Event Notification Report for October 26, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/25/2006 - 10/26/2006
Power Reactor
Event Number: 42938
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JAMES MORELAND
HQ OPS Officer: BILL HUFFMAN
Region: 4 State: AZ
Unit: [1] [] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JAMES MORELAND
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/27/2006
Notification Time: 07:03 [ET]
Event Date: 10/26/2006
Event Time: 23:53 [MST]
Last Update Date: 10/27/2006
Notification Time: 07:03 [ET]
Event Date: 10/26/2006
Event Time: 23:53 [MST]
Last Update Date: 10/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JEFFREY CLARK (R4)
JEFFREY CLARK (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 |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF POWER TO THE UNIT 1 AND UNIT 3 TRAIN B SAFETY BUSES WITH EMERGENCY DIESEL GENERATOR ACTUATION
"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.
"On October 26, 2006, at approximately 23:53 Mountain Standard Time (MST) a valid actuation of the Palo Verde Nuclear Generating Station Unit 1 Train B Emergency Diesel Generator (EDG) and Unit 3 Train B EDG occurred as a result of undervoltage on their respective safety buses. Both EDGs started and loaded as designed. No Emergency Plan declaration was made and none was required.
"The loss of power to the two safety buses was the result of an apparent spurious protective relay actuation of Startup Transformer X01 output breakers to Unit 1 NAN-S06 and Unit 3 NAN-S06 busses. Unit 1 NAN-S06 bus was being supplied by its Alternate breaker (1ENANS06F) and Unit 3 NAN-S06 was being supplied by its Normal breaker (3ENANS06C). Prior to the event, maintenance personnel were restoring potential Transformer (PT) fuses at Unit 1 breaker 1ENANS06, Cubicle G. Preliminary information is that the two simultaneous LOP conditions occurred when the outer doors were closed on 1ENANS06, Cubicle G. This condition apparently caused the output breakers of Startup Transformer X01 to open. There was no electrical fault or damage to any electrical components.
"Both Units 1 and 3 entered Technical Specification LCO 3.8.1 Condition A for one (of two) required offsite circuits inoperable. [The licensee is] proceeding with restoration of Normal offsite power to each safety bus in Units 1 and 3. Once offsite power is restored, the LCOs will be exited and the Unit 1 and 3 train B EDGs will be returned to standby.
"Both Unit 1 and Unit 3 were at approximately 100% power, at normal operating temperature and pressure prior to and following the EDG actuations. Unit 2 was defueled and was not impacted by the electrical disturbance. No other ESF actuations occurred and none were required. No major equipment was inoperable prior to the event that contributed to the event. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public."
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.
"On October 26, 2006, at approximately 23:53 Mountain Standard Time (MST) a valid actuation of the Palo Verde Nuclear Generating Station Unit 1 Train B Emergency Diesel Generator (EDG) and Unit 3 Train B EDG occurred as a result of undervoltage on their respective safety buses. Both EDGs started and loaded as designed. No Emergency Plan declaration was made and none was required.
"The loss of power to the two safety buses was the result of an apparent spurious protective relay actuation of Startup Transformer X01 output breakers to Unit 1 NAN-S06 and Unit 3 NAN-S06 busses. Unit 1 NAN-S06 bus was being supplied by its Alternate breaker (1ENANS06F) and Unit 3 NAN-S06 was being supplied by its Normal breaker (3ENANS06C). Prior to the event, maintenance personnel were restoring potential Transformer (PT) fuses at Unit 1 breaker 1ENANS06, Cubicle G. Preliminary information is that the two simultaneous LOP conditions occurred when the outer doors were closed on 1ENANS06, Cubicle G. This condition apparently caused the output breakers of Startup Transformer X01 to open. There was no electrical fault or damage to any electrical components.
"Both Units 1 and 3 entered Technical Specification LCO 3.8.1 Condition A for one (of two) required offsite circuits inoperable. [The licensee is] proceeding with restoration of Normal offsite power to each safety bus in Units 1 and 3. Once offsite power is restored, the LCOs will be exited and the Unit 1 and 3 train B EDGs will be returned to standby.
"Both Unit 1 and Unit 3 were at approximately 100% power, at normal operating temperature and pressure prior to and following the EDG actuations. Unit 2 was defueled and was not impacted by the electrical disturbance. No other ESF actuations occurred and none were required. No major equipment was inoperable prior to the event that contributed to the event. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public."
The licensee notified the NRC Resident Inspector.
Hospital
Event Number: 42941
Rep Org: ST LUKES HOSPITAL
Licensee: ST LUKES HOSPITAL
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-00889-01
Agreement: N
Docket:
NRC Notified By: GREG SACKETT
HQ OPS Officer: BILL GOTT
Licensee: ST LUKES HOSPITAL
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-00889-01
Agreement: N
Docket:
NRC Notified By: GREG SACKETT
HQ OPS Officer: BILL GOTT
Notification Date: 10/27/2006
Notification Time: 13:22 [ET]
Event Date: 10/26/2006
Event Time: 15:00 [CDT]
Last Update Date: 10/27/2006
Notification Time: 13:22 [ET]
Event Date: 10/26/2006
Event Time: 15:00 [CDT]
Last Update Date: 10/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MARK RING (R3)
CINDY FLANNERY (NMSS)
MARK RING (R3)
CINDY FLANNERY (NMSS)
MEDICAL EVENT
"On October 26, 2006 an incident regarding a high-dose rate (HDR) mammosite treatment was discovered.
"At approximately 15:00 hours the physicist was verifying source positions and dwell times prior to treatment number eight of ten. The physicist noted that the first (most distal) source position was different from previous treatments (94.5 cm vs. 92.3 cm). When he queried the dosimetrists about the change, he was told that a different value was given for the measurement of the overall catheter length. The measured catheter length for the first seven treatments was 96.6 cm, while the most recent measurement gave 96.75 cm. The dosimetrist entered 95.15 cm (subtracting the 1.6 cm correction factor for the actual position of the most distal source dwell point within the catheter). However, this did not explain a 2.2 cm difference in the first dwell position.
"The subsequent investigation into the discrepancy revealed that the usable catheter length entered into the planning computer was 93.0 cm rather than the correct value of 95 cm. This erroneous usable catheter length was used for the first seven treatments, which resulted in an unplanned dose to tissue proximal to the mammosite balloon. It is presently believed that a typographical error occurred in entering the usable catheter length into the treatment planning computer that was the root cause of the unplanned dose.
"The referring physician and patient have been notified of the event. The authorized user (radiation oncologist) is currently evaluating the clinical status of the patient. Further treatments are on hold pending a clinical decision."
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.
* * * UPDATE FROM C. FLANNERY (FSME) TO W. GOTT AT 1641 ON 10/27/06 * * *
This event has been reviewed by the NRC medical review committee and determined to be a reportable medical event.
"On October 26, 2006 an incident regarding a high-dose rate (HDR) mammosite treatment was discovered.
"At approximately 15:00 hours the physicist was verifying source positions and dwell times prior to treatment number eight of ten. The physicist noted that the first (most distal) source position was different from previous treatments (94.5 cm vs. 92.3 cm). When he queried the dosimetrists about the change, he was told that a different value was given for the measurement of the overall catheter length. The measured catheter length for the first seven treatments was 96.6 cm, while the most recent measurement gave 96.75 cm. The dosimetrist entered 95.15 cm (subtracting the 1.6 cm correction factor for the actual position of the most distal source dwell point within the catheter). However, this did not explain a 2.2 cm difference in the first dwell position.
"The subsequent investigation into the discrepancy revealed that the usable catheter length entered into the planning computer was 93.0 cm rather than the correct value of 95 cm. This erroneous usable catheter length was used for the first seven treatments, which resulted in an unplanned dose to tissue proximal to the mammosite balloon. It is presently believed that a typographical error occurred in entering the usable catheter length into the treatment planning computer that was the root cause of the unplanned dose.
"The referring physician and patient have been notified of the event. The authorized user (radiation oncologist) is currently evaluating the clinical status of the patient. Further treatments are on hold pending a clinical decision."
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.
* * * UPDATE FROM C. FLANNERY (FSME) TO W. GOTT AT 1641 ON 10/27/06 * * *
This event has been reviewed by the NRC medical review committee and determined to be a reportable medical event.