Event Notification Report for September 27, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/26/2006 - 09/27/2006
EVENT NUMBERS
42865428744319246842
Power Reactor
Event Number: 42865
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK G. GORLEY
HQ OPS Officer: MIKE RIPLEY
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK G. GORLEY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/27/2006
Notification Time: 04:26 [ET]
Event Date: 09/27/2006
Event Time: 02:47 [EDT]
Last Update Date: 09/29/2006
Notification Time: 04:26 [ET]
Event Date: 09/27/2006
Event Time: 02:47 [EDT]
Last Update Date: 09/29/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (R2)
DAVID AYRES (R2)
| 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 |
TECHNICAL SUPPORT CENTER HVAC REMOVED FROM SERVICE FOR MAINTENANCE
"On 9/27/2006, the HVAC for the Hatch Nuclear Plant's Technical Support Center (TSC) was removed from service for planned preventive maintenance and inspections and testing activities. These work activities are planned to be performed and completed within a 12 hour work shift. During the time these activities are being performed, the TSC air handling unit, TSC condensing unit, TSC filter train and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered non-functional during the performance of this work activity.
"If an emergency condition requiring activation of the TSC occurs during the time these work activities are being performed, then contingency plans call for utilization of the TSC as long as radiological conditions allow. The site Technical Support Center activation procedure provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the TSC so that TSC functions can be continued.
"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the evolution."
The licensee will notify the NRC Resident Inspector.
* * * UPDATE RECEIVED FROM ANDY DISMUKE TO JOE O'HARA AT 1014 ON 9/28/06 * * *
"The maintenance outage affecting the normal power supply for the TSC HVAC was not completed yesterday (September 27, 2006) as originally scheduled. The work schedule called for the normal power supply to the TSC HVAC to be returned to service within 12 hours; however, problems occurred in the functional test of the associated bus that provides the normal power supply to the TSC HVAC. During the functional test, the bus successfully swapped from normal supply to alternate supply, however the swap back to normal was unsuccessful. When the alternate breaker was tripped per procedure, the normal breaker indicated closed (green and amber lights extinguish, red light illuminated as expected, but the motor control center (MCC) was not energized. Maintenance has subsequently reenergized the MCC from alternate supply and TSC HVAC is now functional as of 0808 today (September 28, 2006). The total out of service time for the TSC HVAC was approximately 29 hours, 21 minutes.
"A repair plan is being developed to make necessary repairs to the breaker for the normal supply. Once repairs are completed, the breaker will be re-installed so that the MCC can be re-energized from the normal supply. This repair activity will require the TSC HVAC to be removed from service again in order to switch back to the normal power supply. An update will be provided when this evolution is expected to occur.
"This event is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG-1022 Rev 2 since this work activity affects an emergency response facility for the duration of the evolution."
The licensee will notify the NRC Resident Inspector. The R2DO(Collins) has been notified.
* * * UPDATE ON 9/28/06 AT 15:02 FROM HATCH (DISMUKE) TO ABRAMOVITZ
"On 9/28/06, the HVAC for the Hatch Nuclear Plant's Technical Support Center (TSC) is being removed from service to install the normal supply breaker in the MCC that supplies power to the TSC HVAC following breaker repairs. Estimated time for the TSC HVAC being out of service is 6 -8 hours. An update will be provided when the TSC HVAC is returned to service."
The licensee will notify the NRC Resident Inspector. Notified the R2DO (Collins).
* * * UPDATE 9/29/06 AT 0004 ET FROM HATCH (F. GORLEY) TO M. RIPLEY
"On 09/28/06 at 2329 ET, the HVAC System for the TSC was returned to functional status following the replacement of the normal supply breaker to the MCC and energizing the MCC that supplies the TSC HVAC. Walk-down of the HVAC System for proper operation was completed at 2335 ET."
The licensee will notify the NRC Resident Inspector. Notified the R2DO (Ayres).
"On 9/27/2006, the HVAC for the Hatch Nuclear Plant's Technical Support Center (TSC) was removed from service for planned preventive maintenance and inspections and testing activities. These work activities are planned to be performed and completed within a 12 hour work shift. During the time these activities are being performed, the TSC air handling unit, TSC condensing unit, TSC filter train and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered non-functional during the performance of this work activity.
"If an emergency condition requiring activation of the TSC occurs during the time these work activities are being performed, then contingency plans call for utilization of the TSC as long as radiological conditions allow. The site Technical Support Center activation procedure provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the TSC so that TSC functions can be continued.
"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the evolution."
The licensee will notify the NRC Resident Inspector.
* * * UPDATE RECEIVED FROM ANDY DISMUKE TO JOE O'HARA AT 1014 ON 9/28/06 * * *
"The maintenance outage affecting the normal power supply for the TSC HVAC was not completed yesterday (September 27, 2006) as originally scheduled. The work schedule called for the normal power supply to the TSC HVAC to be returned to service within 12 hours; however, problems occurred in the functional test of the associated bus that provides the normal power supply to the TSC HVAC. During the functional test, the bus successfully swapped from normal supply to alternate supply, however the swap back to normal was unsuccessful. When the alternate breaker was tripped per procedure, the normal breaker indicated closed (green and amber lights extinguish, red light illuminated as expected, but the motor control center (MCC) was not energized. Maintenance has subsequently reenergized the MCC from alternate supply and TSC HVAC is now functional as of 0808 today (September 28, 2006). The total out of service time for the TSC HVAC was approximately 29 hours, 21 minutes.
"A repair plan is being developed to make necessary repairs to the breaker for the normal supply. Once repairs are completed, the breaker will be re-installed so that the MCC can be re-energized from the normal supply. This repair activity will require the TSC HVAC to be removed from service again in order to switch back to the normal power supply. An update will be provided when this evolution is expected to occur.
"This event is reportable per 10CFR50.72(b)(3)(xiii) as described in NUREG-1022 Rev 2 since this work activity affects an emergency response facility for the duration of the evolution."
The licensee will notify the NRC Resident Inspector. The R2DO(Collins) has been notified.
* * * UPDATE ON 9/28/06 AT 15:02 FROM HATCH (DISMUKE) TO ABRAMOVITZ
"On 9/28/06, the HVAC for the Hatch Nuclear Plant's Technical Support Center (TSC) is being removed from service to install the normal supply breaker in the MCC that supplies power to the TSC HVAC following breaker repairs. Estimated time for the TSC HVAC being out of service is 6 -8 hours. An update will be provided when the TSC HVAC is returned to service."
The licensee will notify the NRC Resident Inspector. Notified the R2DO (Collins).
* * * UPDATE 9/29/06 AT 0004 ET FROM HATCH (F. GORLEY) TO M. RIPLEY
"On 09/28/06 at 2329 ET, the HVAC System for the TSC was returned to functional status following the replacement of the normal supply breaker to the MCC and energizing the MCC that supplies the TSC HVAC. Walk-down of the HVAC System for proper operation was completed at 2335 ET."
The licensee will notify the NRC Resident Inspector. Notified the R2DO (Ayres).
General Information or Other
Event Number: 42874
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GOOLSBY TESTING
Region: 4
City: HUMBLE State: TX
County:
License #: 03115
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL GOTT
Licensee: GOOLSBY TESTING
Region: 4
City: HUMBLE State: TX
County:
License #: 03115
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL GOTT
Notification Date: 10/04/2006
Notification Time: 11:01 [ET]
Event Date: 09/27/2006
Event Time: 00:00 [CDT]
Last Update Date: 10/04/2006
Notification Time: 11:01 [ET]
Event Date: 09/27/2006
Event Time: 00:00 [CDT]
Last Update Date: 10/04/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4)
MICHELE BURGESS (NMSS)
GREG PICK (R4)
MICHELE BURGESS (NMSS)
AGREEMENT STATE REPORT - PERSONNEL OVEREXPOSURE
"A technician was performing radiography operations at an off site facility. The technician had completed an exposure and had returned the source to the camera. The technician noted the survey meter setting about six [feet] in front of the camera was going towards zero. Was setting up for the next exposure. The technician disconnected the guide tube from the camera and relocated it to the new location. Upon returning to pick up the camera, the technician noticed the source hanging out of the camera. The technician cranked the source into the camera. The technician notified his supervisor of the event. The supervisor instructed the technician to cease all work and to bring his film badge, alarming dosimeter, and dosimeter to the office. The film badge was overnighted to the licensee's processor. On 10/3/06, the processor reported the exposure for the film badge to be 16543 mrem DDE. The workers total for the year is reported as 19538 mrem DDE. A safety meeting was held for all radiographers at the licensee facility on October 3, 2006 to discuss proper performance of surveys when conducting radiography operations. It appears at this time that no other persons were exposed to the high dose rates."
Texas Incident #: I-8365
"A technician was performing radiography operations at an off site facility. The technician had completed an exposure and had returned the source to the camera. The technician noted the survey meter setting about six [feet] in front of the camera was going towards zero. Was setting up for the next exposure. The technician disconnected the guide tube from the camera and relocated it to the new location. Upon returning to pick up the camera, the technician noticed the source hanging out of the camera. The technician cranked the source into the camera. The technician notified his supervisor of the event. The supervisor instructed the technician to cease all work and to bring his film badge, alarming dosimeter, and dosimeter to the office. The film badge was overnighted to the licensee's processor. On 10/3/06, the processor reported the exposure for the film badge to be 16543 mrem DDE. The workers total for the year is reported as 19538 mrem DDE. A safety meeting was held for all radiographers at the licensee facility on October 3, 2006 to discuss proper performance of surveys when conducting radiography operations. It appears at this time that no other persons were exposed to the high dose rates."
Texas Incident #: I-8365
General Information or Other
Event Number: 43192
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120-78-0000
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JEFF ROTTON
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120-78-0000
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2007
Notification Time: 14:04 [ET]
Event Date: 09/27/2006
Event Time: 00:00 [EST]
Last Update Date: 03/01/2007
Notification Time: 14:04 [ET]
Event Date: 09/27/2006
Event Time: 00:00 [EST]
Last Update Date: 03/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ROGER LANKSBURY (R3)
GREG MORELL (FSME)
ROGER LANKSBURY (R3)
GREG MORELL (FSME)
AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT
At 1405 EST on 02/26/07, the state received a report via the US Mail from Akron General Medical Center. On 09/27/06 a patient was receiving a 10 fraction dose for Mammo-site Breast Brachytherapy using a HDR afterloader with a total prescribed dose of 3400 RAD. A problem with the PLATO planning computer digitized the breast image using an incorrect treatment factor which doubled the fractional dose. The same total prescribed dose was delivered but in 5 vice 10 fractional doses. The patient was made aware of the error on 09/27/06. Tissue necrosis was observed due to the procedure, but it is being evaluated if any additional necrosis occurred due to the delivery of the total dose in 5 fractions vice the 10 planned fractional doses. The licensee is taking corrective action to prevent a reoccurrence of this type of error.
* * * UPDATE FROM FSME (FLANNERY) TO KNOKE ON 02/28/07 * * *
This event has been reviewed and determined to be a reportable medical event.
* * * UPDATE FROM OHIO DEPARTMENT OF HEALTH (MARK LIGHT) TO HUFFMAN ON 03/01/07 AT 1000 EST * * *
The State provided the following update to this report via facsimile:
"On September 28, 2006, the licensee notified the ODH Bureau of Radiation protection that they had an event which did not meet the reporting requirement of a medical event but they were revising their HDR program to prevent a recurrence. The Bureau requested a report that was received on February 26, 2006. The patient was to receive a total dose of 3400 rad total dose through 10 fractions of 340 rad each. The patient received 5 fractions of 680 rad for a total dose of 3400 rad. Upon review of the report it was determined by consultation with NRC Region 3 that a medical event did occur because 'Prescribed Dose' for remote afterloaders includes Total Dose and Fractionated dose. The reason for the event was the Physicist entered the wrong planning film magnification into the treatment system. The patient has experienced some tissue necrosis at the treatment site, although some necrosis is expected with this therapy (MammoSite). The necrosis may have been exacerbated by the dosage scheme. The patient is being followed by her attending physician. The patient and attending physician were notified on 09/27/2006. The Bureau conducted an inspection on November 2, 2006 and identified problems with the licensee's HDR program an additional inspection will be conducted during the week of March 5, 2007."
The R3DO (Lanksbury) and FSME EO (Morell) were notified.
Ohio Report OH2007-11
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.
At 1405 EST on 02/26/07, the state received a report via the US Mail from Akron General Medical Center. On 09/27/06 a patient was receiving a 10 fraction dose for Mammo-site Breast Brachytherapy using a HDR afterloader with a total prescribed dose of 3400 RAD. A problem with the PLATO planning computer digitized the breast image using an incorrect treatment factor which doubled the fractional dose. The same total prescribed dose was delivered but in 5 vice 10 fractional doses. The patient was made aware of the error on 09/27/06. Tissue necrosis was observed due to the procedure, but it is being evaluated if any additional necrosis occurred due to the delivery of the total dose in 5 fractions vice the 10 planned fractional doses. The licensee is taking corrective action to prevent a reoccurrence of this type of error.
* * * UPDATE FROM FSME (FLANNERY) TO KNOKE ON 02/28/07 * * *
This event has been reviewed and determined to be a reportable medical event.
* * * UPDATE FROM OHIO DEPARTMENT OF HEALTH (MARK LIGHT) TO HUFFMAN ON 03/01/07 AT 1000 EST * * *
The State provided the following update to this report via facsimile:
"On September 28, 2006, the licensee notified the ODH Bureau of Radiation protection that they had an event which did not meet the reporting requirement of a medical event but they were revising their HDR program to prevent a recurrence. The Bureau requested a report that was received on February 26, 2006. The patient was to receive a total dose of 3400 rad total dose through 10 fractions of 340 rad each. The patient received 5 fractions of 680 rad for a total dose of 3400 rad. Upon review of the report it was determined by consultation with NRC Region 3 that a medical event did occur because 'Prescribed Dose' for remote afterloaders includes Total Dose and Fractionated dose. The reason for the event was the Physicist entered the wrong planning film magnification into the treatment system. The patient has experienced some tissue necrosis at the treatment site, although some necrosis is expected with this therapy (MammoSite). The necrosis may have been exacerbated by the dosage scheme. The patient is being followed by her attending physician. The patient and attending physician were notified on 09/27/2006. The Bureau conducted an inspection on November 2, 2006 and identified problems with the licensee's HDR program an additional inspection will be conducted during the week of March 5, 2007."
The R3DO (Lanksbury) and FSME EO (Morell) were notified.
Ohio Report OH2007-11
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.
Agreement State
Event Number: 46842
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: DECATUR MEMORIAL HOSPITAL
Region: 3
City: DECATUR State: IL
County:
License #: IL-01410-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Licensee: DECATUR MEMORIAL HOSPITAL
Region: 3
City: DECATUR State: IL
County:
License #: IL-01410-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: VINCE KLCO
Notification Date: 05/11/2011
Notification Time: 17:11 [ET]
Event Date: 09/27/2006
Event Time: 00:00 [CDT]
Last Update Date: 05/11/2011
Notification Time: 17:11 [ET]
Event Date: 09/27/2006
Event Time: 00:00 [CDT]
Last Update Date: 05/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVE PASSEHL (R3DO)
JAMES DANNA (FSME)
DAVE PASSEHL (R3DO)
JAMES DANNA (FSME)
AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERENT THAN PRESCRIBED DOSE
The following information was received by e-mail:
"The Director of Oncology Services at Decatur Memorial Hospital contacted the Agency [state] to give a preliminary notification of a medical event that happened in September 2006. Following the receipt of additional training by their oncologists regarding medical event criteria, they began to conduct a retrospective review of past prostate cancer treatments that have been performed at their facility since 2002. A particular case was readily notable when the comparison of dose intended vs. dose received was made. Using 81 I-125 seeds, the prescribed dose to the target (D100) was 132.5 Gray, the delivered dose was 32.5 Gray which is only 24.5 percent of the intended dose. However the review showed all seeds intended to be implanted were successfully placed under guided ultrasound and post operative x-ray imaging showed all seeds to be within the target volume. Subsequent follow-ups with the patient over the past 5 years have shown a significant reduction in PSA levels, no evidence of recurrent cancer and no adverse side effects to the bladder, rectum, urethra or other associated dysfunction for the now 87 year old patient. At the time of implant, there were no notes in the surgical file to suggest a change in shape or size of the prostate which would suggest pre-treatment planning performed was invalid. Routine CT imaging conducted at 30 days post treatment as part of the follow-up process showed the prostate had expected swelling present. When dosimetry calculations were performed using the increase in volume, the total delivered dose value for the intended treatment site fell, resulting in the criteria for a medical event being met. The attending oncologist does not intend to notify the patient of this recent discovery. The doctor believes that such a notification would be against his medical judgment and would do unnecessary harm to the patient in this instance considering the success of the treatment.
"The responsible oncologists and the rest of the treatment team were interviewed by the [Illinois Emergency Management] Agency yesterday afternoon regarding additional details of this event and planned actions. The team indicated that [they] would continue review of the 240 cases but didn't believe that any changes to its current program were warranted at this time based on this one observation. Anecdotally, none of the physicians could remember any of their patients having adverse or unexpected effects during subsequent follow-ups. Nor had any [patients] required additional or supplemental treatment of any kind (i.e. hormonal, surgery, external beam, additional seeds) for recurrent cancer. [The team] couldn't rule out that a similar medical event requiring reporting wouldn't be discovered as they continued their review."
Illinois Event: IL11053
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.
The following information was received by e-mail:
"The Director of Oncology Services at Decatur Memorial Hospital contacted the Agency [state] to give a preliminary notification of a medical event that happened in September 2006. Following the receipt of additional training by their oncologists regarding medical event criteria, they began to conduct a retrospective review of past prostate cancer treatments that have been performed at their facility since 2002. A particular case was readily notable when the comparison of dose intended vs. dose received was made. Using 81 I-125 seeds, the prescribed dose to the target (D100) was 132.5 Gray, the delivered dose was 32.5 Gray which is only 24.5 percent of the intended dose. However the review showed all seeds intended to be implanted were successfully placed under guided ultrasound and post operative x-ray imaging showed all seeds to be within the target volume. Subsequent follow-ups with the patient over the past 5 years have shown a significant reduction in PSA levels, no evidence of recurrent cancer and no adverse side effects to the bladder, rectum, urethra or other associated dysfunction for the now 87 year old patient. At the time of implant, there were no notes in the surgical file to suggest a change in shape or size of the prostate which would suggest pre-treatment planning performed was invalid. Routine CT imaging conducted at 30 days post treatment as part of the follow-up process showed the prostate had expected swelling present. When dosimetry calculations were performed using the increase in volume, the total delivered dose value for the intended treatment site fell, resulting in the criteria for a medical event being met. The attending oncologist does not intend to notify the patient of this recent discovery. The doctor believes that such a notification would be against his medical judgment and would do unnecessary harm to the patient in this instance considering the success of the treatment.
"The responsible oncologists and the rest of the treatment team were interviewed by the [Illinois Emergency Management] Agency yesterday afternoon regarding additional details of this event and planned actions. The team indicated that [they] would continue review of the 240 cases but didn't believe that any changes to its current program were warranted at this time based on this one observation. Anecdotally, none of the physicians could remember any of their patients having adverse or unexpected effects during subsequent follow-ups. Nor had any [patients] required additional or supplemental treatment of any kind (i.e. hormonal, surgery, external beam, additional seeds) for recurrent cancer. [The team] couldn't rule out that a similar medical event requiring reporting wouldn't be discovered as they continued their review."
Illinois Event: IL11053
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.