Event Notification Report for September 20, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/19/2005 - 09/20/2005
EVENT NUMBERS
42036420034200442019
General Information or Other
Event Number: 42036
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: SOUTHERN REGIONAL MEDICAL CENTER
Region: 1
City: RIVERDALE State: GA
County:
License #: GA 1039-1
Agreement: Y
Docket:
NRC Notified By: LAUREN PALMER
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: SOUTHERN REGIONAL MEDICAL CENTER
Region: 1
City: RIVERDALE State: GA
County:
License #: GA 1039-1
Agreement: Y
Docket:
NRC Notified By: LAUREN PALMER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/04/2005
Notification Time: 07:30 [ET]
Event Date: 09/20/2005
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2005
Notification Time: 07:30 [ET]
Event Date: 09/20/2005
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN ROGGE (R1)
CHARLIE PAYNE (R2)
MICHELE BURGESS (NMSS)
JOHN ROGGE (R1)
CHARLIE PAYNE (R2)
MICHELE BURGESS (NMSS)
AGREEMENT STATE REPORT - MEDICAL UNDEREXPOSURE
On Thursday morning, 9/20/05, a technologist gave a cancer patient receiving Iodine-131 therapy only one capsule of a prescribed 2-capsule dose. Consequently, only 93 milliCuries of an ordered 150 milliCuries was delivered to the patient. The referring endocrinologist was notified and determined that his patient had received adequate amount for the patient's therapy.
On Thursday afternoon, the licensee's Manager of Nuclear Medicine telephoned the Department and reported that the technologist involved in the event had also been responsible for a previous misadministration and had been fired. The capsule that was not administered was found in the lead container while preparing for a subsequent procedure on another patient.
Georgia report number: GA-2005-29
On Thursday morning, 9/20/05, a technologist gave a cancer patient receiving Iodine-131 therapy only one capsule of a prescribed 2-capsule dose. Consequently, only 93 milliCuries of an ordered 150 milliCuries was delivered to the patient. The referring endocrinologist was notified and determined that his patient had received adequate amount for the patient's therapy.
On Thursday afternoon, the licensee's Manager of Nuclear Medicine telephoned the Department and reported that the technologist involved in the event had also been responsible for a previous misadministration and had been fired. The capsule that was not administered was found in the lead container while preparing for a subsequent procedure on another patient.
Georgia report number: GA-2005-29
Power Reactor
Event Number: 42003
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: SARA ANDERSON
HQ OPS Officer: BILL GOTT
Region: 1 State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: SARA ANDERSON
HQ OPS Officer: BILL GOTT
Notification Date: 09/20/2005
Notification Time: 12:48 [ET]
Event Date: 09/20/2005
Event Time: 05:00 [EDT]
Last Update Date: 09/20/2005
Notification Time: 12:48 [ET]
Event Date: 09/20/2005
Event Time: 05:00 [EDT]
Last Update Date: 09/20/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JOHN WHITE (R1)
JOHN WHITE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Hot Shutdown | 0 | Cold Shutdown |
DEGRADED CONDITION - SMALL LEAK ON RHR INJECTION DRAIN LINE
"After shutting down for refueling outage, a small leak was discovered on a 1-inch drain line for the 'A' Loop RHR injection line. This leak is at a weld.
"Tech Spec 3.4.4 was entered for RCS Operational Leakage due to potential Class I pressure boundary leakage.
"This report is being made IAW 10CFR50.72(b)(3)."
The licensee will notify the NRC Resident Inspector.
"After shutting down for refueling outage, a small leak was discovered on a 1-inch drain line for the 'A' Loop RHR injection line. This leak is at a weld.
"Tech Spec 3.4.4 was entered for RCS Operational Leakage due to potential Class I pressure boundary leakage.
"This report is being made IAW 10CFR50.72(b)(3)."
The licensee will notify the NRC Resident Inspector.
Power Reactor
Event Number: 42004
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DAVE DEES
HQ OPS Officer: ARLON COSTA
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: DAVE DEES
HQ OPS Officer: ARLON COSTA
Notification Date: 09/21/2005
Notification Time: 02:37 [ET]
Event Date: 09/20/2005
Event Time: 22:40 [CDT]
Last Update Date: 11/08/2005
Notification Time: 02:37 [ET]
Event Date: 09/20/2005
Event Time: 22:40 [CDT]
Last Update Date: 11/08/2005
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):
MICHAEL SHANNON (R4)
MICHAEL SHANNON (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN COMMENCED DUE TO INOPERABILITY OF RESIDUAL HEAT REMOVAL CONTAINMENT SUMP ISOLATION VALVES
"At 2240 09/20/2005 an engineering evaluation concluded that the Residual Heat Removal Containment Sump Isolation Valves were inoperable based on their inability to open against a higher differential pressure than had been previously evaluated. Historically Wolf Creek has operated with the Component Cooling Water isolated to the Residual Heat Removal Heat Exchangers. If the pumps started during accident conditions there is a potential that the pump heat generated could cause system pressure to increase to the suction relief valve setting of 450 psig. Testing of the valves has shown that they are capable of opening with 207 psid across the valve.
"Technical Specification 3.0.3 was entered at 2240 9/20/2005 due to the inoperability of both Residual Heat Removal trains. Power reduction was commenced at 2340. Component Cooling Water was aligned to the Residual Heat Removal Heat Exchangers at 0004 9/21/2005 restoring operability of the Residual Heat Removal trains. At 0017 9/21/2005 actions were commenced to restore power to 100%.
"This event is reportable under 10 CFR50.72(b)(2)(i) Technical Specification required shut down (4 hour) and 10 CFR50.72(b)(3)(v)(B) Event or Condition that could have prevented fulfillment of a Safety Function (8 hour).
"The NRC Resident has been contacted."
*** UPDATE AT 15:39 EST ON 11/08/05 FROM DEES TO KNOKE ***
"Evaluation of the Residual Heat Removal Containment Sump Isolation Valves concluded that the valves were operable and the Residual Heat Removal trains were capable of fulfilling their safety function. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(B)."
Based on the information above, 10 CFR 50.72(b)(3)(v)(B) has been deleted from the original event notification.
The licensee notified the NRC Resident Inspector. Notified the R4DO (Whitten).
"At 2240 09/20/2005 an engineering evaluation concluded that the Residual Heat Removal Containment Sump Isolation Valves were inoperable based on their inability to open against a higher differential pressure than had been previously evaluated. Historically Wolf Creek has operated with the Component Cooling Water isolated to the Residual Heat Removal Heat Exchangers. If the pumps started during accident conditions there is a potential that the pump heat generated could cause system pressure to increase to the suction relief valve setting of 450 psig. Testing of the valves has shown that they are capable of opening with 207 psid across the valve.
"Technical Specification 3.0.3 was entered at 2240 9/20/2005 due to the inoperability of both Residual Heat Removal trains. Power reduction was commenced at 2340. Component Cooling Water was aligned to the Residual Heat Removal Heat Exchangers at 0004 9/21/2005 restoring operability of the Residual Heat Removal trains. At 0017 9/21/2005 actions were commenced to restore power to 100%.
"This event is reportable under 10 CFR50.72(b)(2)(i) Technical Specification required shut down (4 hour) and 10 CFR50.72(b)(3)(v)(B) Event or Condition that could have prevented fulfillment of a Safety Function (8 hour).
"The NRC Resident has been contacted."
*** UPDATE AT 15:39 EST ON 11/08/05 FROM DEES TO KNOKE ***
"Evaluation of the Residual Heat Removal Containment Sump Isolation Valves concluded that the valves were operable and the Residual Heat Removal trains were capable of fulfilling their safety function. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(B)."
Based on the information above, 10 CFR 50.72(b)(3)(v)(B) has been deleted from the original event notification.
The licensee notified the NRC Resident Inspector. Notified the R4DO (Whitten).
General Information or Other
Event Number: 42019
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEOTECHNICAL ENGINEERING INC
Region: 4
City: BRENTWOOD State: CA
County:
License #: 4674-01
Agreement: Y
Docket:
NRC Notified By: NIKA HEWADIKARAM
HQ OPS Officer: BILL GOTT
Licensee: GEOTECHNICAL ENGINEERING INC
Region: 4
City: BRENTWOOD State: CA
County:
License #: 4674-01
Agreement: Y
Docket:
NRC Notified By: NIKA HEWADIKARAM
HQ OPS Officer: BILL GOTT
Notification Date: 09/27/2005
Notification Time: 15:36 [ET]
Event Date: 09/20/2005
Event Time: 00:00 [PDT]
Last Update Date: 09/27/2005
Notification Time: 15:36 [ET]
Event Date: 09/20/2005
Event Time: 00:00 [PDT]
Last Update Date: 09/27/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4)
GREG MORELL (NMSS)
BLAIR SPITZBERG (R4)
GREG MORELL (NMSS)
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The State provided the following information via email:
"On September 20, 2005, a Troxler moisture density gauge, S/N 8161 was run over by a compactor at a job site in Brentwood. According to the report (fax on 9/21/05 and letter dated 9/21/05) provided by the licensee, the gauge shell and base were in pieces. The rod was in one piece but was bent out of shape. The RSO was not available on 9/20/05 and he was immediately notified of the incident. The technician transported the damaged gauge to the Pacific Nuclear Technology (PNT) of Antioch for disposal. The leak test performed on 9/20/05 at PNT indicated no contamination.
"The inspector learned of this incident on 9/27/05 and contacted the licensee and PNT to get further information. According to PNT, the rod was not in the shielded position when it was transported to their location. RHB will perform an investigation to try to determine the cause of this incident."
Incident number: 092105
The State provided the following information via email:
"On September 20, 2005, a Troxler moisture density gauge, S/N 8161 was run over by a compactor at a job site in Brentwood. According to the report (fax on 9/21/05 and letter dated 9/21/05) provided by the licensee, the gauge shell and base were in pieces. The rod was in one piece but was bent out of shape. The RSO was not available on 9/20/05 and he was immediately notified of the incident. The technician transported the damaged gauge to the Pacific Nuclear Technology (PNT) of Antioch for disposal. The leak test performed on 9/20/05 at PNT indicated no contamination.
"The inspector learned of this incident on 9/27/05 and contacted the licensee and PNT to get further information. According to PNT, the rod was not in the shielded position when it was transported to their location. RHB will perform an investigation to try to determine the cause of this incident."
Incident number: 092105