CAMERON (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM DUE TO LOSS OF FEEDWATER
"The Perry Nuclear Power Plant experienced an automatic reactor scram due to a loss of feedwater, which resulted in receiving valid reactor vessel water Level 3 and Level 2 initiation signals. The High Pressure Core Spray system and the Reactor Core Isolation Cooling system started and injected. Reactor water level and pressure have been stabilized in the required bands. The motor feed pump automatically started and is being used to control reactor vessel water level. The High Pressure Core Spray and Reactor Core Isolation Cooling systems have been returned to the standby mode. As a result of receiving a reactor vessel water Level 2 signal a Balance of Plant containment isolation signal was received. All systems isolated as required and the plant is restoring isolated systems in accordance with plant procedures.
"During the scram, all rods fully inserted into the core. Decay heat is being removed via turbine bypass valves to the main condenser. The electrical grid is stable and is supplying plant loads. An emergency diesel generator [Division 3 High Pressure Core Spray] started, as designed, as a result of the reactor vessel water Level 2 signal. No safety relief valves lifted as a result of the transient.
"The plant is stable with cooldown and depressurization to Mode 4 in progress. The cause of the loss of feedwater is under investigation.
"The NRC Resident Inspector has been notified. The State of Ohio and local officials will be notified."
"The Perry Nuclear Power Plant experienced an automatic reactor scram due to a loss of feedwater, which resulted in receiving valid reactor vessel water Level 3 and Level 2 initiation signals. The High Pressure Core Spray system and the Reactor Core Isolation Cooling system started and injected. Reactor water level and pressure have been stabilized in the required bands. The motor feed pump automatically started and is being used to control reactor vessel water level. The High Pressure Core Spray and Reactor Core Isolation Cooling systems have been returned to the standby mode. As a result of receiving a reactor vessel water Level 2 signal a Balance of Plant containment isolation signal was received. All systems isolated as required and the plant is restoring isolated systems in accordance with plant procedures.
"During the scram, all rods fully inserted into the core. Decay heat is being removed via turbine bypass valves to the main condenser. The electrical grid is stable and is supplying plant loads. An emergency diesel generator [Division 3 High Pressure Core Spray] started, as designed, as a result of the reactor vessel water Level 2 signal. No safety relief valves lifted as a result of the transient.
"The plant is stable with cooldown and depressurization to Mode 4 in progress. The cause of the loss of feedwater is under investigation.
"The NRC Resident Inspector has been notified. The State of Ohio and local officials will be notified."