Event Notification Report for September 05, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/04/2024 - 09/05/2024
Non-Agreement State
Event Number: 57310
Rep Org: Washington University
Licensee: Washington University
Region: 3
City: St Louis State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: Briana Davis
HQ OPS Officer: Robert A. Thompson
Licensee: Washington University
Region: 3
City: St Louis State: MO
County:
License #: 24-00167-11
Agreement: N
Docket:
NRC Notified By: Briana Davis
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/06/2024
Notification Time: 15:01 [ET]
Event Date: 09/05/2024
Event Time: 09:40 [CDT]
Last Update Date: 09/06/2024
Notification Time: 15:01 [ET]
Event Date: 09/05/2024
Event Time: 09:40 [CDT]
Last Update Date: 09/06/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Hills, David (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Hills, David (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
THERASPHERE FRACTIONATED DOSE MISADMINISTRATION
The following is a summary of information provided by the licensee via phone:
A TheraSphere treatment comprised of three fractions was planned to be administered to the patient's liver. The first fraction was planned to be 1.1 GBq Y-90, the second fraction 1.1 GBq Y-90, and the third fraction 1.46 GBq Y-90.
When the treatment was administered, the third fraction (actual activity 1.48 GBq Y-90) was administered first, in place of the intended first fraction. The second fraction was administered as planned. The error was discovered when the vial containing the third fraction was found to have already been used. The treatment plan was then revised to use the remaining first fraction vial (actual activity 1.02 GBq).
All fractions were administered to the patient's liver as planned and the total dose was in accordance with the treatment plan.
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 summary of information provided by the licensee via phone:
A TheraSphere treatment comprised of three fractions was planned to be administered to the patient's liver. The first fraction was planned to be 1.1 GBq Y-90, the second fraction 1.1 GBq Y-90, and the third fraction 1.46 GBq Y-90.
When the treatment was administered, the third fraction (actual activity 1.48 GBq Y-90) was administered first, in place of the intended first fraction. The second fraction was administered as planned. The error was discovered when the vial containing the third fraction was found to have already been used. The treatment plan was then revised to use the remaining first fraction vial (actual activity 1.02 GBq).
All fractions were administered to the patient's liver as planned and the total dose was in accordance with the treatment plan.
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.
Independent Spent Fuel Storage Installation
Event Number: 57305
Rep Org: San Onofre
Licensee: Southern California Edison Company
Region: 4
City: San Clemente State: CA
County: San Diego
License #: GL
Agreement: Y
Docket: 72-41
NRC Notified By: Guadalupe Robles
HQ OPS Officer: Robert A. Thompson
Licensee: Southern California Edison Company
Region: 4
City: San Clemente State: CA
County: San Diego
License #: GL
Agreement: Y
Docket: 72-41
NRC Notified By: Guadalupe Robles
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/05/2024
Notification Time: 11:06 [ET]
Event Date: 09/05/2024
Event Time: 08:00 [PDT]
Last Update Date: 09/05/2024
Notification Time: 11:06 [ET]
Event Date: 09/05/2024
Event Time: 08:00 [PDT]
Last Update Date: 09/05/2024
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Drake, James (R4DO)
Drake, James (R4DO)
EN Revision Imported Date: 9/9/2024
EN Revision Text: OFFSITE AGENCY NOTIFICATION OF LOW-LEVELS OF TRITIUM DETECTED IN GROUNDWATER
The following information was provided by the licensee via phone and email:
"On September 5, 2024, Southern California Edison reported, as a proactive measure, detectable levels of tritium in onsite groundwater wells to offsite government agencies. The tritium levels do not exceed reporting thresholds in the [Nuclear Energy Institute's] NEI 07-07 communication protocol, the offsite dose calculation manual, nor the NRC regulations in 10 CFR Part 20. Offsite ocean water samples have not identified the presence of tritium above detectable levels. An investigation is currently ongoing to determine the source of tritium and determine mitigative actions, if any.
"This notification is being made solely as a four-hour, non-emergency notification for a notification of another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel."
The NRC regional inspector will be notified.
EN Revision Text: OFFSITE AGENCY NOTIFICATION OF LOW-LEVELS OF TRITIUM DETECTED IN GROUNDWATER
The following information was provided by the licensee via phone and email:
"On September 5, 2024, Southern California Edison reported, as a proactive measure, detectable levels of tritium in onsite groundwater wells to offsite government agencies. The tritium levels do not exceed reporting thresholds in the [Nuclear Energy Institute's] NEI 07-07 communication protocol, the offsite dose calculation manual, nor the NRC regulations in 10 CFR Part 20. Offsite ocean water samples have not identified the presence of tritium above detectable levels. An investigation is currently ongoing to determine the source of tritium and determine mitigative actions, if any.
"This notification is being made solely as a four-hour, non-emergency notification for a notification of another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel."
The NRC regional inspector will be notified.