Event Notification Report for June 18, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/17/2007 - 06/18/2007
General Information or Other
Event Number: 43434
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: TERRY LINDSEY
HQ OPS Officer: JEFF ROTTON
Licensee: OREGON HEALTH SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: TERRY LINDSEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/20/2007
Notification Time: 18:54 [ET]
Event Date: 06/18/2007
Event Time: 16:00 [PDT]
Last Update Date: 06/20/2007
Notification Time: 18:54 [ET]
Event Date: 06/18/2007
Event Time: 16:00 [PDT]
Last Update Date: 06/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4)
JACK DAVIS (FSME)
BLAIR SPITZBERG (R4)
JACK DAVIS (FSME)
OREGON AGREEMENT STATE REPORT - POTENTIAL UNDERDOSE TREATMENT TO LIVER
"Written order was requested for a therapy dose of 2.45 GBq (66.2 milliCuries) of Y-90 TheraSphere for treatment to the patient's liver. 1.74 GBq (47 milliCuries) was received from MDS Nordion and used for treatment. Calculation error may have contributed to under treatment with approximately 80 Gray delivered to the liver with an intended dose of 100-110 Gray. Concern to not exceed lung dose of 15 Gray achieved with treatment dose at low end of optimal range. Physician notified and will consult with patient to decide whether to conduct additional treatment."
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.
"Written order was requested for a therapy dose of 2.45 GBq (66.2 milliCuries) of Y-90 TheraSphere for treatment to the patient's liver. 1.74 GBq (47 milliCuries) was received from MDS Nordion and used for treatment. Calculation error may have contributed to under treatment with approximately 80 Gray delivered to the liver with an intended dose of 100-110 Gray. Concern to not exceed lung dose of 15 Gray achieved with treatment dose at low end of optimal range. Physician notified and will consult with patient to decide whether to conduct additional treatment."
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.
Fuel Cycle Facility
Event Number: 43429
Facility: HONEYWELL INTERNATIONAL, INC.
Region: 2 State: IL
Unit: [] [] []
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
NRC Notified By: LARRY PARSCALE
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: IL
Unit: [] [] []
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
NRC Notified By: LARRY PARSCALE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/18/2007
Notification Time: 14:31 [ET]
Event Date: 06/18/2007
Event Time: 08:00 [CDT]
Last Update Date: 07/11/2007
Notification Time: 14:31 [ET]
Event Date: 06/18/2007
Event Time: 08:00 [CDT]
Last Update Date: 07/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
SCOTT SHAEFFER (R2)
GREG MORELL (FSME)
SCOTT SHAEFFER (R2)
GREG MORELL (FSME)
DIGITAL CONTROL SYSTEM FAILED FOR UNKNOWN REASON
"At approximately 0800, lost all FMB control room monitors associated with Digital Control System (DCS). Several valves in UF6 process failed in unexpected position. No release and no exposures. System immediately put in a safe configuration. Root cause has begun and system will be kept in safe configuration for now (not restarted) until cause determined and corrected. This is a Courtesy Notification."
The NRC Resident Inspector and the NRC Regional Project Manager (Pelchat) were informed of this information call by the licensee.
* * * UPDATE FROM PARSCALE TO HUFFMAN AT 1146 EDT ON 7/11/07 * * *
"The cause has been determined to be attributable to a UPS failure. This UPS failure resulted in a re-initialization of system configuration which, upon power restoration, caused process valves to move to the system's default configuration for the subsequent re-start mode. This default configuration was not correct for the state the system was in at the time of the re-initialization. The programming logic for valve alignment in the event of a re-initialization has since been corrected. There was no release and no exposure, and the system was immediately put in a safe configuration. The root cause is continuing. This is an update to the Courtesy Notification made on 6/18/07."
Notified R2DO (Hopper), FSME (Burgess).
"At approximately 0800, lost all FMB control room monitors associated with Digital Control System (DCS). Several valves in UF6 process failed in unexpected position. No release and no exposures. System immediately put in a safe configuration. Root cause has begun and system will be kept in safe configuration for now (not restarted) until cause determined and corrected. This is a Courtesy Notification."
The NRC Resident Inspector and the NRC Regional Project Manager (Pelchat) were informed of this information call by the licensee.
* * * UPDATE FROM PARSCALE TO HUFFMAN AT 1146 EDT ON 7/11/07 * * *
"The cause has been determined to be attributable to a UPS failure. This UPS failure resulted in a re-initialization of system configuration which, upon power restoration, caused process valves to move to the system's default configuration for the subsequent re-start mode. This default configuration was not correct for the state the system was in at the time of the re-initialization. The programming logic for valve alignment in the event of a re-initialization has since been corrected. There was no release and no exposure, and the system was immediately put in a safe configuration. The root cause is continuing. This is an update to the Courtesy Notification made on 6/18/07."
Notified R2DO (Hopper), FSME (Burgess).