United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for September 4, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/31/2007 - 09/04/2007

** EVENT NUMBERS **


43601 43606 43607 43609 43611 43612 43613

To top of page
Other Nuclear Material Event Number: 43601
Rep Org: MICRON TECHNOLOGY INC.
Licensee: NRD
Region: 4
City: BOISE State: ID
County: ADA
License #:
Agreement: N
Docket:
NRC Notified By: KEVIN LUNDHAGEN
HQ OPS Officer: PETE SNYDER
Notification Date: 08/27/2007
Notification Time: 16:12 [ET]
Event Date: 08/27/2007
Event Time: [MDT]
Last Update Date: 08/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
REBECCA NEASE (R4)
EDWIN HACKETT (FSME)
ILTAB (email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST STATIC ELIMINATORS

On 7/27/07 when completing an inventory, Micron Technology, discovered that nine (9) static eliminators were missing. The company did a thorough search of areas in and around where these instruments were expected to be installed and looked in their warehouse where removed equipment is typically taken when removed from use but the eliminators were not found. The company is continuing its search.

All of the eliminators had Po-210 sources with an activity of about 10 millicuries when purchased. One source was purchased in August of 2003. Four sources were purchased in June of 2005 and four sources were purchased in August of 2005.

The company plans on implementing a number of measures to ensure that eliminators are not lost in the future: 1. A cradle to grave tracking system will be implemented along with; 2. implementation of additional training and; 3. procedures for a more structured process from start to finish.


* * * UPDATE ON 08/31/07 AT 1201 EDT FROM KEVIN LUNDHAGEN TO MACKINNON * * *

4 of the 9 missing static eliminators have been found and they have been confirmed by their serial numbers. The 4 static eliminators were found inside a purge box. They are being shipped back, today 08/31/07, to the license holder, NRD, which is located in Grand Island, New York. Linda Gersey of NRC Region IV asked Micron Technology to update this event with the above information. Micron Technology is still looking for the other 5 missing static eliminators.

FSME EO (S. Wastler) and R4DO (R. Nease) notified. E-mailed to ILTAB.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

To top of page
General Information or Other Event Number: 43606
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PHYSICIAN RELIANCE, LP TEXAS ONCOLOGY
Region: 4
City: FORT WORTH State: TX
County:
License #: L05545-000
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: PETE SNYDER
Notification Date: 08/29/2007
Notification Time: 13:42 [ET]
Event Date: 08/29/2007
Event Time: [CDT]
Last Update Date: 08/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
CYNTHIA FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - HIGHER THAN PRESCRIBED DOSE

"On 08/29/07 at 10:55 a.m., the agency received a call from [the] RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency.

"The misadministration was discovered today after an independent physicist's review of the treatment plan.

"The RSO stated the patient denies any symptoms and was being seen by the Radiation Oncologist. He stated the patient's family and referring physician were also notified."

Texas Incident No.: I-8439
Texas Event Report No.: TX-07-43606


* * * UPDATED INFORMATION ON 08/31/07 VIA EMAIL FROM LATISCHA HANSON TO MACKINNON * * *


Telephone call placed to (deleted), Ph.D., L.M.P., RSO for the licensee for updated information from 08/29/07 after the patient was seen by the Radiation Oncologist:

"Deleted reports that the patient was seen by the Radiation Oncologist & is being observed in a 'wait & watch' following. (Deleted) reported that the patient's Pulmonologist has taken over & (deleted) stated the Pulmonologist said 'We may have gotten lucky & even cured the guy.'

"The patient is still reported as doing well, with no adverse side effects being reported, as stated by (deleted).

"(Deleted) stated a CT was performed prior to the planned second treatment on 08/29/07, with no adverse effects viewed on the CT scan.

" ***ADDITIONAL NOTE TO ORIGINAL REPORTED INFORMAITON***

"Deleted reported on 08/29/07 that this HDR misadministration occurred as a result of the incorrect isodose line being chosen & entered into the treatment planning system. (Deleted) reported that the treatment planning system then normalized the calculations to this incorrect isodose line & the resulting treatment dose was what was delivered on the first treatment day. (Deleted) stated the Oncologist signed & approved this treatment plan & that (deleted) himself, did a second calculation check on the treatment plan. The calculation error was caught by an independent physicist PRIOR to the planned second treatment.

"Incident Investigations will continue to update this incident as current information is received.

"Incident Investigation personnel plan to conduct an onsite investigation upon receipt and review of the required 15-day report from the licensee."

FSME EO (Sandra Wastler) & R4DO (R. Nease) 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.

To top of page
Power Reactor Event Number: 43607
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK GORLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/30/2007
Notification Time: 09:18 [ET]
Event Date: 08/30/2007
Event Time: 08:58 [EDT]
Last Update Date: 08/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
SCOTT SHAEFFER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

PLANNED ELECTRICAL MAINTENANCE REMOVES TSC HVAC FROM SERVICE

"Planned preventive maintenance activities are being performed today (August 30, 2007) on the Hatch Nuclear Plant's Normal Supply Breaker (1C) to the Diesel Generator Building Motor Control Center (MCC) (MPL # 1R24-S026). This MCC feeds the Technical Support Center (TSC) 480V AC distribution panel (MPL# 1R25-S102) which supplies power to the TSC HVAC. The work activities affecting the TSC are planned to be performed and completed expeditiously within one work shift (<12 hours). During this work activity the TSC HVAC system will be removed from service. If an emergency condition occurs that requires activation of the Technical Support Center, during the time these work activities are being performed, it will take no more than four hours to return the equipment back to functional status, dependent on the stage of the work activity at the time the emergency occurs. Plans are to utilize the TSC for any declared emergency during the time these work activities are being performed as long as radiological conditions allow. Procedure 73EP-EIP-063-0, Technical Support Center Activation provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the primary TSC.

"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the evolution."


The licensee will notify the NRC Resident Inspector.

* * * UPDATE PROVIDED BY FRANK GORLEY TO JEFF ROTTON AT 0923 EDT ON 08/31/07 * * *

The planned maintenance was completed successfully and the TSC HVAC system was returned to service at 1748 EDT on 08/30/07.

The licensee notified the NRC Resident Inspector. Notified the R2DO (Shaeffer)

To top of page
General Information or Other Event Number: 43609
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ENVIRONMENTAL ANALYSTS
Region: 4
City: NEW ORLEANS State: LA
County:
License #: GL-266
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/30/2007
Notification Time: 11:22 [ET]
Event Date: 08/13/2007
Event Time: [CDT]
Last Update Date: 08/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
REBECCA NEASE (R4)
ILTAB EMAIL ()
CINDY FLANNERY (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST GAS CHROMATOGRAPH

The licensee provided the following information via facsimile:

"A portable gas chromatograph with a 15 mCi source of Ni-63 was lost during Hurricane Katrina when the levees broke. This is a General License device. LDEQ was not notified of this loss until August 13, 2007."

LA Event Report - LA070025

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

To top of page
Power Reactor Event Number: 43611
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: STEVE KOCHERT
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/31/2007
Notification Time: 11:05 [ET]
Event Date: 08/31/2007
Event Time: 07:03 [CDT]
Last Update Date: 08/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
REBECCA NEASE (R4)

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

LOSS OF EMERGENCY RESPONSE CAPABILITY - TSC SUPPORT CENTER (TSC) DUE TO PLANNED ELECTRICAL MAINTENANCE

"This report is being made pursuant to 10CFR50.72(b)(3)(xiii), 8-hour Non-Emergency Report due to the loss of emergency assessment capability. The normal AC power supply and backup diesel generator were taken out of service for planned load center cleaning maintenance activities and the Technical Support Center (TSC) was declared non functional at 0703 Central Daylight Time on 8/31/2007. The maintenance activities are expected to last approximately 16 hours. Affected Emergency Response Organization members have been, instructed to report to designated backup facilities, per procedure EIP-ZZ-00240, in the event of an emergency.

"Though this does not affect state or local response capabilities, the SEMA Senior Radiological Emergency Program Planner and local personnel have been notified of this planned maintenance outage as a courtesy.

"The licensee has notified the NRC Resident Inspector."

* * * UPDATE ON 08/31/07 AT 1730 EDT BY STEVE KOCHERT TO MACKINNON * * *

"The normal AC power supply and backup diesel generator were restored to service and the TSC was declared functional at 1627 CDT on 8/31/2007. Affected Emergency Response Organization members have been instructed to resume normal use of the TSC in the event of a emergency.

"The licensee has notified the NRC Resident Inspector."

R4DO (Troy Pruett) notified.

To top of page
Power Reactor Event Number: 43612
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: R. SCARBOROUGH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/01/2007
Notification Time: 20:22 [ET]
Event Date: 09/01/2007
Event Time: 16:58 [CDT]
Last Update Date: 09/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
TROY PRUETT (R4)
PAO-TSIN KUO (NRR)
BRIAN McDERMOTT (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION RELATED TO FATALITY

"The purpose of this report is to notify the NRC of a fatality involving a contract worker at the South Texas Project. Specifically, at 15:35 (CST), the South Texas Project Unit 1 Control Room was notified that an individual located outside of the protected area but in the owner controlled area had loss consciousness. The site emergency medical team responded and an ambulance was requested at 15:39. At 16:58 the South Texas project was notified that the individual was pronounced dead upon arrival at Matagorda General Hospital. The South Texas Project will be notifying OSHA of the fatality. A press release is not planned at this time, but is under consideration."

The resident NRC inspector has been notified

To top of page
Power Reactor Event Number: 43613
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW RASMUSSEN
HQ OPS Officer: JASON KOZAL
Notification Date: 09/03/2007
Notification Time: 05:05 [ET]
Event Date: 09/03/2007
Event Time: 02:14 [CDT]
Last Update Date: 09/03/2007
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):
SCOTT SHAEFFER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO ELECTRO-HYDRAULIC CONTROL (EHC) SYSTEM LEAK

"At 0214 [CDT] on 09/03/2007 with Unit 1 at 100% power a core flow runback and manual reactor scram were initiated due to a Electro-Hydraulic Control (EHC) System leak. Units 2 and 3 were also at 100% power and were unaffected by the event. As expected reactor water level momentarily lowered below +2 inches (Reactor Low Water Level) and all appropriate PCIS [Primary Containment Isolation System] isolations, Group 2 (RHR Shutdown Cooling). Group 3 (RWCU), Group 6 (Ventilation), and Group 8 (TIP) were received along with the auto start of CREVs [Control Room Emergency Ventilation] and 3 SBGT trains.

"This event is reportable as a 4-hour and 8-hour non-emergency notification along with a 60-day written report in accordance with 10 CFR 50.72(b)(2)(iv)(B), 10 CFR 50 72(b)(3)(iv)(A) and 10 CFR 50.73(a)(2)(iv)(A) as 'any event or condition that results in valid actuation of RPS or PCIS.'

"All control rods fully inserted, the electrical grid is stable, the EDGs and ESF systems remain available, and decay heat is being removed via the Turbine Bypass Valves and reactor water level is being controlled by the Reactor Feedwater System. The licensee notified the NRC Resident Inspector.

"Investigation into the cause of the leak is ongoing."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012