| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
11/29/2005 - 11/30/2005 ** EVENT NUMBERS ** |
 | Power Reactor | Event Number: 42173 | Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ETHAN TREPTOW
HQ OPS Officer: PETE SNYDER | Notification Date: 11/29/2005
Notification Time: 01:24 [ET]
Event Date: 11/28/2005
Event Time: 22:20 [CST]
Last Update Date: 11/29/2005 | 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
| Person (Organization):
PATRICK LOUDEN (R3)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby | Event Text AUTOMATIC REACTOR TRIP FOLLOWING MAIN FEED PUMP TRIP
"At 22:19 CST, Main Feedwater Pump B tripped on over current. A secondary plant runback from 100% power was automatically initiated. During the secondary plant runback, the reactor automatically tripped on Steam Generator B low-low level at 22:20 CST.
"All three Auxiliary Feedwater pumps automatically started due to low-low Steam Generator level. The plant has been stabilized at Hot Shutdown (RCS temperature approximately 547 degrees F, RCS pressure approximately 2235 psig). Investigation into the cause of the trip is on-going.
"This event is being reported under 10CFR50.72(b)(2)(iv)(B) for actuation of the reactor protection system (RPS) when the reactor is critical and 10CFR50.72(b)(3)(iv)(A) for valid actuation of the Auxiliary Feedwater System."
All control rods fully inserted on the automatic trip. Steam generator water levels have recovered to indicate in the narrow range. The current decay heat removal path is auxiliary feedwater to the steam generators steaming through the power operated relief valves. There are no known primary to secondary leaks. All safety related buses are powered from offsite power. Emergency diesel generators are available and in standby.
The licensee notified the NRC Resident Inspector. |
| Hospital | Event Number: 42174 | Rep Org: HOSP ONCOLOGICO ANDRES GRILLASCA
Licensee: HOSP ONCOLOGICO ANDRES GRILLASCA
Region: 1
City: PONCE State: PR
County:
License #: 52-11832-02
Agreement: N
Docket:
NRC Notified By: MIGUEL RIOS
HQ OPS Officer: STEVE SANDIN | Notification Date: 11/29/2005
Notification Time: 15:40 [ET]
Event Date: 11/29/2005
Event Time: [EST]
Last Update Date: 11/29/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
TODD JACKSON (R1)
GREG MORELL (NMSS)
| Event Text MEDICAL EVENT INVOLVING ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE
On 11/22/05 a female patient undergoing treatment for cervical cancer received the third fraction of a five (5) fraction treatment plan using a HDR Brachytherapy source. Each fraction was scheduled to deliver 600 cGy to the intended treatment site for a total delivered dose of 3000 cGy. During the third treatment, the delivered dose was 200 cGy, instead of 600 cGy, due to a miscalculation in the distance factor. The treating physician does not believe there will be any adverse effects upon the patient. |
| Hospital | Event Number: 42175 | Rep Org: STEELE MEMORIAL MEDICAL CENTER
Licensee: NON LICENSED FACILITY
Region: 4
City: SALMON State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: LINDA ASTALOS
HQ OPS Officer: JEFF ROTTON | Notification Date: 11/29/2005
Notification Time: 18:27 [ET]
Event Date: 11/29/2005
Event Time: 15:20 [MST]
Last Update Date: 11/29/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
| Person (Organization):
REBECCA NEASE (R4)
ROBERT PIERSON (NMSS)
LEN WERT (R4)
| Event Text POTENTIAL OVEREXPOSURE DUE TO SURGICAL REMOVAL OF PROSTATE WITH SEED IMPLANTS
During surgery to remove a patient's prostate gland, the surgeon announced that there were radioactive seed implants present. The surgeon warned surgical staff in the operating room after the surgery commenced to don lead apron shielding and the prostate gland was covered with a lead apron. The prostate was placed in a plastic container submerged in 5 inches of water in a 5 gallon container with the lead apron over the container based on a consultant's recommendation. The container is in an area with limited access and labeled as a radiation hazard. The hospital does not have a nuclear medicine department or any devices to measure radioactivity. The seed implants were supposedly implanted 90 days ago at a hospital in California with approximately a 30 day half life. The hospital will be ordering a lead shipping container for proper disposal later. |
| Fuel Cycle Facility | Event Number: 42176 | Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: TONY HUDSON
HQ OPS Officer: JOHN KNOKE | Notification Date: 11/29/2005
Notification Time: 23:36 [ET]
Event Date: 11/29/2005
Event Time: 08:45 [CST]
Last Update Date: 11/29/2005 | Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
ROBERT HAAG (R2)
ROBERT PIERSON (NMSS)
| Event Text FAULTY SWITCH RENDERED CRITICALITY ACCIDENT ALARM SYSTEM INOPERABLE
"At 0845 CST, on 11/29/2005 the C-337 process building Criticality Accident Alarm System (CAAS) was being tested when a building horn control switch in C-300 Central Control Facility which supplies voltage to actuate the building CAAS evacuation horns was found to not be properly made up. This switch caused the building CAAS horns not to sound when a cluster was actuated. The test which revealed this problem, was the initial
'as found' test, which means the failure most likely occurred prior to today's testing. The C-337 CAAS system is a TSR system which is required to be operable in the current operating mode unless LCO actions are in place. The C-337 CAAS system was last tested on 11/05/2005 and indications are that the switch problem has existed since that time.
"During testing the CAAS alarm was received in C-300, but the evacuation horns did not automatically sound. Per procedure if a criticality alarm had occurred the C-300 operator would have actuated the horn switch manually which would have sounded the evacuation horns. To ensure that not only the C-337 switch was properly repaired, but also to verify all other building horn control switches were in the proper state, a plant wide LCO was implemented and switch outputs were checked to verify the proper voltage output."
The NRC Senior Resident has been notified of this event. | |