Event Notification Report for February 06, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/05/2007 - 02/06/2007
EVENT NUMBERS
43155431474314843149
General Information or Other
Event Number: 43155
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CAPTECH
Region: 1
City: TALLAHASSEE State: FL
County:
License #: 2608-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: STEVE SANDIN
Licensee: CAPTECH
Region: 1
City: TALLAHASSEE State: FL
County:
License #: 2608-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/08/2007
Notification Time: 11:57 [ET]
Event Date: 02/06/2007
Event Time: 11:00 [EST]
Last Update Date: 02/08/2007
Notification Time: 11:57 [ET]
Event Date: 02/06/2007
Event Time: 11:00 [EST]
Last Update Date: 02/08/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM COOK (R1)
GREG MORELL (NMSS)
WILLIAM COOK (R1)
GREG MORELL (NMSS)
AGREEMENT STATE REPORT INVOLVING PERSONNEL EXTREMITY OVEREXPOSURE
"[Captech representative] reported an overexposure to a Captech employee. [The individual] received 50.68 rem to her left hand as per her dosimetry report. [The individual] is no longer an employee at Captech [and] left at her own volition as per [the Captech representative]. Incident referred to radioactive materials for investigation."
Captech is an independent Nuclear Pharmacy. The individual receiving the overexposure handled various isotopes during the period measured by the dosimetry report.
FL Incident No.: FL07-019
"[Captech representative] reported an overexposure to a Captech employee. [The individual] received 50.68 rem to her left hand as per her dosimetry report. [The individual] is no longer an employee at Captech [and] left at her own volition as per [the Captech representative]. Incident referred to radioactive materials for investigation."
Captech is an independent Nuclear Pharmacy. The individual receiving the overexposure handled various isotopes during the period measured by the dosimetry report.
FL Incident No.: FL07-019
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 43147
Rep Org: ST. FRANCIS HOSPITAL, HARTFORD, CT
Licensee: ST. FRANCIS HOSPTIAL, HARTFORD, CT
Region: 1
City: HARTFORD State: CT
County: HARTFORD
License #: 06-00854-03
Agreement: N
Docket:
NRC Notified By: E. WILCOX
HQ OPS Officer: JOHN MacKINNON
Licensee: ST. FRANCIS HOSPTIAL, HARTFORD, CT
Region: 1
City: HARTFORD State: CT
County: HARTFORD
License #: 06-00854-03
Agreement: N
Docket:
NRC Notified By: E. WILCOX
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/06/2007
Notification Time: 13:49 [ET]
Event Date: 02/06/2007
Event Time: 07:00 [EST]
Last Update Date: 03/07/2007
Notification Time: 13:49 [ET]
Event Date: 02/06/2007
Event Time: 07:00 [EST]
Last Update Date: 03/07/2007
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):
WILLIAM COOK (R1)
GREG MORELL (NMSS)
WILLIAM COOK (R1)
GREG MORELL (NMSS)
MEDICAL EVENT
A patient was being treated for cancer of the cervix. The planned total dose to the cervix was to be 2046.5 cGy, over a 39 hour time period. The licensee was using an LDR Selectron Afterloader. Nine cesium-137 sources, activity of each source 16.7 millicuries, were used in the afterloader. The patient started treatment on 02/05/07 at 1235 EST. Today, 02/06/07, between the hours of 0630 - 0717 EST the patient pulled the applicator out approximately 4 centimeters.
The patient was given the correct dose to the cervix for 16.09 hours for a total dose of 844.5 cGy. The patient was given an incorrect dose to the vaginal area for between 30 - 60 minutes. The total dose to the incorrect area is between 50 - 200 (Max) cGy. This incident was not harmful to the patient. The patient's doctor was notified of this incident. The patient will not be retreated.
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.
* * * RETRACTION AT 11:50 ON 3/7/2007 BY DR E. WILCOX TO M. ABRAMOVITZ * * *
This event is not reportable because of patient intervention. The patient refused continuing treatment.
Notified the R1DO (Caruso) and FSME (Morell).
A patient was being treated for cancer of the cervix. The planned total dose to the cervix was to be 2046.5 cGy, over a 39 hour time period. The licensee was using an LDR Selectron Afterloader. Nine cesium-137 sources, activity of each source 16.7 millicuries, were used in the afterloader. The patient started treatment on 02/05/07 at 1235 EST. Today, 02/06/07, between the hours of 0630 - 0717 EST the patient pulled the applicator out approximately 4 centimeters.
The patient was given the correct dose to the cervix for 16.09 hours for a total dose of 844.5 cGy. The patient was given an incorrect dose to the vaginal area for between 30 - 60 minutes. The total dose to the incorrect area is between 50 - 200 (Max) cGy. This incident was not harmful to the patient. The patient's doctor was notified of this incident. The patient will not be retreated.
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.
* * * RETRACTION AT 11:50 ON 3/7/2007 BY DR E. WILCOX TO M. ABRAMOVITZ * * *
This event is not reportable because of patient intervention. The patient refused continuing treatment.
Notified the R1DO (Caruso) and FSME (Morell).
Power Reactor
Event Number: 43148
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBIN BELL
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBIN BELL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/06/2007
Notification Time: 16:08 [ET]
Event Date: 02/06/2007
Event Time: 10:45 [EST]
Last Update Date: 02/06/2007
Notification Time: 16:08 [ET]
Event Date: 02/06/2007
Event Time: 10:45 [EST]
Last Update Date: 02/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
CAROLYN EVANS (R2)
CAROLYN EVANS (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 |
FITNESS FOR DUTY REPORT
A licensed employee (currently inactive) had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been denied. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
A licensed employee (currently inactive) had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been denied. Contact the Headquarters Operations Officer for additional details.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 43149
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ERIC SCHULTZ
HQ OPS Officer: BILL HUFFMAN
Region: 3 State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ERIC SCHULTZ
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/06/2007
Notification Time: 19:08 [ET]
Event Date: 02/06/2007
Event Time: 14:15 [CST]
Last Update Date: 02/06/2007
Notification Time: 19:08 [ET]
Event Date: 02/06/2007
Event Time: 14:15 [CST]
Last Update Date: 02/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTINE LIPA (R3)
CHRISTINE LIPA (R3)
| 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 |
CONTROL ROOM EMERGENCY FILTRATION SYSTEM DECLARED INOPERABLE
"The Control Room Emergency Filtration System (CREFS) was declared inoperable at 1957 on 02/03/07 due to W-14B, 'F-16 Control Room Charcoal Filter Fan,' being declared inoperable during monthly Technical Specification surveillance testing. Upon subsequent investigation of the inoperability of the W-14B fan, the W-14A fan was declared inoperable at 1415 CST on 02/06/07. The cause of the failure of the fans is under investigation.
"These fans are required to be operable to support operability of the CREFS System. This condition is covered by TS 3.7.9 'Control Room Emergency Filtration System' and both units have entered Action Condition A 'CREFS Inoperable,' with a Required Action to 'Restore CREFS to an OPERABLE Status' by 1957 CST on 02/10/07.
"Although the W-14 fans are redundant, CREFS is a single train system. Based on the guidance in NUREG-1022 for single train systems that perform safety functions, this condition was determined to be reportable under 10 CFR 50.72(b)(3)(v)(D), 'Event or Condition That Could Have Prevented Fulfillment of a Safety Function.' Additionally, the failure places PBNP CREFS in a degraded condition that significantly affects plant safety under 50.72(b)(3)(ii)(A), 'Degraded or Unanalyzed Condition.'"
The licensee notified the NRC Resident Inspector.
"The Control Room Emergency Filtration System (CREFS) was declared inoperable at 1957 on 02/03/07 due to W-14B, 'F-16 Control Room Charcoal Filter Fan,' being declared inoperable during monthly Technical Specification surveillance testing. Upon subsequent investigation of the inoperability of the W-14B fan, the W-14A fan was declared inoperable at 1415 CST on 02/06/07. The cause of the failure of the fans is under investigation.
"These fans are required to be operable to support operability of the CREFS System. This condition is covered by TS 3.7.9 'Control Room Emergency Filtration System' and both units have entered Action Condition A 'CREFS Inoperable,' with a Required Action to 'Restore CREFS to an OPERABLE Status' by 1957 CST on 02/10/07.
"Although the W-14 fans are redundant, CREFS is a single train system. Based on the guidance in NUREG-1022 for single train systems that perform safety functions, this condition was determined to be reportable under 10 CFR 50.72(b)(3)(v)(D), 'Event or Condition That Could Have Prevented Fulfillment of a Safety Function.' Additionally, the failure places PBNP CREFS in a degraded condition that significantly affects plant safety under 50.72(b)(3)(ii)(A), 'Degraded or Unanalyzed Condition.'"
The licensee notified the NRC Resident Inspector.