United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 20, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/19/2011 - 04/20/2011

** EVENT NUMBERS **


46753 46754 46761 46766 46767 46768 46769

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Hospital Event Number: 46753
Rep Org: MEMORIAL HEALTHCARE HOSPITAL
Licensee: MEMORIAL HEALTHCARE HOSPITAL
Region: 3
City: OWOSSO State: MI
County:
License #: 21-11475-01
Agreement: N
Docket:
NRC Notified By: ART EWALD
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/14/2011
Notification Time: 12:02 [ET]
Event Date: 02/23/2010
Event Time: [EDT]
Last Update Date: 04/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT - BRACHYTHERAPY UNDERDOSE TO PROSTATE GLAND

On 2/23/10, a patient went to Memorial Healthcare Hospital for brachytherapy treatment to the prostate gland. The prescribed treatment was 125 Gy (75 seeds) to the prostate gland. Due to swelling, the enlarged organ resulted in a lower radiation dose within the prostate. Even though all 75 seeds were implanted, the actual dose to the patient was 81.07 Gy. On 4/12/10 the physician notified the patient of the underdose and made arrangements for a second treatment. On 5/4/10 the second brachytherapy treatment of 57.26 Gy (8 seeds) was performed on the patient. In evaluating the patient's second treatment results, no further action was required.

This event is being reported due to a finding from an NRC audit.


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: 46754
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: VIRGINIA HOSPITAL CENTER
Region: 1
City: Arlington State: VA
County:
License #: 013-220-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/14/2011
Notification Time: 13:59 [ET]
Event Date: 01/11/2011
Event Time: [EDT]
Last Update Date: 04/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE- UNDER DOSE ADMINISTERED TO PATIENT

The following was received via facsimile.

"In January 2011 a patient was administered 1.58 millicuries of (Iodine) I-I31 for a whole body scan. The written directive specified a 2.0 millicurie dosage. The difference was discovered during a routine audit by the licensee's health physics consultant in March 2011. Calculations by the health physicist indicated the difference between the written directive and the administered dose differed by more than 20 percent, that the difference in the effective dose exceeded 5 rem and that the difference in the dose to the thyroid exceeded 50 rem. A report dated March 24, 2011 was received by (Virginia Department of Health) VDH on April 4, 2011. An on-site investigation by VDH was performed on April 8, 2011. The licensee indicated that the quality of the whole body scan was not compromised and that because the administered dose was less than the written directive, there is no radiological hazard to the patient."

Virginia Radioactive Materials Program Event Report ID.: VA-11-01

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: 46761
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: GEOFFREY HILL
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/16/2011
Notification Time: 19:24 [ET]
Event Date: 04/16/2011
Event Time: 18:55 [EDT]
Last Update Date: 04/19/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
VICTOR MCCREE (RA)
ERIC LEEDS (NRR)
KATHLEEN O'DONOHUE (R2DO)
WILLIAM GOTT (IRD)
ALLEN HOWE (NRR)

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
2 A/R Y 98 Power Operation 0 Hot Shutdown

Event Text

UNUSUAL EVENT DECLARED DUE TO LOSS OF ALL OFFSITE POWER FROM TORNADO DAMAGE

"At 1849 hrs, Surry Power Station (SPS) Unit 1 and Unit 2 experienced an automatic Reactor Trip from a Loss of Offsite Power, as a result of a tornado touching down in the station's switchyard. Unit 1 reactor tripped as a result of a Loss of Coolant Flow > P-8 (35% power), and the Unit 2 reactor tripped as a result of a 500 kV Leads Differential Turbine-Generator trip. Both units responded as designed.

"Unit 1 electrical power is being provided by Number 1 Emergency Diesel Generator (EDG) to the 1H emergency bus, with the Station Blackout (SBO) diesel loaded on to the 1J emergency bus. Unit 2 electrical power is being supplied by the number 2 EDG to the 2H emergency bus, with the number 3 EDG loaded on to the 2J emergency bus.

"All Unit 1 control rods inserted on the reactor trip, and all Unit 2 control rods inserted on its respective reactor trip. The Low Level Intake Structure (LLIS) is without power. All three Emergency Service Water Pumps are running to supply the intake canal. Efforts are underway to restore Bus 7, which will give each unit an emergency bus powered by offsite power (Unit 1 1J, Unit 2 2H) and restore power to the LLIS.

"Decay heat is being removed by auxiliary feedwater on both units and atmospheric steam release via the steam generator PORVs. Both units are currently on natural circulation. All other system parameters are normal and stable.

"At 1855 hrs a NOUE was declared due to a loss of offsite power (applicable to U1 and U2). Additionally, due to an estimated 100 gallon fuel oil spill from an above ground storage tank near the station's garage, the Virginia State Department of Environmental Quality was notified at 2041 and the Surry County Local Emergency Planning Coordinator was notified at 2114. At 2334, the Virginia State Department of Environmental Quality was notified and the Surry County Local Emergency Planning Coordinator was notified at 2336, due to an estimated 200 gallon oil leak to the ground from a station switchyard transformer damaged during the tornado.

"The NRC Resident Inspector has been notified and is on-site."

Notified DHS (Rickerson), FEMA (Boscoe), DOE (Turner), HHS (Hoskins), and USDA (Russell).

See related EN #46762

* * * UPDATE FROM TUCKER CARLSON TO CHARLES TEAL ON 4/19/11 AT 0756 * * *

The licensee exited the emergency condition at 0745 EDT on 4/19/11. Offsite power has been restored, and the plant is shutdown and cooled down.

Notified R2DO (O'Donohue), NRR EO (Thorpe) and IRD (Gott). Informed the following Federal Agencies via Blast Dial: DHS, FEMA, USDA, HHS and DOE.

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Power Reactor Event Number: 46766
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RANDALL RAHRIG
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/19/2011
Notification Time: 00:44 [ET]
Event Date: 04/18/2011
Event Time: 23:09 [CDT]
Last Update Date: 04/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MONTE PHILLIPS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

PLANT PROCESS COMPUTER REMOVED FROM SERVICE FOR PLANNED REPLACEMENT

"At 2309 [CDT] on April 18, 2011, the Unit 2 Plant Process Computer (PPC) was removed from service for planned replacement in the current Unit 2 refueling outage. The Unit 2 PPC feeds the Safety Parameter Display System (SPDS) used in the Main Control Room (MCR) and the Technical Support Center (TSC). The Unit 2 PPC also feeds the Emergency Response Data System (ERDS). The Unit 1 and Unit 2 PPCs also feed the Plant Parameter Display System (PPDS) used in the MCR, TSC and Emergency Operations Facility (EOF). Meteorological data will remain available. The dose assessment program will remain functional as the Unit 1 Plant Process computer will be capable of providing the necessary data through PPDS to run the program. The dose assessment program is not affected by the Unit 2 PPC being out of service. As compensatory measures, the backup method to fax or communicate via a phone circuit applicable data to the NRC, TSC and EOF exists. There is no impact to the Emergency Notification System (ENS) or Health Physics Network (HPN) communications systems.

"The new Unit 2 PPC is scheduled to be functional on April 23, 2011. However, based on the mode Unit 2 will be in, this will limit the number of points that would provide usable data. The Unit 2 PPC will be tested as mode changes occur. The Unit 2 PPC is planned to be declared functional by Mode 2. A follow-up ENS call will be made once the Unit 2 PPC is declared functional.

"The loss of SPDS and ERDS is a 'major loss of assessment capability' and is reportable under 10CFR50.72(b)(3)(xiii).

"The NRC Senior Resident Inspector and the State of Illinois (through the Illinois Emergency Management Agency Resident Inspector) have been notified of this ENS call."

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Power Reactor Event Number: 46767
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: CHRISTOPHER TRENT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/19/2011
Notification Time: 12:50 [ET]
Event Date: 04/19/2011
Event Time: 10:45 [EDT]
Last Update Date: 04/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JONATHAN BARTLEY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
4 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

OFFSITE NOTIFICATION DUE TO FATALITY OF A CONTRACT EMPLOYEE

"This notification is a 4-hour Non-Emergency notification being performed in accordance with 10CFR50.72(b)(2)(xi) for notification to an off-site government agency.

"At 0708 [EDT] on 4/19/2011, off-site medical assistance was requested for a Turkey Point Nuclear Power Plant Station contract employee experiencing an apparent heart attack while being in-processed to the plant. The individual was transported to the hospital and was later pronounced dead.

"At 1045 on 4/19/2011, the Occupational Safety and Health Administration (OSHA) was notified. The Turkey Point Unit 3/4 control room was notified of the OSHA notification at 1058 on 4/19/2011.

"Unit 3 remains in Mode 1 at 100% power.

"Unit 4 is in a planned refueling outage.

"The NRC Resident Inspector was informed."

The contract employee was outside of the Protected Area and had not performed any work at the facility.

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Non-Agreement State Event Number: 46768
Rep Org: NAVAL UNDERSEA WARFARE CENTER
Licensee: NAVAL UNDERSEA WARFARE CENTER
Region: 4
City: KEYPORT State: WA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL WALSH
HQ OPS Officer: JOE O'HARA
Notification Date: 04/19/2011
Notification Time: 14:21 [ET]
Event Date: 04/18/2011
Event Time: [PDT]
Last Update Date: 04/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
LINDA HOWELL (R4DO)
MICHELE BURGESS (FSME)
PAUL KROHN (R1DO)

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

Event Text

UNACCOUNTED FOR IONIZING AIR GUNS CONTAINING 10 MILLICURIES OF Po-210

Naval Undersea Warfare Command (NUSW) located in Keyport, Washington has identified fifty seven (57) ionizing air guns that are unaccounted for. The devices were manufactured by NRD, LLC of New York, NY and contained 10 milliCuries of Po-210. NUSW is missing five (5) Model P-2021 devices and fifty-two (52) P-2051 devices. These are general license devices.

The unaccounted devices were found during a command inspection after questions arose surrounding the number of devices in the command. The inspection revealed the majority of the devices seem to have gone unaccounted for during the 1994 - 1995 timeframe.

Contamination surveys have confirmed there are no contamination issues or workforce exposure issues associated with this event.

A command investigation is ongoing.

The following serial numbers were identified as unaccounted for: For Model P-2021: A2GQ217, A2GQ241, A2BY498, A2AW678, and A2AQ471. For Model P-2051: 95609, 83722, 79841, 79225, 76422, 76423, 76424, 76425, 76427, 76428, 76429, 76430, 76431, 76432, 76433, 72859, 72860, 72861, 70708, 70709, 70710, 70711, 70712, 70713, 70714, 67850, 67851, 67853, 67854, 67855, 67856, 67857, 67860, 67861, 67862, 67863, 67881, 67882, 67883, 67884, 67888, 56477, 56303, 55244, 46840, 46844, 46914, 46952, 46954, 46963, 38242, AND 38348.

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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 46769
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RONALD RUSTICK
HQ OPS Officer: JOE O'HARA
Notification Date: 04/19/2011
Notification Time: 20:29 [ET]
Event Date: 04/19/2011
Event Time: 14:30 [CDT]
Last Update Date: 04/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MONTE PHILLIPS (R3DO)

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

BOTH DIVISIONS OF RESIDUAL HEAT REMOVAL INOPERABLE

"At 1430 hours, a water leak was discovered on the Unit 1 Emergency Diesel Generator Cooling Water Pump (EDGCWP) room cooler. As a result, the Unit 1 EDG (Division II) was declared inoperable and Technical Specification (TS) 3.8.1 was entered.

"At this time, Division I RHR was inoperable for planned maintenance on the Division I RHR room cooler. In the event of a LOOP/LOCA scenario, RHR would not have been able to perform its safety function (i.e., Division I RHR was impacted by the ongoing room cooler maintenance and Division II RHR would not have had an operable on-site emergency power source). Given the impact on the RHR system, this event is reportable under 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function required to mitigate the consequences of an accident.

"Note that at the time of discovery, offsite power was available to Division II RHR as well as the Division I and Division II Core Spray systems.

"At 1816 hours, the Division I RHR system room cooler was restored and Division I RHR was declared operable."

The licensee has notified the NRC Resident Inspector.

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