United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 1, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/31/2012 - 02/01/2012

** EVENT NUMBERS **


47599 47623 47624 47628

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Non-Agreement State Event Number: 47599
Rep Org: AVERA MCKENNAN HOSPITAL
Licensee: AVERA MCKENNAN HOSPITAL
Region: 4
City: SIOUX FALLS State: SD
County: MINNEHAHA
License #: 4016571-01
Agreement: N
Docket:
NRC Notified By: RICHARD MASSOTH
HQ OPS Officer: VINCE KLCO
Notification Date: 01/17/2012
Notification Time: 13:04 [ET]
Event Date: 01/16/2012
Event Time: 16:00 [MST]
Last Update Date: 01/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GREG PICK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT DUE TO POTENTIAL DIFFERENT FRACTIONAL DOSE DELIVERED THAN PRESCRIBED

The licensee provided notification that a patient received 2 occurrences of a dose less than prescribed when delivering ten fractions of a treatment. Each of the underdoses were approximately 50% of the 340 Gray prescribed fractional dose. The patient will receive additional dose fractions in order to achieve the written directive total dose. The Radiation Oncologist has notified the patient and attending physician.

* * UPDATE FROM RICHARD MASSOTH TO JOHN KNOKE AT 1826 EST ON 01/31/12 * *

"On January 17, 2012 the NRC Operations Center was verbally notified of two Therapeutic Underdose Occurrences discovered by the licensee on January 16 and 17, 2012. These occurrences involved a fractionated Breast High Dose Rate Afterloader (HDR) treatment with a SenoRx Contura multicatheter breast applicator. The first and third delivered treatment fractions were found to be less than 50% of the intended fractional dose. The entire course of the treatment in the written directive included ten equal-dose fractions of 3.4 Gray per fraction for a total dose of 34 Gray to the prescribed treatment site. To correct for the underdose occurrences, two additional treatment fractions were added and the treatment plan was modified to achieve the total dose specified in the written directive.

"The licensee now believes that this medical event has also caused an unintended dose to skin outside of the prescribed treatment site, requiring notification under 10CFR35.3045(a)(3). The licensee has performed computer simulation, calculations and physical measurements using TLDs simulating the treatment geometry to model the unintended skin dose. The event delivered an unintended skin dose exceeding at least the skin erythema threshold (2 Gy). The licensee is continuing to monitor the patient response to the skin dose and is working to refine the unintended skin dose estimates. An NRC reactive inspection team is on-site."

Notified R4DO (Jeff Clark) and FSME (Greg Suber)

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 47623
Rep Org: BAYHEALTH MEDICAL CENTER
Licensee: BAYHEALTH MEDICAL CENTER
Region: 1
City: MILFORD State: DE
County:
License #: 07-148-50-01
Agreement: N
Docket:
NRC Notified By: CATHY MUNDORF
HQ OPS Officer: JOE O'HARA
Notification Date: 01/26/2012
Notification Time: 15:22 [ET]
Event Date: 01/25/2012
Event Time: 09:30 [EST]
Last Update Date: 01/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GLENN DENTEL (R1DO)
KEVIN HSUEH (FSME)

Event Text

MISADMINISTRATION OF THALLIUM DURING CARDIO STRESS TEST

A patient received 100% more than the prescribed dose of thallium. The patient was to receive 3.5 milliCuries of thallium followed by 30 milliCuries of Cardiolite, a Tc-99M radiopharmaceutical. Instead, the patient received 3.5 milliCuries of thallium then received an additional 3.6 milliCuries of Thallium. The technician stated that he got confused where the patient was in the treatment process.

The patient and physician have been informed. The licensee is awaiting dosimetry results to determine the organ dosage but does not believe there will be any recurring medical effects from this event.

* * * RETRACTION AT 1227 EST ON 1/27/12 FROM MUNDORF TO HUFFMAN * * *

The licensee is retracting this event report after a review and evaluation of the doses administered. The licensee has determined that this event is not reportable based on the unintended dose being less than 5 Rem effective dose equivalent and therefore not reportable under 10 CFR 35.3045.

The licensee has discussed this conclusion with NRC Region 1 (Lanzisera).

R1DO (Dental) and FSME (McIntosh) have been notified.

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Power Reactor Event Number: 47624
Facility: BYRON
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: LEO WEHNER
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/30/2012
Notification Time: 11:39 [ET]
Event Date: 01/30/2012
Event Time: 10:01 [CST]
Last Update Date: 01/31/2012
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)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMNES CAMERON (R3DO)
CYNTHIA PEDERSON (R3)
BRUCE BOGER (ET)
JEFFERY GRANT (IRD)
SIL MOUVONE (DOE)
DEBBY HASSEL (DHS)
LOU BURCKANT (FEMA)
SAM WILLIS (HHS)
MIKE BEVERLY (USDA)

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

Event Text

UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER GREATER THAN 15 MINUTES

At 1101 EST, Byron Unit-2 experienced a reactor trip due to RCP undervoltage. All rods fully inserted, MSIV's were manually closed and decay heat is being removed by Auxiliary Feedwater pumps running and steam leaving via atmospheric relief valves. The unit is currently in a natural circulation cooldown with the diesels supplying station emergency loads. Licensee will be cooling the plant down to Mode 5.

At 1118 EST, Byron declared an Unusual Event due to a loss of offsite power on Unit 2 from a faulted Station Auxiliary Transformer (SAT). The faulted SAT caused both 6.9 kV and 4.1 kV bus voltage to drop. Smoke was observed coming from the SAT with no visible flames being apparent. This caused bus loads to trip without a complete loss of ESF busses 241 and 242. These buses were manually disconnected from the SAT, which transferred the load to the emergency diesel generators 2A and 2B. Both diesel generators started and loaded without incident. Offsite assistance was requested from the local fire department as a precaution.

The licensee is also declaring notification for 10 CFR 50.72(b)(3)(v)(D)

Unit 1 is not being affected by this event and remains at 100% power.

The licensee has notified the NRC Resident Inspector.

* * UPDATE FROM GREG BALESTRIERI TO JOHN KNOKE AT 2119 EST ON 01/31/12 * *

"At 2000 CST on 1/31/12, Byron terminated their Unusual Event due to the Loss of Offsite Power to Unit 2. Switchyard repairs were completed and offsite power has been restored to essential busses 241 and 242 thru System Auxiliary Transformers 242-1 and 242-2. Unit 2 Emergency Diesel Generators have been shutdown."

The licensee is citing classification 10 CFR 50.72(c)(1)(iii)

The licensee has notified the NRC Resident Inspector. Notified R3DO (James Cameron), NRR EO (Louise Lund), IRD MOC (Scott Morris), DHS (Konopka) and FEMA (Hollis). Licensee may issue a press release.

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Power Reactor Event Number: 47628
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: DOUG FOOTE
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/31/2012
Notification Time: 22:58 [ET]
Event Date: 01/31/2012
Event Time: 17:30 [PST]
Last Update Date: 01/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JEFF CLARK (R4DO)
SCOTT MORRIS (IRD)
LOUISE LUND (NRR)

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

Event Text

MANUAL TRIP DUE TO A PRIMARY TO SECONDARY LEAK GREATER THAN 30 GAL/HR

"At 1505 PST, Unit 3 entered Abnormal Operation Instruction S023-13-14 'Reactor Coolant Leak' for a steam generator leak exceeding 5 gallons per day.

"At 1549 PST, the leak rate was determined to be 82 gallons per day. At 1610 PST, a leak rate greater than 75 gallons per day with an increasing rate of leakage exceeding 30 gallons per hour was established and entry into S023-13-28 'Rapid Power Reduction' was performed.

"At 1630 PST, commenced rapid power reduction per S023-13-28 'Rapid Power Reduction'. At 1731 PST, with reactor power at 35% the Unit was manually tripped. At 1738 PST, Unit 3 entered Emergency Operation Instruction S023-12-4 'Steam Generator Tube Rupture'.

"At 1800 PST the affected steam generator was isolated."

All control rods fully inserted on the trip. Decay heat is being removed thru the main steam bypass valves into the main condenser. Main feedwater is maintaining steam generator level. No relief valves lifted during the manual trip. The plant is in normal shutdown electrical lineup.

Unit 2 is presently in a refueling outage and was not affected by this event.

The licensee has notified the NRC Resident Inspector. The licensee has issued a press release.

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