| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/31/2006 - 09/01/2006 ** EVENT NUMBERS ** |
 | General Information or Other | Event Number: 42811 | Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH COPELY MEDICAL CENTER
Region: 3
City: AURORA State: IL
County:
License #: IL-01207-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MIKE RIPLEY | Notification Date: 08/29/2006
Notification Time: 10:35 [ET]
Event Date: 08/22/2006
Event Time: [CDT]
Last Update Date: 08/29/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
HIRONORI PETERSON (R3)
MICHELE BURGESS (NMSS)
| Event Text AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via email:
"Yesterday [name deleted] the medical physicist for this Aurora, IL based licensee (IL-01207-01) called to report a medical event which had come to her attention. While preparing a 'Mammosite' treatment plan for an upcoming patient, she had found that two previously administered therapy treatments were not as intended (on 7/28/06 and 8/22/06). Both treatment plans called for a dose of 3400 cGy to be administered to each of the patients over 10 fractions at 340 cGy per fraction with two fractions delivered each of 5 days. However, due to confusion and misunderstanding of the data entry into the treatment planning software, an error occurred and the dose per fraction delivered was only 34 cGy for a total treatment dose of only 340 cGy. Thus, both patients received only 10% of the dose they should have received for their cancer treatments.
"The treatment planning software, named Eclipse, developed by Varian Medical Systems had a known issue with regards to 'fractionated doses'. A company technical bulletin, (CTB-BV-318) had been generated by the company in March of 2003 and provided to its customers alerting them to the appropriate method for data entry for fractionated doses. The technical bulletin for the treatment planning software contains a warning that 'incorrect use could possibly cause a misadministration.' However, Rush Copley did not acquire its high dose rate afterloading system and treatment planning software until August of 2005 and although the treatment planning software had been updated to a newer version, the same issue remained in the new version. According to the authorized user and the medical physicist, there was no training provided on this aspect of use of the treatment planning software when they had attended the manufacturer's training last year.
"The hospital has administered only these two fractionated doses since they acquired the unit. Both patients have been contacted by the authorized user and the patients are considering the available options for additional treatment if necessary. Considering the treatment regimen is designed for post surgical lumpectomies of the breast, the physician believes the effect of the under dose on the patients will be minimal. The licensee has been advised of the need to file the appropriate report in the next 15 days including its corrective action.
"Because the dose to the patient differs by more than 20% from that originally prescribed, the Agency must notify the U.S. NRC Operations Center with this event.
"Patient Information:
"Patient Number: 1; Patient Informed: Y; Date Informed: 08/28/2006
"Therapeutic: BRACHY, REMOTE AFTERLOADER, HDR
"Organ: BREAST, RIGHT
"Dose: 340 rad 3.4 Gy; % Dose is Less Than Prescribed: 90
"Effect on Patient: OTHER
Administered By: PHYSICIAN
"Patient Number: 2; Patient Informed: Y; Date Informed: 08/28/2006
"Therapeutic: BRACHY, REMOTE AFTERLOADER, HDR
"Organ: BREAST, RIGHT
"Dose: 340 rad 3.4 Gy; % Dose is Less Than Prescribed: 90
"Effect on Patient: OTHER
"Administered By: PHYSICIAN
"Source of Radiation:
"Form of Radioactive: SEALED SOURCE; Radionuclide or Voltage (kVp/MeV): IR-192
"Source Use: BRACHYTHERAPY; Activity: 10.2 Ci 377.4 GBq; Manufacturer: ALPH-OMEGA SERVICES
"Model Number: VS2000; Serial Number: 02-01-0699-001-062106-10250-03
"Device/Associated Equipment:
"Device Name: REMOTE AFTERLOADER HDR Model Number: VARISOURCE
"Manufacturer: VARIAN Serial Number: VS60037
"Reporting Requirements:
"Reporting Requirement: 32 IAC 335.1080 - Any administration of radioactive materials that results in a 'reportable event' (misadministration), licensee shall notify the agency by telephone NLT next day after licensee ascertains and confirms that a reportable event has occurred. Mode Reported: Telephone" |
| General Information or Other | Event Number: 42812 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: BLACKBURN CONSULTING, INC.
Region: 4
City: AUBURN State: CA
County:
License #: 6589-31
Agreement: Y
Docket:
NRC Notified By: KEN FUREY
HQ OPS Officer: STEVE SANDIN | Notification Date: 08/30/2006
Notification Time: 00:00 [ET]
Event Date: 08/29/2006
Event Time: 12:30 [PDT]
Last Update Date: 08/30/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
CHUCK CAIN (R4)
C.W. (BILL) REAMER (NMSS)
| Event Text AGREEMENT STATE REPORT INVOLVING A POTENTIALLY DAMAGED TROXLER
The State provided the following information via facsimile:
"[The] Alternate Radiation Safety Officer called RHB to report their Troxler 3430, serial # 31984 (containing 8 mCi of Cesium-137 and 40 mCi of Americium-241) had just been run over by a water truck on a construction site in Lincoln, CA. [The Alternate RSO] stated the source rod was still intact. The gauge was taken to the Troxler facility in Rancho Cordova, CA. Troxler performed a leak test with negative results. The gauge is to be sent to Troxler headquarters in Research Triangle Park, NC for repair or eventual disposal." |
| Power Reactor | Event Number: 42816 | Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JIM COSTEDIO
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/30/2006
Notification Time: 17:04 [ET]
Event Date: 08/30/2006
Event Time: 14:47 [EDT]
Last Update Date: 08/31/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
| Person (Organization):
JAMES DWYER (R1)
MELVYN LEACH (IRD)
|
| 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 POTENTIALLY CONTAMINATED INDIVIDUAL TRANSPORTED TO A HOSPITAL
"While performing work on the refuel floor, an operator received a hand injury. The first aid team responded and the injured hand was covered. Radiation Protection personnel verified that the individual was free of contamination with the exception of the injured hand that had been covered by the first aid team. The individual was transported to an offsite medical facility for treatment as a potentially contaminated injured man."
The licensee notified the NRC Resident Inspector and will notify the state.
* * * UPDATE PROVIDED BY COSTEDIO TO KOZAL ON 8/31/2006 AT 1402 EDT * * *
"Two site Radiation Protection (RP) technicians accompanied the injured man to the hospital. These technicians collected the materials that came into contact with the injured hand that had not been surveyed prior to transport. At the hospital, the bandage that had been applied by the first aid team was removed and no contamination was found on the bandage. The cotton glove liner, that had been left on the hand when the first aid team removed the rubber outer glove, was surveyed and found to have low level contamination on it (100 - 250 Counts per minute above background (CPM)). The cotton glove liner was removed and the hand was surveyed and found to be free of contamination. Prior to leaving the hospital the RP technicians and the hospital radiation safety officer surveyed the patient, the areas of the hospital facility where the patient had been, and the ambulance. The results of these surveys showed no radiological contamination.
"The contamination of the cotton glove liner is believed to be due to leaching or transference from the rubber glove, that was being worn by the individual as he was working on the refuel bridge mast, when it was removed by the first aid team."
The licensee notified the NRC Resident Inspector.
Notified R1DO (Dwyer). |
| Power Reactor | Event Number: 42817 | Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RON FRY
HQ OPS Officer: JASON KOZAL | Notification Date: 08/31/2006
Notification Time: 14:26 [ET]
Event Date: 08/31/2006
Event Time: 11:11 [EDT]
Last Update Date: 08/31/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
JAMES DWYER (R1)
|
| 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 HPCI DECLARED INOPERABLE DUE TO STOP VALVE INDICATION ISSUE
"At 1111, on August 31, 2006, during performance of SO-152-006 HPCI was declared inoperable when the HPCI Turbine Stop Valve FV-15612 had dual position indication. Local observation of the stop valve by plant operators and a report from the system engineer verified the valve was closed, and the problem appears to be a limit switch problem. With the lower limit switch not responding correctly the system engineer informed the control room the HPCI Ramp Generator is not reset, which will result in an over speed condition of the HPCI turbine if an actuation signal is received.
"To prevent possible damage to the HPCI turbine, control room personnel overrode HPCI injection in accordance with plant operating procedures.
"Plans are being developed to investigate the problem, and adjust the limit switch if required.
"This is being reported as an event or condition that could have prevented fulfillment of a safety function required to mitigate the consequences of an accident in accordance with 10CFR50.72(b)(3)(v)(D)."
The licensee has entered the provisions of TS 3.5.1 for this condition.
No other accident mitigation systems are currently inoperable.
The licensee notified the NRC Resident Inspector. |
| Other Nuclear Material | Event Number: 42819 | Rep Org: ALASKA INDUSTRIAL X-RAY, INC
Licensee: ALASKA INDUSTRIAL X-RAY, INC
Region: 4
City: ANCHORAGE State: AK
County:
License #:
Agreement: N
Docket:
NRC Notified By: PETE MILLAR
HQ OPS Officer: JASON KOZAL | Notification Date: 08/31/2006
Notification Time: 14:36 [ET]
Event Date: 08/31/2006
Event Time: 10:30 [YDT]
Last Update Date: 08/31/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
| Person (Organization):
MICHELLE BURGESS (NMSS)
CHUCK CAIN (R4)
|
| This material event contains a "Category 3" level of radioactive material. | Event Text LOST RADIOGRAPHY CAMERA ON WAKE ISLAND
The licensee reported a loss of a 10 Ci [based on source decay starting December of 2005] IR-192 radiography camera on Wake Island. In preparation for evacuation of the island on 8/29/2006 the camera was loaded in a type B(U) storage container. On 8/30/2006 Super Typhoon Yoke made land fall on Wake Island producing 150 mph winds and 30 - 40 ft storm surge. The status of the camera is unknown due to the uncertain condition of Wake Island. There currently is no information of the habitability of Wake Island and thus it is uncertain when a search can be conducted.
The licensee will update the status of the material as more information becomes available.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example, level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging.
Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Category 3 event.
Note: the value assigned by device type "Category 2" is different than the calculated value "Category 3" |
| Power Reactor | Event Number: 42820 | Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: KEN BROWN
HQ OPS Officer: JASON KOZAL | Notification Date: 08/31/2006
Notification Time: 16:35 [ET]
Event Date: 08/31/2006
Event Time: 15:30 [EDT]
Last Update Date: 08/31/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
| Person (Organization):
JAMES DWYER (R1)
TIM MCGINTY (NRR)
MELVYN LEACH (IRD)
MICHEAL WEBER (NRR)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 60 | Power Operation | Event Text PLANT REQUIRED SHUTDOWN DUE TO 'A' AND 'B' EDG INOPERABLE.
"On August 31, 2006 at 1530 EST Seabrook Station initiated a plant shutdown in accordance with TS 3.8.1.1 Action (f). On August 28, 2006 the Train 'A' Emergency Diesel Generator (EDG) was removed from service for planned maintenance. During the planned maintenance, an emergent issue [suspected diode failure on the control circuitry] was discovered. That required starting the Train 'B' EDG in accordance with the provisions of TS 3.8.1.1 Action (b). During the start of the Train 'B' EDG a voltage control anomaly was discovered that required the Train 'B' EDG to also be declared inoperable.
"With two EDG's inoperable, TS 3.8.1.1 requires a plant shutdown. This event is reportable pursuant to 10CFR50.72(b)(2)(i) as the initiation of plant shutdown required by the plant's Technical Specifications. The Station currently has all three offsite power supplies and the Supplemental Emergency Power System operable."
The licensee is in the process of shutting down and is currently at 60% power at a 20%/hr ramp rate with the intention of entering Mode 3.
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 42822 | Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL KENNEDY
HQ OPS Officer: JASON KOZAL | Notification Date: 08/31/2006
Notification Time: 18:42 [ET]
Event Date: 08/31/2006
Event Time: 14:09 [PDT]
Last Update Date: 08/31/2006 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
| Person (Organization):
CHUCK CAIN (R4)
TIM MCGINTY (NRR)
MELVYN LEACH (IRD)
MICHAEL WEBER (NRR)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 90 | Power Operation | Event Text TECHNICAL SPECIFICATION REQUIRED SHUDOWN DUE TO RCS LEAKAGE
"On August 31, 2006, licensed plant operators identified that Technical Specification 3.4.13 was not met due to a one to two gallon per minute unidentified reactor coolant system (RCS) leak. Plant Operators initiated a ramp of reactor power to take Unit 2 to mode 3, Hot Standby, at 1409 PDT. A containment entry has been initiated to identify the source of the RCS leak. The estimated restart date is preliminary, pending investigation of the leakage location. The Unit is currently ramping off line at 4-5 MW/min. Current reactor power level is 90% and 937 MW electric."
The licensee stated that the suspected source of the leak is the seal table room where radiation levels have risen consistent with the containment leakage. Current unidentified leak rate is 1.3 gpm. The TS limit is 1 gpm. Current coolant activity is 1.88 microCi/ml.
A press release is planned to be issued on 9/1/2006.
The licensee notified the NRC Resident Inspector.
* * * UPDATE PROVIDED BY D. PATTY TO O'HARA ON 08/31/06 AT 2254 EST * * *
"This is a follow up to the 4 hour notification that was initiated due to initiating a Technical Specification (TS) required shutdown when Technical Specification 3.4.13 was not met.
"Plant Operators entered containment and identified RCS leakage from one of the thimble tubes in the seal table 10 path. At 1622 on 8/31/06 the leakage was classified as identified leakage. The TS required shut down was stopped at 1623 as the leak rate is less than the TS leak rate limit for identified leakage. Operators have isolated the 10 path by closing the valve and the RCS leakage has stopped."
Notified R4DO (Cain), NRR EO (McGinty) via e-mail, IRD MOC (Leach) via e-mail. | |