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Event Notification Report for June 13, 2006

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
06/12/2006 - 06/13/2006

EVENT NUMBERS
426444311242637

Power Reactor
Event Number: 42644
Facility: SAN ONOFRE
Region: 4     State: CA
Unit: [1] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: LINDA CONKLIN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 06/15/2006
Notification Time: 15:31 [ET]
Event Date: 06/13/2006
Event Time: 22:05 [PDT]
Last Update Date: 06/15/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY GODY (R4)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned
2 N Y 99 Power Operation 99 Power Operation
3 N Y 100 Power Operation 100 Power Operation
Event Text
OFFSITE NOTIFICATION - AUTO ACCIDENT FATALITY

"On Tuesday, June 13, 2006, at approximately 2205 PDT, an on duty SONGS security officer driving an SCE vehicle struck a pedestrian on a public road outside the Owner Controlled Area. At that time, the officer was performing routine rounds and was driving between the plant and SCE's MESA facility.

"SCE notified local authorities including the California Highway Patrol and the Orange County Fire Authority.

"The individual sustained serious injuries and was transported to a local hospital. SCE has been notified unofficially that the individual passed away on June 14, 2006. The identity of the individual is unknown by SCE. SCE is reporting this occurrence in accordance with 10CFR50.72(b)(2)(xi). No news release is planned by SCE at this time.

"At the time of this report, Units 2 and 3 were operating at about 99 and 100 percent power, respectively. The NRC Resident Inspectors have been notified of this occurrence and will be provided with a copy of this report."


General Information or Other
Event Number: 43112
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SURGICAL CENTER OF CENTRAL FLORIDA
Region: 1
City: SEBRING   State: FL
County:
License #: 3704-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/22/2007
Notification Time: 13:26 [ET]
Event Date: 06/13/2006
Event Time: 12:00 [EST]
Last Update Date: 01/22/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
MARIE MILLER (R1)
MICHELE BURGESS (NMSS)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT - MISADMINISTRATION OF BRACHTHERAPY SEEDS

The State of Florida was notified on 01/11/07 by Florida Agency for Health Care Administration that while performing an audit of the licensee it appeared a misadministration of brachytherapy seeds on June 13, 2006 was not reported to DOH-BRC, nor was there any documentation it was done. The State is planning to visit the licensee in the next few days to obtain details of this medical event from the Radiation Oncologist.

The auditor provide the following documentation to the State concerning a prostate seed implant procedure performed on June 13, 2006 at the Surgical Center of Central Florida:

"A review of preplanning, live planning and post planning documents was conducted on June 22, 2006, and a wrong site administration (as defined in Florida Administrative Code 64&5. 101, 88-6) was declared by the prescribing radiation oncologist and the Radiation Safety Officer associated with the Cancer Care Center of Sebring. Their conclusion was supported by diagnostic films and the physics calculations. Consistent with the Florida Radiation Safety Guidelines, the patient's referring physician was also contacted by the treating urologist on June 23, 2006 and [the] facility was advised within 24 hours of the finding. Both the patient and his wife have been informed of the post procedure evaluation results and the patient has undergone a diagnostic computed tomography exam and follow-up appointment at the Cancer Care Center in Sebring.

"As a result of further assessment, the apparent misadministration incident was determined to be reportable to the State of Florida pursuant to Florida Administrative Code Section 53E-5.345 4A by the license holder and its' Radiation Safety Officer. . . . "

The procedure involved the implant of sixty I-125 seeds totaling approximately 20 milliCuries.

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.


General Information or Other
Event Number: 42637
Rep Org: NAK ENGINEERING INC
Licensee: NORDBERG
Region: 4
City: WINDSOR   State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NAK ENGINEERING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/13/2006
Notification Time: 15:29 [ET]
Event Date: 06/13/2006
Event Time: 00:00 [PDT]
Last Update Date: 06/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVID AYRES (R2)
THOMAS BLOUNT (IRD)
IAN JUNG (NRR)
Event Text
10 CFR PART 21 NOTIFICATION - DEFECTIVE NORDBERG EMERGENCY DIESEL GENERATOR VALVE SEAT INSERTS

The manufacturer provided the following information via facsimile:

"Significant Safety Hazard regarding the potential of Nordberg Valve Seat Inserts (VSI) to 'drop' from the bore of the cylinder head into the cylinder with probable resulting damage to the cylinder head, power valves, piston, cylinder liner, exhaust manifold and turbocharger which could result in the loss of the intended 'Safety Function' of the EDG.

"There exists a potential problem with the original specification for the specified value of interference fit of the inlet and exhaust Valve Seat Insert (VSI) in the area between the cylinder head bore and the VSI."

Two sites, Brunswick and McGuire, had the defective parts with Brunswick already having changed out the affected parts.