Event Notification Report for June 05, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/04/2006 - 06/05/2006
EVENT NUMBERS
42620426464266942734
General Information or Other
Event Number: 42620
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: MERCY HEALTH CENTER
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-07018-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Licensee: MERCY HEALTH CENTER
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-07018-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: PETE SNYDER
Notification Date: 06/06/2006
Notification Time: 18:06 [ET]
Event Date: 06/05/2006
Event Time: 09:00 [CDT]
Last Update Date: 06/06/2006
Notification Time: 18:06 [ET]
Event Date: 06/05/2006
Event Time: 09:00 [CDT]
Last Update Date: 06/06/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MIKE RUNYAN (R4)
SANDRA WASTLER (NMSS)
MIKE RUNYAN (R4)
SANDRA WASTLER (NMSS)
AGREEMENT STATE REPORT - MEDICAL TREATMENT UNDERDOSE
The licensee administered a 66% under dose during one of a series of brachytherapy doses to a patient. On June 6, 2006, during the second fractional dose in the series, the licensee noted that the administration of the dose took a longer time period than the dose administered to the patient on June 5, 2006. This was unexpected so the licensee performed a preliminary investigation. The licensee discovered that the computer used to time the dose incorrectly recorded the time taken for a quality control (QC) check and the dose time to the patient as one period of time. This was a first time use of this equipment by the licensee. The licensee determined that the patient received a dose of 116 centigray instead of 360 centigray during the administration of the first dose on June 5, 2006. A sealed 6 curie Ir-192 brachytherapy source manufactured by Varian was used. The licensee has informed the patient of the dose discrepancy. Additional controls have been implemented by the licensee to ensure that the computer will not record the time taken for the QC check as dose time to the patient in the future.
The State of Oklahoma is following up on the report by sending an inspector to the site.
*** UPDATE FROM STATE TO KNOKE AT 10:34 EDT ON 06/07/06 ***
The State provided the following information via facsimile:
"This was the first use of a new HDR modality mammosite treatment. The QC on this instrument was done prior to patient treatment. The treatment plan was sent from dosimetry computer to HDR control computer. Computer (or possibly human, not clear at this writing) chose the plan used from QC. Computer interpreted this to mean that a particular amount of dose had already been given. The computer delivered the remainder of dose, 116 centigrays, out of the prescribed 360 centigrays. Time was noted to be shorter than expected, but no alarm raised at the time. A second fraction was given later that day, and it was noticed that the time to deliver the dose was longer than in first dose. Inspection of computer records showed the dose had been stopped during treatment on the first fraction. It was then realized for sure that there was a problem.
"Corrective Action: QC ACTIVITY WILL BE DONE IN A WAY THAT IT CANT BE CONFUSED WITH THERAPY."
Notified NMSS (Wastler ) and R4DO (Runyan).
The licensee administered a 66% under dose during one of a series of brachytherapy doses to a patient. On June 6, 2006, during the second fractional dose in the series, the licensee noted that the administration of the dose took a longer time period than the dose administered to the patient on June 5, 2006. This was unexpected so the licensee performed a preliminary investigation. The licensee discovered that the computer used to time the dose incorrectly recorded the time taken for a quality control (QC) check and the dose time to the patient as one period of time. This was a first time use of this equipment by the licensee. The licensee determined that the patient received a dose of 116 centigray instead of 360 centigray during the administration of the first dose on June 5, 2006. A sealed 6 curie Ir-192 brachytherapy source manufactured by Varian was used. The licensee has informed the patient of the dose discrepancy. Additional controls have been implemented by the licensee to ensure that the computer will not record the time taken for the QC check as dose time to the patient in the future.
The State of Oklahoma is following up on the report by sending an inspector to the site.
*** UPDATE FROM STATE TO KNOKE AT 10:34 EDT ON 06/07/06 ***
The State provided the following information via facsimile:
"This was the first use of a new HDR modality mammosite treatment. The QC on this instrument was done prior to patient treatment. The treatment plan was sent from dosimetry computer to HDR control computer. Computer (or possibly human, not clear at this writing) chose the plan used from QC. Computer interpreted this to mean that a particular amount of dose had already been given. The computer delivered the remainder of dose, 116 centigrays, out of the prescribed 360 centigrays. Time was noted to be shorter than expected, but no alarm raised at the time. A second fraction was given later that day, and it was noticed that the time to deliver the dose was longer than in first dose. Inspection of computer records showed the dose had been stopped during treatment on the first fraction. It was then realized for sure that there was a problem.
"Corrective Action: QC ACTIVITY WILL BE DONE IN A WAY THAT IT CANT BE CONFUSED WITH THERAPY."
Notified NMSS (Wastler ) and R4DO (Runyan).
General Information or Other
Event Number: 42646
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SCHLUMBERGER TECHNOLOGY CORPORATION
Region: 1
City: State: MS
County: LAMAR
License #: MS-463-01
Agreement: Y
Docket:
NRC Notified By: B. J. SMITH
HQ OPS Officer: MIKE RIPLEY
Licensee: SCHLUMBERGER TECHNOLOGY CORPORATION
Region: 1
City: State: MS
County: LAMAR
License #: MS-463-01
Agreement: Y
Docket:
NRC Notified By: B. J. SMITH
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/15/2006
Notification Time: 16:39 [ET]
Event Date: 06/05/2006
Event Time: 00:00 [CDT]
Last Update Date: 06/15/2006
Notification Time: 16:39 [ET]
Event Date: 06/05/2006
Event Time: 00:00 [CDT]
Last Update Date: 06/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID SILK (R1)
ELMO COLLINS (NMSS)
DAVID SILK (R1)
ELMO COLLINS (NMSS)
MISSISSIPPI AGREEMENT STATE REPORT - STUCK WELL LOGGING SOURCE
The State provided the following information via email:
"[The State] received notification on 6-5-06 from Schlumberger that they had logging tool stuck in the Patterson #2 exploration well located at Midway Dome, Lamar County, Mississippi. Logging tool containing a 1.7 curie Cesium -137 source and a 16 curie Americium- 241:Be source was stuck below 12,000 feet. Operating company was fishing for logging tool string. Schlumberger discussed initial procedure of abandoning sources with DRH. During fishing operations logging tool containing sources was pushed to a depth of 14,854 feet. The fishing operation was successful in retrieving the tool string containing the Americium-241:Be source but they did not get the density tool skid containing the Cesium-137 source back. Licensee stated that tool would be cemented in hole with 200 feet of cement and whip stock deflection device. Plan was later modified to drill into cement plug and set casing 160 feet above the abandoned source prior to re-drilling the well to the side of the abandoned source.
"Schlumberger took survey readings of the recovered source and tool string and did not observe any readings out of the normal readings. Leak tests were also taken of the Americium-241:Be source, with no evidence of leaking.
"30 [-day] written report required from licensee. Licensee must also place a plaque on the well bore signifying that abandoned source is in well bore."
The State provided the following information via email:
"[The State] received notification on 6-5-06 from Schlumberger that they had logging tool stuck in the Patterson #2 exploration well located at Midway Dome, Lamar County, Mississippi. Logging tool containing a 1.7 curie Cesium -137 source and a 16 curie Americium- 241:Be source was stuck below 12,000 feet. Operating company was fishing for logging tool string. Schlumberger discussed initial procedure of abandoning sources with DRH. During fishing operations logging tool containing sources was pushed to a depth of 14,854 feet. The fishing operation was successful in retrieving the tool string containing the Americium-241:Be source but they did not get the density tool skid containing the Cesium-137 source back. Licensee stated that tool would be cemented in hole with 200 feet of cement and whip stock deflection device. Plan was later modified to drill into cement plug and set casing 160 feet above the abandoned source prior to re-drilling the well to the side of the abandoned source.
"Schlumberger took survey readings of the recovered source and tool string and did not observe any readings out of the normal readings. Leak tests were also taken of the Americium-241:Be source, with no evidence of leaking.
"30 [-day] written report required from licensee. Licensee must also place a plaque on the well bore signifying that abandoned source is in well bore."
Power Reactor
Event Number: 42669
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: ROSEMARY PEKAROVIC
HQ OPS Officer: MARK ABRAMOVITZ
Region: 1 State: CT
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: ROSEMARY PEKAROVIC
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/27/2006
Notification Time: 09:57 [ET]
Event Date: 06/05/2006
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2006
Notification Time: 09:57 [ET]
Event Date: 06/05/2006
Event Time: 00:00 [EDT]
Last Update Date: 06/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NEIL PERRY (R1)
NEIL PERRY (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Decommissioned | 0 | Decommissioned |
IRON DISCHARGE ABOVE NPDES LIMIT
"A discharge to the canal on June 5, 2006 had an Iron result above the NPDES limit. A sample of the discharge was analyzed on site using a non-approved method, which showed the result was well below the NPDES limit. Off-site lab results were received on June 16, 2006, which showed the Iron was above the NPDES limit, 650 ppb. The lab results were re-analyzed and the re-analysis on June 22, 2006 verified it was above the permitted limit. In the past, the onsite testing were comparable to the offsite lab tests."
The lab results were 720 and 950 ppb. This information was transmitted to the Department of Environmental Protection.
"A discharge to the canal on June 5, 2006 had an Iron result above the NPDES limit. A sample of the discharge was analyzed on site using a non-approved method, which showed the result was well below the NPDES limit. Off-site lab results were received on June 16, 2006, which showed the Iron was above the NPDES limit, 650 ppb. The lab results were re-analyzed and the re-analysis on June 22, 2006 verified it was above the permitted limit. In the past, the onsite testing were comparable to the offsite lab tests."
The lab results were 720 and 950 ppb. This information was transmitted to the Department of Environmental Protection.
Power Reactor
Event Number: 42734
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: RAY BUZARD
HQ OPS Officer: MIKE RIPLEY
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: RAY BUZARD
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/27/2006
Notification Time: 14:04 [ET]
Event Date: 06/05/2006
Event Time: 18:44 [MST]
Last Update Date: 07/27/2006
Notification Time: 14:04 [ET]
Event Date: 06/05/2006
Event Time: 18:44 [MST]
Last Update Date: 07/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
THOMAS FARNHOLTZ (R4)
THOMAS FARNHOLTZ (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
INVALID EMERGENCY DIESEL GENERATOR START
'The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"This report is being made under 50.73 (a)(2)(iv)(A).
"On June 5, 2006, at approximately 1844 Mountain Standard Time (MST), Palo Verde Nuclear Generating Station Unit 1 experienced an invalid 'A' train emergency diesel generator (EDG) start in the emergency mode. The EDG had been stopped at 1835 MST following completion of troubleshooting steps related to the balance of plant engineered safety features actuation system (BOP-ESFAS) sequencer. The start occurred as additional troubleshooting steps progressed. The related 4160 VAC class 1E bus, PBA-S03, remained energized by off-site power during the event. The EDG started successfully and remained unloaded until it was stopped at 2014 MST. No other engineered safety feature (ESF) equipment in the 'A' train actuated.
"(a) The specific train(s) and system(s) that were actuated:
Unit 1 'A' train EDG started in the emergency mode.
"(b) Whether each train actuation was complete or partial:
Only EDG 'A' started as a single component and remained unloaded until it was stopped. No other ESF equipment actuated or was required. Essential spray pond pump 'A' was already running to provide EDG 'A' cooling water, from the previous EDG run. Bus PBA-S03 remained energized by off-site power throughout the duration of the event.
(c) Whether or not the system started and functioned successfully:
EDG 'A' started successfully and reached required speed, frequency, and voltage. Loading onto bus PBA-S03 was not required. Operations noted the EDG started with no anomalies.
"The exact cause of the invalid start was not known at the time of this report.
The licensee notified the NRC Resident Inspector.
'The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"This report is being made under 50.73 (a)(2)(iv)(A).
"On June 5, 2006, at approximately 1844 Mountain Standard Time (MST), Palo Verde Nuclear Generating Station Unit 1 experienced an invalid 'A' train emergency diesel generator (EDG) start in the emergency mode. The EDG had been stopped at 1835 MST following completion of troubleshooting steps related to the balance of plant engineered safety features actuation system (BOP-ESFAS) sequencer. The start occurred as additional troubleshooting steps progressed. The related 4160 VAC class 1E bus, PBA-S03, remained energized by off-site power during the event. The EDG started successfully and remained unloaded until it was stopped at 2014 MST. No other engineered safety feature (ESF) equipment in the 'A' train actuated.
"(a) The specific train(s) and system(s) that were actuated:
Unit 1 'A' train EDG started in the emergency mode.
"(b) Whether each train actuation was complete or partial:
Only EDG 'A' started as a single component and remained unloaded until it was stopped. No other ESF equipment actuated or was required. Essential spray pond pump 'A' was already running to provide EDG 'A' cooling water, from the previous EDG run. Bus PBA-S03 remained energized by off-site power throughout the duration of the event.
(c) Whether or not the system started and functioned successfully:
EDG 'A' started successfully and reached required speed, frequency, and voltage. Loading onto bus PBA-S03 was not required. Operations noted the EDG started with no anomalies.
"The exact cause of the invalid start was not known at the time of this report.
The licensee notified the NRC Resident Inspector.