Event Notification Report for November 16, 2006

AGREEMENT STATE - STOLEN TRUCK CONTAINING RADIOPHARMICEUTICALS

The State provided the following information via email:

"DRH [Department of Radiation Health] received notification on 11-17-06 from Cardinal Health about a delivery vehicle that was car-jacked at a gas station located in Jackson, MS. The driver was driving a Ford Ranger delivery truck that was carrying approximately 540 millicuries of Technetium-99m. The vehicle was delivering radiopharmaceuticals to area hospitals and clinics. At the time of the report to DRH, the doses had already gone through 3 half-lives of decay. As of Monday 11-20-06, the vehicle has not been recovered."

The State notified Flowood, MS and Jackson, MS police departments, Mississippi Emergency Management Agency (MEMA), and the FBI.

Mississippi State report number: MS 06014

* * * UPDATE FROM MISSISSIPPI (B.J. SMITH) TO HUFFMAN VIA E-MAIL AT 1629 EST ON 11/20/06 * * *

"Vehicle recovered by Jackson Police Department 11-20-06 at about 2:00 PM CST. Ammo boxes [shipping containers] were not tampered with and all material recovered. Security seals were still attached."

R4DO (Campbell), NMSS EO (Camper) and ILTAB (via e-mail) have been notified.

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.

AGREEMENT STATE - WASHINGTON - GAMMA KNIFE OVEREXPOSURE

The Washington State Department of Health (DOH) received a preliminary telephone report, November 22, from University of Washington, Harborview Gamma Knife, that a dose of 28 Grays had been administered to a patient. The exposure exceeded the prescribed exposure of 18 Grays by 10 Grays. The cause, thus far, is unknown. DOH is to receive a written report within 15 days.

The dose was administered by a Leksell Gamma System Model 24001 Type C gamma knife with 7,236 Curies of Co-60.

The patient or responsible relative has been notified.

The licensee is required to notify DOH within 24 hours. The notification is apparently several days late.

Washington State report number: #WA-06-066


* * * UPDATE PROVIDED VIA EMAIL FROM SCROGGS TO ROTTON AT 1955 EST ON 12/11/06 * * *

The State provided the following update information via email:

"The cause was stated by the licensee to be human error. The prescribing physician, apparently in a hurry to leave for the day, had prescribed 18 Gy. The physician then entered the Rx value into the computer treatment plan rather than having the medical physicist do it as is the usual procedure. The physician erroneously entered 28 Gy.

"The licensee stated the tumor undergoing treatment turned out to be larger than expected consequently the 28 Gy administered remains therapeutic with likely no ill-effects expected as a result of this incident.

"The treatment plan has been modified so that a similar event is less likely to occur. The progress of the patient is being closely watched by the licensee. DOH is expecting receipt of a written report from the licensee this week."

Notified the R4DO (Smith) and NMSS EO (Janosko).

* * * UPDATE PROVIDED VIA EMAIL FROM SCROGGS TO KOZAL AT 1841 EST ON 12/19/06 * * *

"The Department has received the licensee's written report of the incident and proposed corrective action. Corrective actions now include a verification process to ensure the correct treatment dose has been transferred from the treatment planning computer to the Gamma Knife computer prior to patient therapy. A plan signed by the treating oncologist, physicist, and neurosurgeon is now required. In addition the treating oncologist and physicist will verify and initial the prescription dose and isodose. Before a patient is treated, the nursing still will confirm: the patient's name/identity; the disease process; the disease site; the prescribed dose; and the prescribed isodose. These actions appear adequate at this time and will be reviewed during the Department's next visit to the facility.

"The effect to the individual is unknown at this time. However, it is expected that there will be minimal symptoms related to the larger radiation dose. A longer course of steroids than was initially planned may be prescribed."

Notified the R4DO (Whitten) and NMSS EO (Pierson).


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.

SPDS UNAVAILIBLE DUE TO PLANNED MAINTENANCE

"The Safety Parameter Display System and ERDS will be out of service for approximately 4 hours for scheduled maintenance. SPDS and ERDS parameters will be monitored by Control Board indications. Work will be continuous until SPDS/ERDS are returned to service. Alternate assessment and communication measures are available to compensate for these temporary impairments.

"This is an 8-hour reportable event per 10 CFR 50.72(b)(3)(xiii) Major Loss of Assessment Capability. Cooper Nuclear Station is currently in a scheduled refueling outage. The operation of Cooper Nuclear Station is not affected by this planned maintenance."

The licensee notified the NRC Resident Inspector.

REACTOR TRIP DUE TO TURBINE TRIP AND DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION OF AN UNSUAL EVENT

At 0018 Calvert Cliffs Unit 2 experienced an automatic reactor trip due to a turbine trip. "At the time a clearance order was being performed for upcoming maintenance on P-13000-2 [transformer]. As a result of the turbine trip, RCS pressure rose to approximately 2420 psia causing the PORV's to open. Unexpectedly, a Pressurizer Safety Valve, RV-200 also lifted and reclosed when RCS pressure was lowered to approximately 1500 psia. As a result of the pressure decrease, a Safety Injection Actuation Signal (SIAS) occurred. Once the Pressurizer Safety Valve reclosed, RCS pressure began to rise to return to normal values.

"Decay heat is being removed via normal methods through the Turbine Bypass Valves to the Condenser.

"Normal Feedwater is being used. No Auxiliary Feedwater actuation occurred.

"Two Reactor Coolant Pumps were secured as a result of the SIAS. The plant responded normally to the event. The plant is currently stable and operators are conducting a plant cooldown to mode 5."

All control rods fully inserted.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM C. MORGAN TO W. GOTT AT 1039 ON 11/16/06 * * *

The automatic trip was due to high RCS pressure from the closure of the Turbine Intercept Valves. Both PORV's opened as designed. One remained open approximately 1.5 minutes causing RCS pressure to reduce to 1500 psia. The PORV should have closed at 2400 psia. Relief Valve 200 (RV-200) did not open as previously reported and was not the cause of the RCS pressure lowering. Acoustic monitoring indication were due to the close proximity of the PORV. Since the SIAS signal did not cause a reportable ECCS actuation, the reported 50.72(b)(2)(iv)(A) ECCS Actuation is retracted.

The licensee notified the NRC Resident Inspector.

Notified R1DO (P. Henderson).


* * * UPDATE FROM C. MORGAN TO W. HUFFMAN AT 1200 EST ON 11/16/06 * * *

Upon further review, the licensee has determined that this event met the criteria for Unusual Event Emergency Action Level (EAL A.U.2.2.1) for identified RCS leakage greater than 25 gpm. The licensee met this criteria for the duration that the PORV valve remained open (less than 2 minutes). The licensee did not recognize that it had met the criteria at the time of the event and is reporting this as an after-the-fact emergency condition of unusual event per the guidance in NUREG-1022. The licensee notified the NRC Resident Inspector.

Notified R1DO (P. Henderson), NRR EO (Ross-Lee), and IRD Manager (Leach).

REACTOR TRIP

"At 0226, North Anna Power Station Unit 2 automatically tripped on steam flow greater than feed flow with low steam generator water level on 'B' Steam Generator. This was caused by a Steam Flow Channel (Channel 3) Low failure. After the reactor trip, Auxiliary Feedwater Pumps automatically started on Low-Low Steam Generator Level."

All control rods fully inserted. RCPs are in operation transferring decay heat to the steam generators. The steam generators are discharging steam to the main condenser using the condenser steam dumps. Main feedwater pumps are running to maintain steam generator water levels. Unit 1 was not affected.

The licensee will notify the NRC Resident Inspector.