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Event Notification Report for April 12, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/11/2016 - 04/12/2016

** EVENT NUMBERS **


51843 51861

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Non-Agreement State Event Number: 51843
Rep Org: CHRISTIANA CARE HEALTH SYSTEM
Licensee: CHRISTIANA CARE HEALTH SYSTEM
Region: 1
City: NEWARK State: DE
County:
License #: 07-12153-02
Agreement: N
Docket:
NRC Notified By: CAROL WEN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/01/2016
Notification Time: 13:57 [ET]
Event Date: 04/01/2016
Event Time: 10:30 [EDT]
Last Update Date: 04/01/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - DOSE 75% OF PRESCRIBED DOSE

A patient was receiving a Y-90 Therasphere treatment to the cancer patient's liver. During the infusion, there was resistance in the tubing. The tubing was disconnected, flushed with a saline solution, and then reattached to the transfer system. The company representative was present during the procedure. After the procedure, the residual activity in the waste was determined to be approximately 25 percent of the total activity. The intended dose to the treatment area was 125 Gy with the actual dose being 94.8 Gy. The prescribing physician and the patient will be notified.

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.

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Power Reactor Event Number: 51861
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: KYLE ROSEK
HQ OPS Officer: VINCE KLCO
Notification Date: 04/11/2016
Notification Time: 15:37 [ET]
Event Date: 04/11/2016
Event Time: 05:35 [MST]
Last Update Date: 04/11/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RAY AZUA (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

REACTOR PRESSURE BOUNDAY LEAKAGE

"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.

"At approximately 2335 [MST] on April 10, 2016, while performing planned routine visual examinations of Unit 1 components in the Containment Building, engineering personnel identified white residue on the piping instrument nozzle for the reactor coolant system (RCS) 2B cold leg resistance temperature detector, 1JRCET121Y. The white residue was dry and no active leakage was noted on the instrument nozzle.

"Preliminary chemical analysis for radionuclide and boron content of the white residue determined the existence of boron and the isotopic content was consistent with RCS fluid. At 0535 [MST] on April 11, 2016, it was determined the residue resulted from RCS pressure boundary leakage, based on results of the chemical analysis and additional examination of the piping and instrument nozzle by qualified engineering personnel. Technical Specifications Limiting Condition of Operation (LCO) 3.4.14 permits no RCS pressure boundary leakage and therefore, the discovery of leakage from the instrument nozzle represents a degradation of a principal safety barrier. This notification is being made for a degraded condition pursuant to the requirements of 10CFR 50.72(b)(3)(ii)(A).

"The unit has been shut down for its 19th refueling outage since 4/9/16 at 0000.

"The NRC resident inspectors have been informed of this condition."

Page Last Reviewed/Updated Tuesday, April 12, 2016
Tuesday, April 12, 2016