| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
07/01/2011 - 07/05/2011 ** EVENT NUMBERS ** |
 | General Information | Event Number: 46476 | Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OUR LADY OF BELLEFONTE HOSPITAL
Region: 1
City: ASHLAND State: KY
County:
License #: 202-144-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: JOHN KNOKE | Notification Date: 12/13/2010
Notification Time: 15:51 [ET]
Event Date: 03/10/2008
Event Time: [CST]
Last Update Date: 07/01/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
DANIEL HOLODY (R1DO)
DIANA DIAZ-TORO (FSME)
| Event Text AGREEMENT STATE REPORT - MEDICAL EVENT - PATIENT RECEIVED LESS THAN THE PRESCRIBED DOSE
"The Kentucky Radiation Health Branch was notified by the U.S. NRC by email on October 4, 2010 of a possible medical event occurring in the Commonwealth. There was no identification of the licensee involved. After extensive research, the Radiation Health Branch identified the licensee where the alleged medical event occurred. During an inspection of the facility, a review of medical documents identified a medical event involving the therapeutic treatment of prostate cancer with Pd-103 seeds.
"The treatment plan called for 100 Pd-103 seeds with an activity of 1.237 mCi per seed. The pretreatment plan of D90=132.78 Gy. The post treatment plan indicated the prostate received a D90=5.18 Gy. The licensee has not acknowledged a medical event. The patient involved has never been notified by the licensee. He was advised of the misadministration by another physician during a second opinion medical evaluation.
"Violations have been issued to the licensee. [An] evaluation [by the state] is ongoing."
* * * UPDATE FROM MICHELE GREENWELL TO JOE O'HARA AT 0841 ON 12/15/10 * * *
The following update was received from the Commonwealth via fax:
"The written directive had a prescribed dose for Pd-103, 100 Gy, act/seed 1.6 U, number of seeds 100."
Notified R1DO(Holody) and FSME(Villamar).
* * * UPDATE FROM MICHELE GREENWELL TO MARK ABRAMOVITZ ON 7/1/2011 AT 1353 EDT * * *
The Commonwealth of Kentucky performed an inspection of Our Lady of Bellefonte Hospital on 11/30/2010 and found 35 additional cases of medical misadministration during prostate seed implantation by one doctor. The date of the misadministration occurred from 10/3/2001 to 2/24/2009. No written directive for the dose prescribed or delivered was found for 14 of the cases with the remainder of the cases not having the post implant dose recorded. There was no post CT scan on 17 cases, and D90 doses ranged from 0% to 162% of the prescribed dose. The physician was notified on all of these cases however, none of the patients were notified.
Notified the R1DO (Welling) and FSME (Jackson).
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. |
| Agreement State | Event Number: 47000 | Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: KAM ENGINEERING SERVICES PC
Region: 1
City: DUNN State: NC
County:
License #: 051-1335-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOE O'HARA | Notification Date: 06/30/2011
Notification Time: 13:39 [ET]
Event Date: 06/30/2011
Event Time: 12:40 [EDT]
Last Update Date: 06/30/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
BLAKE WELLING (R1DO)
DEBORAH JACKSON (FSME)
| Event Text TROXLER MODEL 3400 MOISTURE DENSITY GAUGE WAS DAMAGED AT A CONSTRUCTION SITE
The following was provided by the State of North Carolina via e-mail:
"A Troxler portable nuclear gauge belonging to Kam Engineering Services was run over by a smooth drum roller and has been damaged.
"The event occurred near the intersection of Normandy Street and Half Street in Fort Bragg, NC. Fort Bragg is under a NRC license and the licensee should be working under reciprocity.
"The licensee does not possess any survey instruments but they have an agreement to borrow one from Troxler (RTP, NC.) Someone has been dispatched to Troxler to get a meter and to take it back to the accident site.
"The RSO is on-site and has cordoned off a 20 foot circle around the gauge."
The licensee will notify the State of North Carolina when additional survey results are available. The gauge contained 9 milliCuries Cs-137 and 44 milliCuries of Am-241.
** * * UPDATE FROM HENRY BARNES TO JOE O'HARA VIA E-MAIL AT 1703 ON 6/30/11 * * *
"The RSO called [the state]. The area was surveyed and the dose rate at the 20 ft boundary was 0.02 - 0.04 mR/hr. The RSO worked his way toward the damaged gauge and the readings remained constant. At 1 meter, the reading was still 0.2 mR/hr (Transport Index) On contact, the gauge was about 7 mR/hr. The RSO repositioned the gauge and sent pictures to Troxler. Troxler said it appeared that the tungsten blocks were still in place and there was no damage to the source shielding. The RSO (per Troxler instructions) then placed the gauge in the transport box and locked it.
"The damaged gauge is being transported to the company office tonight and will be transported to Troxler tomorrow."
Notified R1DO(Welling) and FSME(Jackson)
Incident NC 11-35. |
| Power Reactor | Event Number: 47010 | Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: MARK LOOSBROCK
HQ OPS Officer: JOE O'HARA | Notification Date: 07/01/2011
Notification Time: 15:06 [ET]
Event Date: 06/27/2011
Event Time: 13:44 [CDT]
Last Update Date: 07/01/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
CHRISTINE LIPA (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 OFFSITE POWER SOURCES DECLARED INOPERABLE
"At 1344 CDT on June 27, 2011, off-site A.C. power sources to Unit 2 were declared inoperable as a result of Transformer 2RY lockout and less than the required minimum voltage on the transmission system.
"At 1310 CDT on June 27, 2011, Transformer 2RY was locked out. The Transformer 2RY lockout resulted in entering Technical Specification 3.8.1, Condition A and a single path to the transmission system. At 1344 CDT, the site was notified by transmission systems operations that the 345 KV grid voltage could not be maintained at the minimum voltage required per procedure C20.3. The path to the transmission system was declared inoperable and Unit 2 entered Technical Specification 3.8.1, Condition C. Although inoperable, transmission system sources remained connected to Unit 2; emergency diesel generators were available but not required to run.
"By securing a cooling tower pump and fans, the required minimum transmission system voltage was met and determined to be sustainable. Technical Specification 3.8.1, Condition C, was exited on June 28, 2011 at 0038 CDT.
"After additional analysis, it was determined that this condition was a safety system function failure for Unit 2 and reportable under 10 CFR 50.72(b)(3(v)(D). This condition should have been reported on June 27, 2011 under the eight-hour reporting criteria.
"The NRC Resident Inspector has been informed." |
| Fuel Cycle Facility | Event Number: 47014 | Facility: PORTSMOUTH LEAD CASCADE
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817
Region: 2
City: PIKETON State: OH
County: PIKE
License #: SNM-7003
Agreement: Y
Docket: 70-7003
NRC Notified By: RON CRABTREE
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 07/01/2011
Notification Time: 16:34 [ET]
Event Date: 06/11/2011
Event Time: [EDT]
Last Update Date: 07/01/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
MARK FRANKE (R2DO)
ROBERT JOHNSON (NMSS)
| Event Text POWER OUTAGE CAUSING LOSS OF BATTERY ROOM VENTILLATION AND HYDROGEN MONITOR
"At approximately 1451 hours EDT on 07/1/2011, the Nuclear Regulatory Affairs Manager completed his review of the initial (draft) engineering report [related to an event that occurred on June 11, 2011].. [The review determined] the impact the June 11, 2011 power outage may have had on the Battery Room 3/4 forced air ventilation and hydrogen monitoring systems. [The review also] determined the incident should be reported to the NRC because he could find no evidence that either system would have met their respective IROFS [Item Relied On for Safety] surveillance requirements during the power outage.
"This incident is being reported to the Nuclear Regulatory Commission (NRC) as a 24-hour event in accordance with American Centrifuge Administrative Procedure ACD2-RG-044 (Nuclear Regulatory Event Reporting), Appendix B, Section I, which states: 'An event in which equipment is disabled or fails to function as designed as described by any of the following: (Paragraph) 2. The equipment is required to be available and operable when it is disabled or fails to function: AND no redundant equipment is available and operable to perform the required safety function .'"
The licensee will notify the NRC Region II office and site Department of Energy. |
| Part 21 | Event Number: 47015 | Rep Org: AUTOMATIC VALVE CORPORATION
Licensee: AUTOMATIC VALVE CORPORATION
Region: 3
City: NOVI State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: KEVIN ARMSTRONG
HQ OPS Officer: JOE O'HARA | Notification Date: 07/01/2011
Notification Time: 15:56 [ET]
Event Date: 06/28/2011
Event Time: 07:00 [EDT]
Last Update Date: 07/01/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
| Person (Organization):
CHRISTINE LIPA (R3DO)
MARK FRANKE (R2DO)
PART 21 GRP EMAIL ()
| Event Text SEAL FAILURE AND LEAKAGE ASSOCIATED WITH MODEL B5497-301 VALVES
The following was received via fax:
Automatic Valve Corporation made this report based upon its investigation and engineering evaluation of valve serial number 57056 which was leaking following an outage stroke test at McGuire Station. Automatic Valve Corporation determined that the cause of the leakage was seal failure as a result of the seal being displaced from its retaining groove. The displaced seal became trapped between the poppet face and valve seat inside the valve body. Automatic Valve Corporation reported that seal replacement combined with inspection and testing would prevent additional failures.
Shearon Harris and McGuire utilize these types of valves. Automatic Valve Corporation has no reported failures of these valves at Shearon Harris. |
| Power Reactor | Event Number: 47017 | Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: TOM HOLT
HQ OPS Officer: JOE O'HARA | Notification Date: 07/01/2011
Notification Time: 18:07 [ET]
Event Date: 07/01/2011
Event Time: 15:52 [CDT]
Last Update Date: 07/01/2011 | 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):
CHRISTINE LIPA (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | M/R | Y | 100 | Power Operation | 0 | Hot Standby | Event Text UNIT 1 MANUAL TRIP DUE TO ELECTRO-HYDRAULIC CONTROL FLUID LEAK ON TURBINE STOP VALVE
"With Unit 1 at 100% power Unit 1 was manually tripped at 1552. The manual reactor trip was in response to the right main turbine stop valve failing closed as the result of an electro-hydraulic oil leak located at the stop valve. Procedure 1E-0 'Reactor Trip or Safety Injection' was completed at 1600. No SI [safety injection] required. 1ES-0.l 'Reactor Trip Recovery' is in progress. Offsite power remains on all safeguards buses for both units. 11 and 12 AFW pumps auto started on SG [steam generator] low level and are supplying Unit 1 Steam Generators. After the trip, power was lost to non-safety related 4160 VAC buses 11 and 14 as expected due to the electrical lineup. The loss of power to 4160 VAC bus 11 upon the reactor trip resulted in a loss of power to 11 RCP. 12 RCP continues to operate on offsite power. Unit 2 remains at 100% power/Mode 1. Reportable actuations are: Unit 1 reactor protection (scram), and Unit 1 AFW pumps auto start. The NRC Resident Inspector has been notified." |
| Power Reactor | Event Number: 47021 | Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILLY JOHNSON
HQ OPS Officer: CHARLES TEAL | Notification Date: 07/04/2011
Notification Time: 17:21 [ET]
Event Date: 07/04/2011
Event Time: 13:36 [EDT]
Last Update Date: 07/04/2011 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
MARK FRANKE (R2DO)
|
| 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 OFFSITE NOTIFICATION DUE TO SPURIOUS SIREN ACTIVATION
"TVA received notification from Tennessee Emergency Management Agency (TEMA) at 1336 Eastern Daylight Saving Time (EDT) that Rhea County 911 operators had received several calls (approximately 6) regarding a siren sounding in north Rhea County.
"An electronic poll of the siren closest to the location of the reporting parties (Siren 43) indicated no response, although that siren did successfully respond to the 0700 daily poll on 7/4/2011. This may indicate that this siren is not operable.
"A severe thunderstorm warning had been issued by the National Weather Service for the time period this potential activation was reported. During this period there were several spurious acoustic monitor alarms from three additional sirens, although there were no other indications of siren activations (e.g., rotate or timer signals).
"A field investigation has been initiated, and the siren will be repaired as needed in accordance with TVA's corrective action program.
"There was no plant event that required siren actuation, and all plant systems are operating as required."
The licensee will notify the NRC Resident Inspector. | |