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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/12/2016 - 07/13/2016
** EVENT NUMBERS **
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| Non-Agreement State |
Event Number: 52063 |
Rep Org: GEORGETOWN HOSPITAL
Licensee: GEORGETOWN HOSPITAL
Region: 1
City: WASHINGTON State: DC
County:
License #: 08-30577-01
Agreement: N
Docket: 03035409
NRC Notified By: DR. DAVID SMITH
HQ OPS Officer: BETHANY CECERE |
Notification Date: 07/05/2016
Notification Time: 16:03 [ET]
Event Date: 05/19/2016
Event Time: [EDT]
Last Update Date: 07/05/2016 |
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE |
Person (Organization):
NMSS_EVENTS_NOTIFIC (EMAI)
FRED BOWER (R1DO) |
Event Text
MEDICAL EVENT - WRITTEN DIRECTIVE NOT FOLLOWED
The following is excerpted from the report sent via email:
"On June 16, 2016 [the licensee's Director of Radiation Safety] was notified by the Authorized User (AU) of an issue regarding the May 19, 2016 radioembolization of a patient. During the subsequent review of the patient's treatment plan in preparation for an additional radioembolization of the Right Hepatic Lobe (scheduled for June 16, 2016) the AU observed the May 19, 2016 Written Directive/treatment plan was completed for the Right Hepatic Lobe, but treatment had been delivered to the Left Hepatic Lobe.
"Review of the physician notes for the caseú reveal the intended primary treatment site, as noted by the Interventional Radiologist (IR) was the Left Hepatic Lobe, however, communication between the IR and AU requested a treatment plan for the Right Hepatic Lobe. On 16 June 2016 the AU confirmed with the IR that the Left Hepatic Lobe was indeed the intended treatment site for the 19 May 2016 procedure. Of note, the 19 May 2016 delivery was not completed as stasis was achieved.
"The AU and Medical Physicist (MP) recalculated the 19 May 2016 treatment plan based on the administered activity and the treatment volume for the Left Hepatic Lobe. The resultant delivered dose was 119.4% of the prescribed dose. The AU determined there was no harm to the patient.
"After review of the circumstances relative to the requirements stipulated in 10 CFR 35.3045 Report and Notification of a Medical Event, it does not appear this is a Medical Event and therefore, does not meet the reporting requirements of 10 CFR 35.3045. The dose was delivered to the Left Hepatic Lobe prior to the planned delivery to the Right Hepatic Lobe, i.e. both lobes were intended for treatment at different times; the original Written Directive was reviewed and corrected to account for the delivery to the Left Hepatic Lobe and the resultant dose did not exceed any thresholds specified in 10 CFR 35.3045.
"Although not believed to be reportable as a Medical Event, this incident may be a violation of 10 CFR 35.40, Written Directives, paragraph (c) and/or 10 CFR 35.41, Procedures for Administrations Requiring a Written Directive, paragraphs (a)(2) and (b)(2). Therefore, I am submitting this report for your review.
"Actions taken to preclude a recurrence:
1. A Time Out will occur wherein the AU, Medical Physicist and Interventional Radiologist (IR) communicate the specifics of the treatment plan by asking open-ended questions requiring more than a 'yes/no' answer. The Time Out will be documented via signatures from each of the aforementioned team members.
2. After the mapping study, the IR will clearly indicate the preferred treatment site(s) in his notes so the AU is clear as to the development of the treatment plan.
These have been incorporated into the Radiation Medicine Sirsphere Policy and each member of the team has been instructed regarding the changes. Additionally, this incident is being tracked through our internal Risk Management system for further review and potential improvements to the program. These actions/reviews have been conducted and implemented prior to the next case, which is scheduled for 30 June 2016.
"Details of Incident
1. Original Written Directive for Right Hepatic Lobe (19 May 2016)
a. Activity prescribed: 25.49 mCi
b. Dose to Lobe prescribed: 32.13 Gy
c. Activity delivered: 23 .48 mCi
d. Dose to Lobe delivered: 29.59 Gy
2. Revised Written Directive for Left Hepatic Lobe (16 June 2016)
a. Activity prescribed: 19.67 mCi
b. Dose to Lobe prescribed: 43.37 Gy
c. Activity delivered: 23.48 mCi
d. Dose to Lobe delivered: 51. 77 Gy
e. Percent variation of administered activity to that prescribed = 19 .4%"
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: 52082 |
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JONATHAN BENNETT
HQ OPS Officer: MARK ABRAMOVITZ |
Notification Date: 07/12/2016
Notification Time: 21:08 [ET]
Event Date: 07/12/2016
Event Time: 20:39 [EDT]
Last Update Date: 07/12/2016 |
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED |
Person (Organization):
DANIEL RICH (R2DO)
BERN STAPLETON (IRD)
CATHY HANEY (R2RA)
BRIAN McDERMOTT (NRR)
CHRIS MILLER (NRR) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
N |
Y |
100 |
Power Operation |
70 |
Power Operation |
Event Text
ALERT DECLARED FOR A FIRE IN THE SERVICE WATER BUILDING
At approximately 2039 EDT, there was smoke in the Service Water Building with the trip of the 2C service water pump. In accordance with plant procedures, unit-2 was ramped down to 70 percent power and the "Alert" was declared. EAL (emergency action level) SA8.1 was entered for damage with degraded performance including visible damage to the service water pump. Service water pressure was eventually restored by running both the 2A and 2B service water pumps.
At 2118 EDT, the site exited the "Alert" because service water pressure had been restored.
The licensee notified the NRC Resident Inspector.
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, EPA EOC, FEMA National Watch Center (email), FDA EOC (email), Nuclear SSA (email). |
| Power Reactor |
Event Number: 52083 |
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: IVORY BYERS
HQ OPS Officer: MARK ABRAMOVITZ |
Notification Date: 07/12/2016
Notification Time: 21:53 [ET]
Event Date: 07/12/2016
Event Time: 13:00 [MST]
Last Update Date: 07/12/2016 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION |
Person (Organization):
VINCENT GADDY (R4DO) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
N |
Y |
100 |
Power Operation |
100 |
Power Operation |
Event Text
DEGRADED FIRE BARRIER
"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.
"During the performance of a fire seal and barrier surveillance test, a degraded fire seal barrier that provides 1 hour separation between two fire zones containing redundant safe shutdown trains was identified in the 100 foot elevation of the PVNGS Unit 1 Auxiliary Building.
"This condition is reportable in accordance with 10CFR50.72(b)(3)(ii)(B) as an unanalyzed condition.
"Fire protection detection and mitigation systems in both fire zones are operable and compensatory measures (fire watches) have been implemented for affected areas.
"The NRC Resident Inspector has been notified."
The degraded fire barrier consists of two holes in the through wall fire barrier surrounding two two-inch conduits. The two holes are approximately one to one and a half inches across. |
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