Event Notification Report for September 12, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/11/2005 - 09/12/2005
EVENT NUMBERS
41983419844198642207
Power Reactor
Event Number: 41983
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KEITH HANZ
HQ OPS Officer: ARLON COSTA
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KEITH HANZ
HQ OPS Officer: ARLON COSTA
Notification Date: 09/12/2005
Notification Time: 23:27 [ET]
Event Date: 09/12/2005
Event Time: 23:14 [EDT]
Last Update Date: 09/15/2005
Notification Time: 23:27 [ET]
Event Date: 09/12/2005
Event Time: 23:14 [EDT]
Last Update Date: 09/15/2005
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JAMES MOORMAN (R2)
EDWIN HACKETT (NRR)
MELVYN LEACH (IRD)
LIGGETT (FEMA)
JASON (DHS)
JAMES MOORMAN (R2)
EDWIN HACKETT (NRR)
MELVYN LEACH (IRD)
LIGGETT (FEMA)
JASON (DHS)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNUSUAL EVENT DECLARED DUE TO HURRICANE OPHELIA WARNING
"On September 12, 2005, at 2300 hours, a hurricane warning was issued, which resulted in the declaration of an unusual event for both units. Unit 1 and 2 are currently operating at 100 percent of rated thermal power. The plant area is not currently experiencing any hurricane force winds. The wind speed at the site is approximately 24 miles per hour. State and county emergency response organizations have been notified. The resident inspector has been notified.
"There is no significant impact to the safety of the plant at this time.
"The plant is currently in Abnormal Operating Procedure 0AOP-13.0, 'Operation During Hurricane, Flood Conditions, Tornado, or Earthquake,' and Plant Emergency Procedure 0PEP-02.6, 'Severe Weather,' in preparation for hurricane conditions."
On-site facilities are not being activated at this time. No off-site assistance is requested. Request suspension of additional follow up notification unless plant conditions change. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable if needed. The electrical grid is stable.
* * * UPDATE AT 0758 EDT ON 9/14/05 FROM BRUCE HARTSOCK TO S. SANDIN * * *
"Commenced reduction in power on Unit 2 in anticipation of exceeding 74 mph winds. Prediction revised to maximum of 64 mph onsite. Power reduction stopped. Plant stabilized. Power will be restored."
Notified RCT (Hasselberg) and R2IRC (Casto).
* * * UPDATE AT 0028 EDT ON 9/15/05 FROM KENON CHISM TO S. SANDIN * * *
"As of 2300 hours (EDT) on September 14, 2005, the Hurricane Warning south of Cape Fear, North Carolina, has been discontinued; therefore, the Unusual Event has been terminated. Entry into the Unusual Event was reported by Event Notification 41983. Both Unit 1 and Unit 2 continue to operate at 100 percent power. There has been no damage affecting safety equipment or causing operational constraints as a result of Hurricane Ophelia."
The licensee notified state/local agencies and will inform the NRC Resident Inspector. Notified R2DO (Munday), NRR (Mayfield), IRD (McGinty), FEMA (Snyder), and DHS (Gomez).
"On September 12, 2005, at 2300 hours, a hurricane warning was issued, which resulted in the declaration of an unusual event for both units. Unit 1 and 2 are currently operating at 100 percent of rated thermal power. The plant area is not currently experiencing any hurricane force winds. The wind speed at the site is approximately 24 miles per hour. State and county emergency response organizations have been notified. The resident inspector has been notified.
"There is no significant impact to the safety of the plant at this time.
"The plant is currently in Abnormal Operating Procedure 0AOP-13.0, 'Operation During Hurricane, Flood Conditions, Tornado, or Earthquake,' and Plant Emergency Procedure 0PEP-02.6, 'Severe Weather,' in preparation for hurricane conditions."
On-site facilities are not being activated at this time. No off-site assistance is requested. Request suspension of additional follow up notification unless plant conditions change. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable if needed. The electrical grid is stable.
* * * UPDATE AT 0758 EDT ON 9/14/05 FROM BRUCE HARTSOCK TO S. SANDIN * * *
"Commenced reduction in power on Unit 2 in anticipation of exceeding 74 mph winds. Prediction revised to maximum of 64 mph onsite. Power reduction stopped. Plant stabilized. Power will be restored."
Notified RCT (Hasselberg) and R2IRC (Casto).
* * * UPDATE AT 0028 EDT ON 9/15/05 FROM KENON CHISM TO S. SANDIN * * *
"As of 2300 hours (EDT) on September 14, 2005, the Hurricane Warning south of Cape Fear, North Carolina, has been discontinued; therefore, the Unusual Event has been terminated. Entry into the Unusual Event was reported by Event Notification 41983. Both Unit 1 and Unit 2 continue to operate at 100 percent power. There has been no damage affecting safety equipment or causing operational constraints as a result of Hurricane Ophelia."
The licensee notified state/local agencies and will inform the NRC Resident Inspector. Notified R2DO (Munday), NRR (Mayfield), IRD (McGinty), FEMA (Snyder), and DHS (Gomez).
Power Reactor
Event Number: 41984
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICHARD BOLOGNA
HQ OPS Officer: JOHN MacKINNON
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: RICHARD BOLOGNA
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/12/2005
Notification Time: 23:27 [ET]
Event Date: 09/12/2005
Event Time: 17:09 [EDT]
Last Update Date: 09/12/2005
Notification Time: 23:27 [ET]
Event Date: 09/12/2005
Event Time: 17:09 [EDT]
Last Update Date: 09/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES TRAPP (R1)
JAMES TRAPP (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
OVERPOWER OF REACTOR DUE TO CALIBRATION ERROR ON STEAM DUMP CONTROL SYSTEM
"On September 12, 2005 at 1709 hours, one feedwater train bypass valve (TV-1CN-100) unexpectedly opened at Beaver Valley Power Station Unit No. 1, causing the temperature of the feedwater going to the three steam generators to reduce. Reactor power then increased due to cooler feedwater temperature entering the steam generators. Reactor power increased to approximately 103 percent. The control room crew commenced reducing plant load and reactor power. Approximately 4 minutes later, TV-1CN-100 automatically closed as designed following an automatic opening signal. Reactor power decreased below 100% at approximately the same time. Currently, the plant is stable with reactor power at 93 percent.
"A calibration procedure of the Steam Dump Control System was ongoing at the time of the event. Preliminary investigation determined that this event occurred due to removal of an instrument card within the Steam Dump Control System which caused TV-1CN-100 to inappropriately open. Actuation of TV-1CN-100 was not initiated by a valid actuation signal.
"This event is being reported as a voluntary notification since the reactor power exceeded maximum licensed steady state power level of 102 percent."
The licensee notified the NRC Resident Inspector.
"On September 12, 2005 at 1709 hours, one feedwater train bypass valve (TV-1CN-100) unexpectedly opened at Beaver Valley Power Station Unit No. 1, causing the temperature of the feedwater going to the three steam generators to reduce. Reactor power then increased due to cooler feedwater temperature entering the steam generators. Reactor power increased to approximately 103 percent. The control room crew commenced reducing plant load and reactor power. Approximately 4 minutes later, TV-1CN-100 automatically closed as designed following an automatic opening signal. Reactor power decreased below 100% at approximately the same time. Currently, the plant is stable with reactor power at 93 percent.
"A calibration procedure of the Steam Dump Control System was ongoing at the time of the event. Preliminary investigation determined that this event occurred due to removal of an instrument card within the Steam Dump Control System which caused TV-1CN-100 to inappropriately open. Actuation of TV-1CN-100 was not initiated by a valid actuation signal.
"This event is being reported as a voluntary notification since the reactor power exceeded maximum licensed steady state power level of 102 percent."
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 41986
Rep Org: COLORADO DEPT OF HEALTH
Licensee: MIDWEST INSPECTION SERVICES
Region: 4
City: BRIGHTON State: CO
County:
License #: 902-01
Agreement: Y
Docket:
NRC Notified By: T G BONZER
HQ OPS Officer: ARLON COSTA
Licensee: MIDWEST INSPECTION SERVICES
Region: 4
City: BRIGHTON State: CO
County:
License #: 902-01
Agreement: Y
Docket:
NRC Notified By: T G BONZER
HQ OPS Officer: ARLON COSTA
Notification Date: 09/13/2005
Notification Time: 18:07 [ET]
Event Date: 09/12/2005
Event Time: 00:00 [MDT]
Last Update Date: 09/13/2005
Notification Time: 18:07 [ET]
Event Date: 09/12/2005
Event Time: 00:00 [MDT]
Last Update Date: 09/13/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MIKE RUNYAN (R4)
M. WAYNE HODGES (NMSS)
MIKE RUNYAN (R4)
M. WAYNE HODGES (NMSS)
AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT
The State provided the following information via facsimile:
"On 13 September 2005 at approximately 1:00 PM, I received telephone notification from David L. Ezzell, the Corporate RSO for Midwest Inspection Services, informing the Department of a source disconnect that occurred on 12 Sept 05. The source was a 33 Ci Ir-192 radiography source that was being used in Sterling Colorado. The radiography crew identified the source disconnect when approaching the end of the guide tube following a shot. The crew contacted their corporate RSO who proceeded to the location and retrieved the source at approximately 2:45 PM that day. Mr. Ezzell stated that there was no apparent reason for the disconnect and the examination of the connector portion of the pigtail (once the source was returned to the radiography exposure device) did not show damage. A written report providing a detailed description of the events and circumstances is to be submitted by Mr. Ezzell within the next few days."
The State provided the following information via facsimile:
"On 13 September 2005 at approximately 1:00 PM, I received telephone notification from David L. Ezzell, the Corporate RSO for Midwest Inspection Services, informing the Department of a source disconnect that occurred on 12 Sept 05. The source was a 33 Ci Ir-192 radiography source that was being used in Sterling Colorado. The radiography crew identified the source disconnect when approaching the end of the guide tube following a shot. The crew contacted their corporate RSO who proceeded to the location and retrieved the source at approximately 2:45 PM that day. Mr. Ezzell stated that there was no apparent reason for the disconnect and the examination of the connector portion of the pigtail (once the source was returned to the radiography exposure device) did not show damage. A written report providing a detailed description of the events and circumstances is to be submitted by Mr. Ezzell within the next few days."
General Information or Other
Event Number: 42207
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MIKE RIPLEY
Licensee: UNIVERSITY OF CHICAGO HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01678-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: MIKE RIPLEY
Notification Date: 12/15/2005
Notification Time: 12:26 [ET]
Event Date: 09/12/2005
Event Time: 00:00 [CST]
Last Update Date: 12/15/2005
Notification Time: 12:26 [ET]
Event Date: 09/12/2005
Event Time: 00:00 [CST]
Last Update Date: 12/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SONIA BURGESS (R3)
SANDRA WASTLER (NMSS)
SONIA BURGESS (R3)
SANDRA WASTLER (NMSS)
ILLINOIS AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The State provided the following information via email:
"On December 14, 2005 the licensee's Radiation Safety Officer, [name deleted], called the Division and forwarded information describing a medical misadministration that involved a brachytherapy dose that was greater than 10 percent from the intended treatment. The misadministration had occurred some months ago. The event was discovered as a result of a review of past treatments during an attempt to understand, what appeared to be, anomalies for certain cases.
"In a particular case on September 12, 2005, a patient began treatment for cervical cancer with a 'Fletcher Suit' manual brachytherapy afterloader using Cs-137 sealed sources. A transposition error was made in the digitization of the patient's lateral film used to construct the applicator's position and thus the positions of the radiation sources relative to the locations of the dose calculation points. Therefore, the digital locations used for mapping and treatment planning of points 'right A' and 'left A' relative to the sources were incorrectly determined.
"These calculated points used in the treatment planning were located in a region of lower dose rate within the tumor than the true anatomical 'A points', at which the prescription should have been defined. As a result, the prescription/final treatment plan used incorrect lower dose rate points and called for the use of an erroneously high source loading. Based on a retrospective analysis, instead of the calculated average dose rate of 0.545 Gy/hr for the erroneous 'A points', the actual delivered averaged dose rate to the true 'A points' was 0.74 Gy/hr. This resulted in an average dose of 54.3 Gy delivered to the true points A instead of the planned 40.0 Gy. The dose to the other points, namely rectum and bladder, were calculated correctly because their location did not involve the digitization step in which the transposition error occurred. These doses, which were calculated correctly, were all within acceptable limits. Only the tumor dose was in excess of the intended dose.
"This event occurred because of a misunderstanding concerning use of the new treatment planning system (TPS) that was being introduced into the clinic. The TPS allows digitizing either a right or left lateral film for locating the sources, bladder and rectal points for calculating doses. However the location of target point 'A', which is used for dose prescription, must be determined manually. Therefore a separate program is used which requires digitizing the source applicator on AP and lateral films to localize these points. In this additional step, the orientation of the lateral film on the digitizer was reversed left to right from what the program required, resulting in sign reversal of the anterior-posterior coordinate of the left and right 'A points'. This error was discovered in December, when looking into why positions of calculated points sometimes appeared unusual. This error was not caught at the time of the original implants.
"Once this potential source of dose discrepancy was discovered, the licensee reviewed all the patients whose dosimetry plans were determined with the new TPS since treatments were first initiated some three months ago. Three total patients were identified. The magnitude of the effect was found to also depend upon the orientation of the applicator in the patient. Only the case described above had those adverse complications which resulted in a medical event. A review of the two additional dosimetry plans showed that due to the orientation of the apparatus in the patient, the dose to the true prescription point was less than 5% greater than the planned dose. The clinical consequences for the patient concerned in this report are being evaluated by physicians.
"Four Cs-137 sealed sources with a total activity of 178 mCi were inserted into the patient. The planned averaged point A dose was 40.0 Gy and the actual administered dose was 54.3 Gy. Other than the 'point A' dose, no other dose calculation points were outside of the treatment specifications. The physicians are reviewing the revised dosimetry plans to determine if there will be any increased risk of complications for this patient. The clinical consequences for the patient concerned in this report are being evaluated by physicians. The dose at the various calculation points were:
"Dose points/Planned Dose (Gy/hr)/Actual Dose (Gy/hr)
Right A/0.56/0.74, Left A/0.530.74, Right B/0.18/0.18, Left B/0.17/0.17, r-rectum/0.33/0.37, s-rectum/0.35/0.39, t-rectum/0.31/0.32, u-rectum/0.21/0.21, B-bladder/0.47/0.43.
"This matter will be included during an pending routine inspection which will be conducted in the next 30 days.
"Corrective Actions:
Action Number / Corrective Action: 1 PROCEDURE MODIFIED 2 PERSONNEL RECEIVED ADDITIONAL TRAINING
"Patient Information: Patient Number: 1 Patient Informed: N Date Informed:
Therapeutic BRACHY, MANUAL AFTERLOADER
Organ: CERVIX
Dose: 5430 rad 54.3 Gy % Dose Exceeds Prescribed: 36
% Dose is Less Than Prescribed:
Effect on Patient: UNKNOWN Administered By: PHYSICIAN
Dose to Family: 0 rem 0 Sv Dose to Newborn: 0 rem 0 Sv Dose to Fetus: 0 rem 0 Sv
Source of Radiation: Due to the nature of the event, this matter was reported to the U.S. NRC Operations Center on December 15, 2005. It was assigned event number 42207
Source Number: 1
Form of Radioactive: SEALED SOURCE Radionuclide or Voltage (kVp/MeV): CS-137
Source Use: BRACHYTHERAPY Activity: .178 Ci 6.586 GBq
Manufacturer: Model Number: Serial Number: Device/Associated Equipment: Device Number: 1
Device Name: MANUAL AFTERLOADER Model Number: Manufacturer: UNKNOWN Serial Number:
Reporting Requirement: 32 IAC 335.1080 - Any administration of radioactive materials that results in a 'reportable event' (misadministration), licensee shall notify the agency by telephone NLT next day after licensee ascertains and confirms that a 'reportable event' has occurred.
Mode Reported: Written"
Illinois Item No. IL-050073
The State provided the following information via email:
"On December 14, 2005 the licensee's Radiation Safety Officer, [name deleted], called the Division and forwarded information describing a medical misadministration that involved a brachytherapy dose that was greater than 10 percent from the intended treatment. The misadministration had occurred some months ago. The event was discovered as a result of a review of past treatments during an attempt to understand, what appeared to be, anomalies for certain cases.
"In a particular case on September 12, 2005, a patient began treatment for cervical cancer with a 'Fletcher Suit' manual brachytherapy afterloader using Cs-137 sealed sources. A transposition error was made in the digitization of the patient's lateral film used to construct the applicator's position and thus the positions of the radiation sources relative to the locations of the dose calculation points. Therefore, the digital locations used for mapping and treatment planning of points 'right A' and 'left A' relative to the sources were incorrectly determined.
"These calculated points used in the treatment planning were located in a region of lower dose rate within the tumor than the true anatomical 'A points', at which the prescription should have been defined. As a result, the prescription/final treatment plan used incorrect lower dose rate points and called for the use of an erroneously high source loading. Based on a retrospective analysis, instead of the calculated average dose rate of 0.545 Gy/hr for the erroneous 'A points', the actual delivered averaged dose rate to the true 'A points' was 0.74 Gy/hr. This resulted in an average dose of 54.3 Gy delivered to the true points A instead of the planned 40.0 Gy. The dose to the other points, namely rectum and bladder, were calculated correctly because their location did not involve the digitization step in which the transposition error occurred. These doses, which were calculated correctly, were all within acceptable limits. Only the tumor dose was in excess of the intended dose.
"This event occurred because of a misunderstanding concerning use of the new treatment planning system (TPS) that was being introduced into the clinic. The TPS allows digitizing either a right or left lateral film for locating the sources, bladder and rectal points for calculating doses. However the location of target point 'A', which is used for dose prescription, must be determined manually. Therefore a separate program is used which requires digitizing the source applicator on AP and lateral films to localize these points. In this additional step, the orientation of the lateral film on the digitizer was reversed left to right from what the program required, resulting in sign reversal of the anterior-posterior coordinate of the left and right 'A points'. This error was discovered in December, when looking into why positions of calculated points sometimes appeared unusual. This error was not caught at the time of the original implants.
"Once this potential source of dose discrepancy was discovered, the licensee reviewed all the patients whose dosimetry plans were determined with the new TPS since treatments were first initiated some three months ago. Three total patients were identified. The magnitude of the effect was found to also depend upon the orientation of the applicator in the patient. Only the case described above had those adverse complications which resulted in a medical event. A review of the two additional dosimetry plans showed that due to the orientation of the apparatus in the patient, the dose to the true prescription point was less than 5% greater than the planned dose. The clinical consequences for the patient concerned in this report are being evaluated by physicians.
"Four Cs-137 sealed sources with a total activity of 178 mCi were inserted into the patient. The planned averaged point A dose was 40.0 Gy and the actual administered dose was 54.3 Gy. Other than the 'point A' dose, no other dose calculation points were outside of the treatment specifications. The physicians are reviewing the revised dosimetry plans to determine if there will be any increased risk of complications for this patient. The clinical consequences for the patient concerned in this report are being evaluated by physicians. The dose at the various calculation points were:
"Dose points/Planned Dose (Gy/hr)/Actual Dose (Gy/hr)
Right A/0.56/0.74, Left A/0.530.74, Right B/0.18/0.18, Left B/0.17/0.17, r-rectum/0.33/0.37, s-rectum/0.35/0.39, t-rectum/0.31/0.32, u-rectum/0.21/0.21, B-bladder/0.47/0.43.
"This matter will be included during an pending routine inspection which will be conducted in the next 30 days.
"Corrective Actions:
Action Number / Corrective Action: 1 PROCEDURE MODIFIED 2 PERSONNEL RECEIVED ADDITIONAL TRAINING
"Patient Information: Patient Number: 1 Patient Informed: N Date Informed:
Therapeutic BRACHY, MANUAL AFTERLOADER
Organ: CERVIX
Dose: 5430 rad 54.3 Gy % Dose Exceeds Prescribed: 36
% Dose is Less Than Prescribed:
Effect on Patient: UNKNOWN Administered By: PHYSICIAN
Dose to Family: 0 rem 0 Sv Dose to Newborn: 0 rem 0 Sv Dose to Fetus: 0 rem 0 Sv
Source of Radiation: Due to the nature of the event, this matter was reported to the U.S. NRC Operations Center on December 15, 2005. It was assigned event number 42207
Source Number: 1
Form of Radioactive: SEALED SOURCE Radionuclide or Voltage (kVp/MeV): CS-137
Source Use: BRACHYTHERAPY Activity: .178 Ci 6.586 GBq
Manufacturer: Model Number: Serial Number: Device/Associated Equipment: Device Number: 1
Device Name: MANUAL AFTERLOADER Model Number: Manufacturer: UNKNOWN Serial Number:
Reporting Requirement: 32 IAC 335.1080 - Any administration of radioactive materials that results in a 'reportable event' (misadministration), licensee shall notify the agency by telephone NLT next day after licensee ascertains and confirms that a 'reportable event' has occurred.
Mode Reported: Written"
Illinois Item No. IL-050073