Event Notification Report for November 08, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/07/2006 - 11/08/2006
EVENT NUMBERS
429804297642977429714297443080
Hospital
Event Number: 42980
Rep Org: DANVILLE REGIONAL MEDICAL CENTER
Licensee: DANVILLE REGIONAL MEDICAL CENTER
Region: 1
City: Danville State: VA
County:
License #: 451515403
Agreement: N
Docket:
NRC Notified By: DR. G. SHEROUSE
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: DANVILLE REGIONAL MEDICAL CENTER
Region: 1
City: Danville State: VA
County:
License #: 451515403
Agreement: N
Docket:
NRC Notified By: DR. G. SHEROUSE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/09/2006
Notification Time: 16:02 [ET]
Event Date: 11/08/2006
Event Time: 10:10 [EST]
Last Update Date: 11/09/2006
Notification Time: 16:02 [ET]
Event Date: 11/08/2006
Event Time: 10:10 [EST]
Last Update Date: 11/09/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NEIL PERRY (R1)
MICHELE BURGESS (NMSS)
NEIL PERRY (R1)
MICHELE BURGESS (NMSS)
POTENTIAL LEAKAGE FROM A I-125 SEED
Six cartridges of I-125 seeds were received on 11/6/2006. During the inspection of the cartridges, a bent seed was found and removed from one of the cartridges. One additional cartridge was inspected by removing the seeds and reloading the cartridge. The remaining cartridges were visually inspected. No contamination was found on any of the cartridges.
The seeds were implanted in a patient at approximately 10:00 on 11/8/2006. After the procedure, residual activity was found on one of the cartridges. A urine assay on the patient was performed and a low level of activity was found (about four times background). A spectrographic analysis confirmed the activity as I-125.
The licensee is performing a dose assessment. The seed manufacturer was notified and stated that they would notify the state of Illinois.
Source information:
Manufacturer: Bard of Carol Stream, Illinois.
Model: STM1251
Lot #I60539B03
Six cartridges of I-125 seeds were received on 11/6/2006. During the inspection of the cartridges, a bent seed was found and removed from one of the cartridges. One additional cartridge was inspected by removing the seeds and reloading the cartridge. The remaining cartridges were visually inspected. No contamination was found on any of the cartridges.
The seeds were implanted in a patient at approximately 10:00 on 11/8/2006. After the procedure, residual activity was found on one of the cartridges. A urine assay on the patient was performed and a low level of activity was found (about four times background). A spectrographic analysis confirmed the activity as I-125.
The licensee is performing a dose assessment. The seed manufacturer was notified and stated that they would notify the state of Illinois.
Source information:
Manufacturer: Bard of Carol Stream, Illinois.
Model: STM1251
Lot #I60539B03
Power Reactor
Event Number: 42976
Facility: DRESDEN
Region: 3 State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: BRUCE FRANZEN
HQ OPS Officer: MIKE RIPLEY
Region: 3 State: IL
Unit: [] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: BRUCE FRANZEN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/09/2006
Notification Time: 04:33 [ET]
Event Date: 11/08/2006
Event Time: 22:54 [CST]
Last Update Date: 11/09/2006
Notification Time: 04:33 [ET]
Event Date: 11/08/2006
Event Time: 22:54 [CST]
Last Update Date: 11/09/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMNES CAMERON (R3)
JAMNES CAMERON (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 85 | Power Operation | 85 | Power Operation |
| 3 | N | N | 0 | Refueling | 0 | Refueling |
FAILURE OF CONTROL ROOM HVAC TO MAINTAIN CONTROL ROOM TEMPERATURE
"At 22:54 hours on November 8, 2006, the B Control Room HVAC Refrigeration and Condensing Unit (RCU) failed to maintain proper Control Room temperature and cycling excessively. The RCU is a single train system and therefore is reportable per 10CFR50.72(b)(3)(v)(D). The RCU is required to operate during a design basis accident to maintain Main Control Room habitability/temperature. The Air Filtration Unit (AFU) of CREVS remains operable. This places unit 2 in a 30 day LCORA per Tech Spec 3.7.5 Required Action A.1."
The licensee notified the NRC Resident Inspector.
"At 22:54 hours on November 8, 2006, the B Control Room HVAC Refrigeration and Condensing Unit (RCU) failed to maintain proper Control Room temperature and cycling excessively. The RCU is a single train system and therefore is reportable per 10CFR50.72(b)(3)(v)(D). The RCU is required to operate during a design basis accident to maintain Main Control Room habitability/temperature. The Air Filtration Unit (AFU) of CREVS remains operable. This places unit 2 in a 30 day LCORA per Tech Spec 3.7.5 Required Action A.1."
The licensee notified the NRC Resident Inspector.
Hospital
Event Number: 42977
Rep Org: THE VALLEY HOSPITAL
Licensee: THE VALLEY HOSPITAL
Region: 1
City: RIDGEWOOD State: NJ
County:
License #: 29-03845
Agreement: N
Docket:
NRC Notified By: MARK LO
HQ OPS Officer: MIKE RIPLEY
Licensee: THE VALLEY HOSPITAL
Region: 1
City: RIDGEWOOD State: NJ
County:
License #: 29-03845
Agreement: N
Docket:
NRC Notified By: MARK LO
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/09/2006
Notification Time: 10:30 [ET]
Event Date: 11/08/2006
Event Time: 00:00 [EST]
Last Update Date: 11/28/2006
Notification Time: 10:30 [ET]
Event Date: 11/08/2006
Event Time: 00:00 [EST]
Last Update Date: 11/28/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NEIL PERRY (R1)
GREG MORELL (NMSS)
NEIL PERRY (R1)
GREG MORELL (NMSS)
IMPLANTATION SEED FOUND IN MEDICAL WASTE BAG
A single Cs-131 implantation seed (2.66 milliCuries as of 9/25/06) was found in a medical waste bag which had not yet left the hospital. All applicable areas were surveyed and no radioactive contamination was found. The licensee is performing a leak test of the seed and will forward the results. The hospital is performing an investigation into the incident.
* * * UPDATE FROM K. CHAK TO W. GOTT AT 1037 ON 11/28/06 * * *
The licensee completed the leak test - negative results, and properly disposed of the seed. The licensee is taking corrective actions to prevent its recurrence.
Notified NMSS (S. Wastler) and R1DO (J. Dwyer)
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.
A single Cs-131 implantation seed (2.66 milliCuries as of 9/25/06) was found in a medical waste bag which had not yet left the hospital. All applicable areas were surveyed and no radioactive contamination was found. The licensee is performing a leak test of the seed and will forward the results. The hospital is performing an investigation into the incident.
* * * UPDATE FROM K. CHAK TO W. GOTT AT 1037 ON 11/28/06 * * *
The licensee completed the leak test - negative results, and properly disposed of the seed. The licensee is taking corrective actions to prevent its recurrence.
Notified NMSS (S. Wastler) and R1DO (J. Dwyer)
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.
Power Reactor
Event Number: 42971
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BOB VANDERBYE
HQ OPS Officer: JOHN KNOKE
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BOB VANDERBYE
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/08/2006
Notification Time: 09:19 [ET]
Event Date: 11/08/2006
Event Time: 08:05 [CST]
Last Update Date: 11/17/2006
Notification Time: 09:19 [ET]
Event Date: 11/08/2006
Event Time: 08:05 [CST]
Last Update Date: 11/17/2006
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):
PAUL FREDRICKSON (R2)
PAUL FREDRICKSON (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 |
PLANT COMPUTER DOWN FOR UPGRADE
"Farley Nuclear Plant is replacing the Unit 1 plant computer with an upgraded plant computer. The total time that the plant computer may be down is a maximum of 10 days. The functions for emergency preparedness will be completed within the first 12 hours of the outage. During that first 12 hours a contingency plan is in place to ensure that the TSC would have the required data if an emergency was declared. A 5054Q was written for this and was reviewed by the Region 2 NRC EP staff prior to implementation."
The licensee notified the NRC Resident Inspector.
* * * UPDATE AT 2045 EST ON 11/17/06 FROM FOREST LERO TO S. SANDIN * * *
The licensee successfully completed functional testing earlier today of the SPDS and has returned it to service as of 2045 EST on 11/17/06.
The licensee will inform the NRC Resident Inspector. Notified R2DO (Chuck Casto).
"Farley Nuclear Plant is replacing the Unit 1 plant computer with an upgraded plant computer. The total time that the plant computer may be down is a maximum of 10 days. The functions for emergency preparedness will be completed within the first 12 hours of the outage. During that first 12 hours a contingency plan is in place to ensure that the TSC would have the required data if an emergency was declared. A 5054Q was written for this and was reviewed by the Region 2 NRC EP staff prior to implementation."
The licensee notified the NRC Resident Inspector.
* * * UPDATE AT 2045 EST ON 11/17/06 FROM FOREST LERO TO S. SANDIN * * *
The licensee successfully completed functional testing earlier today of the SPDS and has returned it to service as of 2045 EST on 11/17/06.
The licensee will inform the NRC Resident Inspector. Notified R2DO (Chuck Casto).
Power Reactor
Event Number: 42974
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: KEN KINGSTON
HQ OPS Officer: BILL GOTT
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: KEN KINGSTON
HQ OPS Officer: BILL GOTT
Notification Date: 11/08/2006
Notification Time: 14:30 [ET]
Event Date: 11/08/2006
Event Time: 11:06 [CST]
Last Update Date: 11/08/2006
Notification Time: 14:30 [ET]
Event Date: 11/08/2006
Event Time: 11:06 [CST]
Last Update Date: 11/08/2006
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 | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
SPECIFIED SYSTEM ACTUATION - EMERGENCY DIESEL GENERATOR AUTO START
"On November 8, 2006, at approximately 11:06 Central Standard Time (CST) a valid actuation of Fort Calhoun station (FCS) Unit 1 Emergency Diesel Generator 2 (DG-2) occurred as a result of undervoltage on its respective safety bus (1A4). DG-2 started as a result from manually deenergizing bus 1A4 during the performance of the Bus Ground Fault Locator Function Test. The DG-2 output breaker was disabled as part of the test and therefore did not close onto the bus. The procedure was deficient in ensuring that DG-2 was not in automatic.
"No loads were being supplied from Bus 1A4 at the time and thus no loads were lost. No other Safeguards systems or equipment were actuated.
"Fort Calhoun Station is currently in a refueling outage, Mode 5 with the core offloaded to the Spent Fuel Pool. No Technical Specifications were entered as a result of this actuation due to plant being less than 300°F.
"Emergency Diesel Generator 2 was taken out of automatic, lockout relays reset and the engine was shutdown."
The licensee notified the NRC Resident Inspector.
"On November 8, 2006, at approximately 11:06 Central Standard Time (CST) a valid actuation of Fort Calhoun station (FCS) Unit 1 Emergency Diesel Generator 2 (DG-2) occurred as a result of undervoltage on its respective safety bus (1A4). DG-2 started as a result from manually deenergizing bus 1A4 during the performance of the Bus Ground Fault Locator Function Test. The DG-2 output breaker was disabled as part of the test and therefore did not close onto the bus. The procedure was deficient in ensuring that DG-2 was not in automatic.
"No loads were being supplied from Bus 1A4 at the time and thus no loads were lost. No other Safeguards systems or equipment were actuated.
"Fort Calhoun Station is currently in a refueling outage, Mode 5 with the core offloaded to the Spent Fuel Pool. No Technical Specifications were entered as a result of this actuation due to plant being less than 300°F.
"Emergency Diesel Generator 2 was taken out of automatic, lockout relays reset and the engine was shutdown."
The licensee notified the NRC Resident Inspector.
Fuel Cycle Facility
Event Number: 43080
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 2 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: STEVE TOELLE
HQ OPS Officer: PETE SNYDER
Region: 2 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: STEVE TOELLE
HQ OPS Officer: PETE SNYDER
Notification Date: 01/05/2007
Notification Time: 17:34 [ET]
Event Date: 11/08/2006
Event Time: 12:00 [CST]
Last Update Date: 01/05/2007
Notification Time: 17:34 [ET]
Event Date: 11/08/2006
Event Time: 12:00 [CST]
Last Update Date: 01/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
CHARLIE PAYNE (R2)
MICHAEL MARKLEY (NMSS)
OMID TABATABAI (NRR)
CHARLIE PAYNE (R2)
MICHAEL MARKLEY (NMSS)
OMID TABATABAI (NRR)
DEFECT IDENTIFIED IN CRANE BRAKE CALIPER MOUNTING PIN
United States Enrichment Corporation (USEC) identified a defect in a Continental Brake Model No. 95400 crane hoist drum hydraulic brake caliper mounting pin (part no. 3954022). The firm that supplied the item was Continental Brake Equipment Company, Longboat Key, Florida. The item is a commercial grade item, dedicated for use as a Basic Component upon receipt inspection.
The defect involved errors in the machining of a groove which accepts a retaining ring to hold the caliper mounting pin in place. Specifically, the grooves were machined too shallow and too narrow to properly accept and hold the retaining ring. The result is that during use the retaining ring may dislodge from the pin, allowing the pin to loosen. This happened in the certificate holder's C-315 facility during use.
A loose mounting pin can result in the brakes not performing its function as a hoist brake to prevent the uncontrolled lowering of a UF6 cylinder. Per the faxed USEC report: "Failure of the crane hoist resulting in the drop of a cylinder containing liquid UF6 is identified in the PGDP accident analysis as resulting in off-site uranium exposures exceeding the guidelines established for determining a substantial safety hazard."
USEC has inspected all subject mounting pins in service and on-hand. All defective mounting pins were removed from service or shelves. USEC has not communicated with other specific purchasers or licensees but they recommend that users of cranes with similar brakes inspect the subject caliper pins for engagement.
United States Enrichment Corporation (USEC) identified a defect in a Continental Brake Model No. 95400 crane hoist drum hydraulic brake caliper mounting pin (part no. 3954022). The firm that supplied the item was Continental Brake Equipment Company, Longboat Key, Florida. The item is a commercial grade item, dedicated for use as a Basic Component upon receipt inspection.
The defect involved errors in the machining of a groove which accepts a retaining ring to hold the caliper mounting pin in place. Specifically, the grooves were machined too shallow and too narrow to properly accept and hold the retaining ring. The result is that during use the retaining ring may dislodge from the pin, allowing the pin to loosen. This happened in the certificate holder's C-315 facility during use.
A loose mounting pin can result in the brakes not performing its function as a hoist brake to prevent the uncontrolled lowering of a UF6 cylinder. Per the faxed USEC report: "Failure of the crane hoist resulting in the drop of a cylinder containing liquid UF6 is identified in the PGDP accident analysis as resulting in off-site uranium exposures exceeding the guidelines established for determining a substantial safety hazard."
USEC has inspected all subject mounting pins in service and on-hand. All defective mounting pins were removed from service or shelves. USEC has not communicated with other specific purchasers or licensees but they recommend that users of cranes with similar brakes inspect the subject caliper pins for engagement.