United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 2, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/01/2011 - 02/02/2011

** EVENT NUMBERS **


46021 46489 46528 46529 46572 46574 46581 46582

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46021
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES E. MURAIDA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/17/2010
Notification Time: 14:15 [ET]
Event Date: 06/17/2010
Event Time: 05:19 [CDT]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

UNANALYZED CONDITION DUE TO CONTAINMENT SPRAY RECIRC SUMP ISOLATION VALVE FAILURE TO STROKE CLOSED

"At 0519 CDT on June 17th, Unit 2 was closing the 2CS009B, Containment Spray Recirc Sump Isolation Valve, as part of post maintenance testing when the valve stopped stroking (i.e. mid position). The 2CS009B valve was being stroked closed for restoration from a successful timed stroke in the open direction. The 2CS009B valve was manually closed and verified closed via limit switch indication.

"With the 2CS009B valve unable to be closed from the Main Control Room, an unanalyzed condition may have existed where, during a large break LOCA requiring cold leg recirc, the Refueling Water Storage Tank (RWST) had an additional flow path to the containment recirc sump. This potentially challenges the operators to complete the switchover prior to the RWST reaching 9%, the point at which pumps taking a suction from the RWST only are shutdown. This condition is still being evaluated."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM P. MOODY TO P. SNYDER AT 0404 ON 2/1/11 * * *

"At 0509 on June 17, 2010, Unit 2 was closing the 2CS009B, Containment Spray (CS) Recirculation Sump Isolation Valve, as part of post maintenance testing when the valve stopped stroking (i.e., mid-position). The 2CS009B was being stroked closed for restoration from a successful timed stroke in the open direction. The 2CS009B was manually closed and verified closed via limit switch indication.

"With the 2CS009B unable to close from the Main Control Room, an unanalyzed condition may have existed where, during a large break LOCA requiring cold leg recirculation, the Refueling Water Storage Tank (RWST) had an additional flow path to the recirculation sump. This potentially challenged the operators to complete the switchover prior to the RWST reaching 9%, the point at which pumps taking a suction from the RWST only are shutdown. While this condition was being evaluated, an ENS notification was made per ENS 46021 under 10CFR50.72(b)(3)(ii)(B).

"As the evaluation approached the 60-day reporting period, LER 2010-002 was issued in accordance with 10 CFR 50.73(a)(2)(ii)(B), assuming the results would yield an unanalyzed condition.

"Since then, an evaluation was completed. The results concluded the operators would have performed the switchover steps within the allowed time, before reaching the RWST empty alarm set point. Therefore, the Emergency Core Cooling System (ECCS) and CS system would have performed their design functions. The evaluation also determined the RWST outflows with 2CS009B in the open position during the ECCS switchover sequence did not affect the RWST vortex analysis. Based on no loss of design function, the plant was not in an unanalyzed condition and this event is not reportable per 10CFR 50.72(b)(3)(ii)(B) or 10CFR 50.73(a)(2)(ii)(B). This event was screened for additional reportability criteria contained in the Exelon Reportability Manual. Again, since there was no loss of design function there is no reportability requirement.

"Therefore ENS notification 46021 is being retracted."

The licensee notified the NRC Resident Inspector.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information Event Number: 46489
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: H&H X-RAY SERVICES INC.
Region: 4
City: LUFKIN State: TX
County:
License #: 02516
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/17/2010
Notification Time: 19:16 [ET]
Event Date: 12/10/2010
Event Time: [CST]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4DO)
KEVIN O'SULLIVAN (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA LOCKING DEVICE FAILURE RESULTING IN PERSONNEL EXPOSURE

"On December 17, 2010, the Agency [Texas Department of Health Services] was notified by the licensee that on December 10, 2010, the locking device on QSA model 880 camera containing 97 curies of Iridium (Ir) 192 failed to activate. The radiography crew (group A) had completed operations at one site near Lufkin, Texas, and was moving to a new location at the same site. The radiography camera with the cranking device and guide tube still attached were placed in the dark room of the radiographers' truck. The licensee stated that a survey was conducted to verify the source was in the fully shielded, locked position. As the radiographer was driving to the new location, he passed about 5 feet from another group of radiographers (group B) from the same licensee. As group A passed by group B, group B's dosimeters alarmed. Group B stopped group A and told them that their alarms had gone off. Group A went to the camera, picked up the crank for the camera, and found that the source had moved from the locked position approximately one quarter of a turn. The radiographer cranked the source back to the fully shielded position and secured the camera for transportation.

"The radiographers did not inform the licensee of the event until December 16, 2010. At that time, the licensee began an investigation of the event, including reenactments of the event to determine how much dose the radiographers had received. During the investigation, it was discovered that both radiographer's self reading pocket dosimeters had been read after the camera was secured and were reading off scale. The licensee determined that radiographers 'A' were eight feet from the source while they were driving and would have been exposed to the source for approximately 10 minutes. A dose estimate of 1,700 millirem was made for both individuals. The thermoluminescent dosimeters for radiographers 'A' have been sent to the processor for reading. The licensee stated they expected the readings by late Monday December 20. The licensee stated that several pieces of radiography film were lying on the seat of the truck when the event occurred. The film was developed and indicated that it had been exposed to approximately 1,700 millirem. The licensee stated that neither radiographer would have received enough exposure to exceed any limit. The licensee stated that no member of the general public was exposed to any radiation as a result of this event.

"The licensee has not inspected the camera. The licensee stated that the camera is out of service and is currently stored in their storage facility. Additional information has been requested of the licensee. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #I-8803

* * * UPDATE FROM ART TUCKER TO JOE O'HARA VIA E-MAIL AT 1203 EST ON 1/18/11 * * *

"On December 23, 2010, the Agency [Texas Department of Health Services] performed an on-site investigation at the licensee's facility. The investigation determined that the camera did not fail to operate properly, but that the operator failed to fully retract and lock the source in place."

* * * RETRACTION RECEIVED VIA EMAIL FROM A. TUCKER TO J. SHOEMAKER AT 0856 EST ON 2/1/11 * * *

"This event was initially reported as a failure of the locking device on a radiography camera. The investigation into the event determined that it was caused by operator error and not a failure of the equipment to operate as designed."

Notified R4DO(Howell) and FSME(McIntosh).

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Agreement State Event Number: 46528
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: SAINT NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGEN State: WI
County:
License #: 117-1302-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/10/2011
Notification Time: 14:29 [ET]
Event Date: 01/10/2011
Event Time: [CST]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - NUMEROUS MEDICAL EVENTS FROM PROSTATE BRACHYTHERAPY

The following was received from the state via fax;

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an In Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a comprehensive review of all prostate brachytherapy cases to determine whether any medical events had occurred. On January 10, 2011, the licensee's Radiation Safely Officer reported the identification of five medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. The licensee is identifying a medical event of any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only. [D90 is a recognized value in the regulatory guidelines and means a dose of 90% to the prostate. Anything outside of the D90 value is considered to be a medical event.] The licensee performed a comprehensive review of all 44 prostate implants performed since August 2003. The licensee's five medical events include one overdose to the prostate and four underdoses to the prostate. All were patients who received seed implants only. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1)(e).

"Overdoses (medical event criteria used: D90>195 Gy): 11/13/2008: 199.15 Gy

"Underdoses (medical event criteria used: D90<135 Gy):
2/9/2007: 100.20 Gy;
11/12/2007: 127.34 Gy;
6/16/2008: 130.12 Gy; and
7/13/2010: 116.16 Gy"


* * * UPDATE FROM CHRIS TIMMERMAN TO JOHN KNOKE AT 1212 EST ON 2/1/11 * * *

"This is an update to Event Notification 46528. The licensee recently performed post-implant dosimetry on seven prostate brachytherapy patients whose post-implant dosimetry had never been performed. Evaluation of these seven implants prompted the licensee to report two additional medical events. The medical events involved permanent implants of l-125 for prostate brachytherapy where the total dose delivered to the prostate differs from the prescribed dose by 20% or more. The licensee is in the process of notifying the affected patients and referring physicians.

"Underdoses (medical event criteria used: D90<135 Gy):
8/22/2005: 102-89 Gy; and
5/8/2006: 12624 Gy;

"DHS will send a special inspection team to determine the root cause(s) of these medical events."

WI Event Report ID No.: WI 110001 Update

Notified FSME(Angela McIntire) and R3DO (Richard Skokowski)


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.

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Agreement State Event Number: 46529
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1303-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 01/10/2011
Notification Time: 14:29 [ET]
Event Date: 01/10/2011
Event Time: [CST]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY MISDOSING

The following information was received from the State of Wisconsin via fax:

"On January 10, 2011, the licensee's Radiation Safety Officer reported the identification of ten medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more.

"During a recent routine inspection, Department of Health Services inspectors determined that the licensee was not reviewing prostate brachytherapy cases against medical event criteria. The licensee is identifying as a medical event any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only, and D90<100 Gy or D90>145 Gy for patients who receive seed implants in conjunction with external beam therapy (combined therapy). The licensee performed a comprehensive review of all 82 prostate implants performed since August 2003. The licensee's ten medical events include six overdoses to the prostate and four underdoses to the prostate. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1).

"Overdoses (medical event criteria used - D90>195 Gy): 12/23/2003: 204.95 Gy; 10/27/2004: 160.49 Gy {combined therapy, medical event criteria used - D90>145 Gy}; 1/20/2006: 211.23 Gy; 6/14/2006: 207.03 Gy; 9/5/2007: 205.7 Gy; and 10/17/2007: 210.47 Gy.

"Underdoses (medical event criteria used - D90<135 Gy): 9/26/2003: 123.03 Gy; 10/31/2003: 116.78 Gy; 1/14/2004: 126.73 Gy; and 3/31/2009: 123.74 Gy.

"DHS will send a special inspection team to determine the root cause(s) of these medical events on February 2, 2011."

* * * UPDATE FROM CHRIS TIMMERMAN TO JOHN KNOKE AT 1212 EST ON 2/1/11 * * *

"This is an update to Event Notification 46529. On January 31, 2011, the licensee retracted one medical event for a prostate brachytherapy patient treated on 3/31/2009 based on refined post-implant dosimetry. Further updates will be made through NMED.

"DHS will send a special inspection team on February 3 2011. "

WI Event Report ID No.: WI 110001 Update

Notified FSME(Angela McIntire) and R3DO (Richard Skokowski)


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.

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Agreement State Event Number: 46572
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/26/2011
Notification Time: 10:14 [ET]
Event Date: 12/08/2010
Event Time: [EST]
Last Update Date: 01/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL UNDERDOSE TO PATIENT DUE TO ABORTED TREATMENT

The following information was received from the State of Ohio by email:

"Written directive called for Iodine-125 radioactive seed implant of the prostate with 142 seeds, 0.477 mCi each, total activity 67.7 mCi. Transperineal implantation of the needles were attempted on 12/8/10. After placement of four needles (8 sources) in the first (anterior-most) row, it was subsequently noted that patient's pelvic inlet was too narrow for adequate placement of the lateral two columns of seeds after repeated attempts. Authorized User Physician decided to abort procedure at this point. Patient was taken to the recovery room in satisfactory condition. Patient was notified at time of event. Radiation Safety Officer was not notified at time of event.

"Licensee's RSO discovered event during QMP review on morning of 1/25/11 and notified ODH [Ohio Department of Health] by telephone and e-mail that afternoon. ODH inspector will visit licensee's location on 1/31/11.

"Given: Radionuclide: I-125; Activity: 3.2 mCi (118.4 MBq); Dose: 81.1 rad (0.811 Gy).
"Intended: Radionuclide: I-125; Activity: 67.7 mCi (2504.9 MBq); Dose: 14400 rad (144 Gy)."

The source used was a Brachytherapy sealed source I-125; Model Number STM-1251; Serial Number 2357321SO; Activity .477 Ci (17.649 GBq).

Ohio number: OH110001

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.

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Agreement State Event Number: 46574
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSON CLINIC, LTD
Region: 3
City: LA CROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/27/2011
Notification Time: 15:43 [ET]
Event Date: 01/26/2011
Event Time: [CST]
Last Update Date: 01/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY MEDICAL UNDERDOSE

The following report was received via fax:

"On January 27, 2011, the licensee's Radiation Safety Officer reported the identification of three medical events that were discovered on January 26, 2011, involving permanent implants of Pd-103 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, DHS [Wisconsin Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values < 80% or >160% for classifying medical events. The licensee has evaluated all prostate implants performed since April 24, 2008. The licensee has notified the referring physicians and the referring physicians will not be notifying the patients.

"Case 1, November 2008: Prescribed dose 100 Gy. Prostate D90 was 77%.
"Case 2, April 2009: Prescribed dose 100 Gy. Prostate D90 was 71%.
"Case 3, October 2009: Prescribed dose 125 Gy. Prostate D90 was 78%.

"DHS inspectors are investigating these medical events and will send a special inspection team following the receipt of the licensee's 15 day report."

Wisconsin Report Number: WI110003

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.

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Power Reactor Event Number: 46581
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID BONVILLIAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/01/2011
Notification Time: 17:51 [ET]
Event Date: 02/01/2011
Event Time: 14:30 [CST]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LINDA HOWELL (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

SEVERE WEATHER CONDITIONS

"At 1430 on 2-1-2011, due to worsening road conditions from heavy snowfall, a determination was made that there is a loss of plant access for some individuals and some impairment of evacuation routes. This meets the criteria for an immediate notification (8 Hour) per 10 CFR 50.72 (b)(3)(xiii). There is no impact on plant operation, all T/S [Technical Specification] required minimum staffing requirements are satisfied. The weather is predicted to be hazardous until the evening of 2/2/2011. The Missouri Department of Transportation reported they have a plow truck running from Callaway Plant to Jefferson City, MO. They also reported visibility is extremely poor due to blowing snow. The Missouri State Emergency Management Agency duty officer has been notified of the degraded Callaway ERO [Emergency Response Organization] response time and evacuation route issues.

"The NRC Resident Inspector was notified of this event by the licensee."

Two shifts of personnel will be on site throughout this event. Diesel fuel, food, and water are above required minimums.

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Power Reactor Event Number: 46582
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MICHAEL FITZPATRICK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/01/2011
Notification Time: 22:54 [ET]
Event Date: 02/01/2011
Event Time: 19:18 [CST]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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

Event Text

REACTOR SCRAM AFTER A MAIN TRANSFORMER TRIP

"At 1918 CST on February 1st 2011, LaSalle Unit 1 automatically scrammed due to a MPT [Main Power Transformer] trip and subsequent load reject, both RFP [Reactor Feed Pumps] tripped and [the reactor] scrammed on TCV [Throttle Control Valve] fast closure. 'U' safety relief valve actuated in the relief mode on the turbine trip and has subsequently reset with tailpipe temp returning to normal. As a result of the electrical transient, U1 and U2 RWCU [Reactor Water Cleanup] isolated, and this is not reportable due to being a single train system and there was no isolation in multiple systems. The plant is stable with reactor pressure control to the main condenser via the main steam isolation valves. Unit 2 remained at 96% in coastdown throughout the event. The plant is planned to remain in hot shutdown pending investigation of the cause of the MPT trip and load reject."

All control rods fully inserted on the reactor scram. The cause of the RFP trips was swelling of the reactor water level as expected after a scram. The first out alarm was "turbine control valve fast closure." The plant is experiencing severe weather which may have influenced the MPT trip.

The licensee notified the NRC Resident Inspector.

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