Event Notification Report for July 22, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/21/2005 - 07/22/2005
EVENT NUMBERS
41863418724186142082
Power Reactor
Event Number: 41863
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TERRY KANUETTEL
HQ OPS Officer: STEVE SANDIN
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TERRY KANUETTEL
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/22/2005
Notification Time: 14:50 [ET]
Event Date: 07/22/2005
Event Time: 09:12 [CDT]
Last Update Date: 07/22/2005
Notification Time: 14:50 [ET]
Event Date: 07/22/2005
Event Time: 09:12 [CDT]
Last Update Date: 07/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
MIKE ERNSTES (R2)
MIKE ERNSTES (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT INVOLVING A CONTRACT ACTING FOREMAN
A non-licensed contract acting foreman had a confirmed positive for alcohol during a random fitness-for-duty test. The contractor's access to the plant has been terminated. Contact the Headquarters Operation Officer for additional details.
The licensee informed the NRC Resident Inspector and Region 2 (Wallo).
A non-licensed contract acting foreman had a confirmed positive for alcohol during a random fitness-for-duty test. The contractor's access to the plant has been terminated. Contact the Headquarters Operation Officer for additional details.
The licensee informed the NRC Resident Inspector and Region 2 (Wallo).
Hospital
Event Number: 41872
Rep Org: WINCHESTER MEDICAL CENTER
Licensee: VALLEY HEALTH SYSTEM
Region: 1
City: WINCHESTER State: VA
County:
License #: 450158901
Agreement: N
Docket:
NRC Notified By: KERI WILLIAMS
HQ OPS Officer: PETE SNYDER
Licensee: VALLEY HEALTH SYSTEM
Region: 1
City: WINCHESTER State: VA
County:
License #: 450158901
Agreement: N
Docket:
NRC Notified By: KERI WILLIAMS
HQ OPS Officer: PETE SNYDER
Notification Date: 07/26/2005
Notification Time: 16:10 [ET]
Event Date: 07/22/2005
Event Time: 10:00 [EDT]
Last Update Date: 07/27/2005
Notification Time: 16:10 [ET]
Event Date: 07/22/2005
Event Time: 10:00 [EDT]
Last Update Date: 07/27/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GLENN MEYER (R1)
SCOTT MOORE (NMSS)
GLENN MEYER (R1)
SCOTT MOORE (NMSS)
MEDICAL EVENT - ADMINISTRATION OF LOWER DOSE THAN PRESCRIBED
On July 22, 2005 a patient was administered a dose of 2.64 rem from a 66 mCi (millicurie) source of Sm 153 versus the intended dose of 4.28 rem for bone pain therapy. This was discovered later when the medical technologist questioned the dose and raised a question with the supervisor. When the technologists checked the calibration setting of the instrument used to measure the source they discovered that the calibration setting was incorrect. With the incorrect calibration setting a source of 66 mCi of Sm 153 was used versus the intended 107 mCi source. The prescribing physician will notify the patient's doctor who will contact the patient. There was no known adverse affect on the patient.
The hospital took a corrective action of retraining and adding a check on their administration sheet that requires the technologist to check the instrument calibration setting.
* * * UPDATE TO NRC (HUFFMAN) FROM LICENSEE (WILLIAMS) AT 15:11 EDT ON 7/27/05 * * *
The following follow-up calculations related to the dose were provided by the licensee:
Whole body dose (assuming a qualify factor of 10) - 0.108 millisieverts per megabecquerel
Bony Surfaces dose (assuming a qualify factor of 10) - 67.56 millisieverts per megabecquerel
Bone Marrow dose (assuming a qualify factor of 10) - 15.37 millisieverts per megabecquerel
R1DO (Meyers) notified.
On July 22, 2005 a patient was administered a dose of 2.64 rem from a 66 mCi (millicurie) source of Sm 153 versus the intended dose of 4.28 rem for bone pain therapy. This was discovered later when the medical technologist questioned the dose and raised a question with the supervisor. When the technologists checked the calibration setting of the instrument used to measure the source they discovered that the calibration setting was incorrect. With the incorrect calibration setting a source of 66 mCi of Sm 153 was used versus the intended 107 mCi source. The prescribing physician will notify the patient's doctor who will contact the patient. There was no known adverse affect on the patient.
The hospital took a corrective action of retraining and adding a check on their administration sheet that requires the technologist to check the instrument calibration setting.
* * * UPDATE TO NRC (HUFFMAN) FROM LICENSEE (WILLIAMS) AT 15:11 EDT ON 7/27/05 * * *
The following follow-up calculations related to the dose were provided by the licensee:
Whole body dose (assuming a qualify factor of 10) - 0.108 millisieverts per megabecquerel
Bony Surfaces dose (assuming a qualify factor of 10) - 67.56 millisieverts per megabecquerel
Bone Marrow dose (assuming a qualify factor of 10) - 15.37 millisieverts per megabecquerel
R1DO (Meyers) notified.
Power Reactor
Event Number: 41861
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RODNEY NACOSTE
HQ OPS Officer: BILL GOTT
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RODNEY NACOSTE
HQ OPS Officer: BILL GOTT
Notification Date: 07/22/2005
Notification Time: 08:01 [ET]
Event Date: 07/22/2005
Event Time: 03:16 [CDT]
Last Update Date: 07/22/2005
Notification Time: 08:01 [ET]
Event Date: 07/22/2005
Event Time: 03:16 [CDT]
Last Update Date: 07/22/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MIKE ERNSTES (R2)
MIKE ERNSTES (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 98 | Power Operation |
T/S SHUTDOWN DUE TO DC SUBSYSTEM DECLARED INOPERABLE
"During performance of 2-SR-3.8.6.2(I-A) QUARTERLY CHECK FOR SHUTDOWN BOARD A BATTERY, the DC subsystem was declared inoperable due to cell voltage not meeting Technical Specification (TS) acceptance criteria. Concurrently a second DC subsystem was inoperable in support of scheduled maintenance activities. As a result of these subsystems being inoperable, Unit 2 entered TECHNICAL SPECIFICATION LCO 3.0.3. at 0220 and commenced a shutdown at 0316. In accordance with 10CFR50.72(b)(2)(i) this notification is being made.
"Plant conditions are stable at this time and no other plant systems were affected. At 0450 one DC subsystem was returned to an operable status. As a result of this, Unit 2 exited LCO 3.0.3, shutdown activities were terminated and unit 2 has been returned to 100 % power."
The licensee notified the NRC Resident Inspector.
"During performance of 2-SR-3.8.6.2(I-A) QUARTERLY CHECK FOR SHUTDOWN BOARD A BATTERY, the DC subsystem was declared inoperable due to cell voltage not meeting Technical Specification (TS) acceptance criteria. Concurrently a second DC subsystem was inoperable in support of scheduled maintenance activities. As a result of these subsystems being inoperable, Unit 2 entered TECHNICAL SPECIFICATION LCO 3.0.3. at 0220 and commenced a shutdown at 0316. In accordance with 10CFR50.72(b)(2)(i) this notification is being made.
"Plant conditions are stable at this time and no other plant systems were affected. At 0450 one DC subsystem was returned to an operable status. As a result of this, Unit 2 exited LCO 3.0.3, shutdown activities were terminated and unit 2 has been returned to 100 % power."
The licensee notified the NRC Resident Inspector.
Other Nuclear Material
Event Number: 42082
Rep Org: HONEYWELL INC
Licensee: HONEYWELL INC
Region: 3
City: MINNEAPOLIS State: MN
County:
License #:
Agreement: N
Docket:
NRC Notified By: AMELIA DEBAGGIS
HQ OPS Officer: BILL GOTT
Licensee: HONEYWELL INC
Region: 3
City: MINNEAPOLIS State: MN
County:
License #:
Agreement: N
Docket:
NRC Notified By: AMELIA DEBAGGIS
HQ OPS Officer: BILL GOTT
Notification Date: 10/26/2005
Notification Time: 17:36 [ET]
Event Date: 07/22/2005
Event Time: 00:00 [CDT]
Last Update Date: 10/26/2005
Notification Time: 17:36 [ET]
Event Date: 07/22/2005
Event Time: 00:00 [CDT]
Last Update Date: 10/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
CHRISTINE LIPA (R3)
GARY JANOSKO (NMSS)
CHRISTINE LIPA (R3)
GARY JANOSKO (NMSS)
MISSING AIR IONIZER
A generally licensed NRD model P-2021-3000 air ionizer (s/n A2DV726) was discovered missing following the demolition of a wall. During the installation of a new cleaning bench on July 22 and 23, a wall was demolished. The nitrogen line and the attached blow-off gun containing the device was attached to that wall and the assumption is the ionizer was in the demolition debris. The debris was moved to a Waste Management dumpster for a short time and then sent to a landfill in Blaine, MN. The landfill was searched, but the device was not found. These devices generally have an initial activity of 10 mCi of Po-210, but the caller did not know the activity of the lost device.
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.
A generally licensed NRD model P-2021-3000 air ionizer (s/n A2DV726) was discovered missing following the demolition of a wall. During the installation of a new cleaning bench on July 22 and 23, a wall was demolished. The nitrogen line and the attached blow-off gun containing the device was attached to that wall and the assumption is the ionizer was in the demolition debris. The debris was moved to a Waste Management dumpster for a short time and then sent to a landfill in Blaine, MN. The landfill was searched, but the device was not found. These devices generally have an initial activity of 10 mCi of Po-210, but the caller did not know the activity of the lost device.
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.