Event Notification Report for July 24, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/23/2007 - 07/24/2007
EVENT NUMBERS
435224352443517435184351543516
Hospital
Event Number: 43522
Rep Org: LOUDOUN HOSPITAL
Licensee: LOUDOUN HOSPITAL
Region: 1
City: LEESBURG State: VA
County:
License #: 45-16806-01
Agreement: N
Docket:
NRC Notified By: ANNE PATTERSON
HQ OPS Officer: JASON KOZAL
Licensee: LOUDOUN HOSPITAL
Region: 1
City: LEESBURG State: VA
County:
License #: 45-16806-01
Agreement: N
Docket:
NRC Notified By: ANNE PATTERSON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/25/2007
Notification Time: 16:02 [ET]
Event Date: 07/24/2007
Event Time: 15:30 [EDT]
Last Update Date: 07/25/2007
Notification Time: 16:02 [ET]
Event Date: 07/24/2007
Event Time: 15:30 [EDT]
Last Update Date: 07/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PAT FINNEY (R1)
ILTAB (E-MAIL)
CINDY FLANNERY (FSME)
PAT FINNEY (R1)
ILTAB (E-MAIL)
CINDY FLANNERY (FSME)
LOST I-125 SEED
The licensee was performing a prostate seed case requiring 12 loose I-125 seeds with an activity of .34 mCi each. The seeds were assayed in the licensee hot lab and transported to the operating room for the procedure. After completion of the procedure only 11 seeds were accounted for. The RSO was notified. The seed was verified to not be in the patient. The licensee completed search for the material throughout the operating room and hot lab with no success. The licensee contacted the NRC Region 1 representative.
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.
The licensee was performing a prostate seed case requiring 12 loose I-125 seeds with an activity of .34 mCi each. The seeds were assayed in the licensee hot lab and transported to the operating room for the procedure. After completion of the procedure only 11 seeds were accounted for. The RSO was notified. The seed was verified to not be in the patient. The licensee completed search for the material throughout the operating room and hot lab with no success. The licensee contacted the NRC Region 1 representative.
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.
Other Nuclear Material
Event Number: 43524
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: WARREN State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: JASON KOZAL
Licensee: US ARMY
Region: 3
City: WARREN State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: KAREN MCGUIRE
HQ OPS Officer: JASON KOZAL
Notification Date: 07/26/2007
Notification Time: 16:12 [ET]
Event Date: 07/24/2007
Event Time: 00:00 [EDT]
Last Update Date: 07/26/2007
Notification Time: 16:12 [ET]
Event Date: 07/24/2007
Event Time: 00:00 [EDT]
Last Update Date: 07/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
LINDA SMITH (R4)
RICHARD SKOKOWSKI (R3)
DENNIS RATHBUN (FSME)
LINDA SMITH (R4)
RICHARD SKOKOWSKI (R3)
DENNIS RATHBUN (FSME)
FAILED SOURCE SHIELD LOCK ON MOISTURE DENSITY GAUGE
"The Tester, Density and Moisture (Soil and Asphalt) Nuclear Method Campbell Pacific Model MC-1 (CCE), NSN 6635-01-030-6896, Serial Number M17112090, is assigned to the 980th Angering Battalion at Austin, TX. The MC-1 Tester had on manufacture (in 1977) 10 mCi of Cesium 137 and 50 mCi of Americium 241/Be. The sources are solid, sealed, and double encapsulated. The MC-1 Tester is licensed through an Army NRC license 21-01222-05, issued to the US Army TACOM Life Cycle Management Command (LCMC), located in Warren, MI.
"The tester was used in Iraq in 2005 and was shipped back to the unit location in Texas in 2006. It is unknown, if the tester had any mechanical difficulties in Iraq . The tester had received servicing through CPN International, Inc. on June 19, 2003. [Servicing included replacing] standard wear items such as gaskets and the handle. Also, the electronic assembly was bench tested with the two detectors, and the body of the tester is cleaned with the guidetube and rod assembly cleaned/lubed. The tester was also calibrated and leak tested
"The tester hasn't been used since its use in Iraq . The tester has been in storage with the only interaction being physical inventories, radiation surveys of the storage and leak tests of the radioactive sources.
"On 24 July 2007, the undersigned received an e-mail (after-hours) indicating that the referenced tester was inoperative with an inoperative handle lock, that wouldn't engage. The e-mail asking for disposition of the tester. Confirmation of the information was made with two Army personnel doing internal radiation audits of Army radiation programs, who were visiting the unit. The Army personnel were told on their visit, that there was some difficulty with the locking mechanism. They were told, that the tester was hard to unlock and that they (the unit) didn't lock the handle for this reason.
"The tester is inside its transport case, locked inside of a lead lined box, inside of a locked connex container, which is locked inside a gate at the unit location. The tester sources to include rod remain inside the tester housing and no other apparent tester deficiencies outside the lock mechanism has been observed. The shutter is in place and closed. The tester will not lock in the various positions (i.e. safe, 6 inch, 8 inch and 12 inch). When the lock button is pushed in, it springs out. The lock could not be locked with the key. There are no known personnel exposures. The tester sources were last leak tested on July 2, 2007, which showed no leakage.
"The only personnel having access to the keys and the tester is the Local RSO. This ensures that the tester is not used. The transport case containing the tester is also now locked.
"It is planned to transport the tester back to the manufacturer for disposition. The tester has been coded as H for unserviceable. Instructions were provided to the unit today to perform a wipe test of the shipping container, prepare the tester for shipment, and to ship it to the manufacturer.
"Also, a reminder e-mail was sent to the unit and to various Army Commands of the requirement to report tester safety defects immediately to TACOM LCMC Warren, MI. This e-mail was sent again today (July 27, 2007) as it was sent out on July 5, 2007."
"The Tester, Density and Moisture (Soil and Asphalt) Nuclear Method Campbell Pacific Model MC-1 (CCE), NSN 6635-01-030-6896, Serial Number M17112090, is assigned to the 980th Angering Battalion at Austin, TX. The MC-1 Tester had on manufacture (in 1977) 10 mCi of Cesium 137 and 50 mCi of Americium 241/Be. The sources are solid, sealed, and double encapsulated. The MC-1 Tester is licensed through an Army NRC license 21-01222-05, issued to the US Army TACOM Life Cycle Management Command (LCMC), located in Warren, MI.
"The tester was used in Iraq in 2005 and was shipped back to the unit location in Texas in 2006. It is unknown, if the tester had any mechanical difficulties in Iraq . The tester had received servicing through CPN International, Inc. on June 19, 2003. [Servicing included replacing] standard wear items such as gaskets and the handle. Also, the electronic assembly was bench tested with the two detectors, and the body of the tester is cleaned with the guidetube and rod assembly cleaned/lubed. The tester was also calibrated and leak tested
"The tester hasn't been used since its use in Iraq . The tester has been in storage with the only interaction being physical inventories, radiation surveys of the storage and leak tests of the radioactive sources.
"On 24 July 2007, the undersigned received an e-mail (after-hours) indicating that the referenced tester was inoperative with an inoperative handle lock, that wouldn't engage. The e-mail asking for disposition of the tester. Confirmation of the information was made with two Army personnel doing internal radiation audits of Army radiation programs, who were visiting the unit. The Army personnel were told on their visit, that there was some difficulty with the locking mechanism. They were told, that the tester was hard to unlock and that they (the unit) didn't lock the handle for this reason.
"The tester is inside its transport case, locked inside of a lead lined box, inside of a locked connex container, which is locked inside a gate at the unit location. The tester sources to include rod remain inside the tester housing and no other apparent tester deficiencies outside the lock mechanism has been observed. The shutter is in place and closed. The tester will not lock in the various positions (i.e. safe, 6 inch, 8 inch and 12 inch). When the lock button is pushed in, it springs out. The lock could not be locked with the key. There are no known personnel exposures. The tester sources were last leak tested on July 2, 2007, which showed no leakage.
"The only personnel having access to the keys and the tester is the Local RSO. This ensures that the tester is not used. The transport case containing the tester is also now locked.
"It is planned to transport the tester back to the manufacturer for disposition. The tester has been coded as H for unserviceable. Instructions were provided to the unit today to perform a wipe test of the shipping container, prepare the tester for shipment, and to ship it to the manufacturer.
"Also, a reminder e-mail was sent to the unit and to various Army Commands of the requirement to report tester safety defects immediately to TACOM LCMC Warren, MI. This e-mail was sent again today (July 27, 2007) as it was sent out on July 5, 2007."
Power Reactor
Event Number: 43517
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: J. SCHROEDER
HQ OPS Officer: JOHN MacKINNON
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: J. SCHROEDER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 07/24/2007
Notification Time: 19:51 [ET]
Event Date: 07/24/2007
Event Time: 09:02 [CDT]
Last Update Date: 07/24/2007
Notification Time: 19:51 [ET]
Event Date: 07/24/2007
Event Time: 09:02 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
LINDA SMITH (R4)
LINDA SMITH (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 |
PLANT EMPLOYEE TESTED POSITIVE FOR ALCOHOL DURING A RANDOM FITNESS-FOR DUTY TEST
A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been revoked. Contact the Headquarters Operations Officer for additional details.
The NRC Resident Inspector was notified of this event notification by the licensee.
A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been revoked. Contact the Headquarters Operations Officer for additional details.
The NRC Resident Inspector was notified of this event notification by the licensee.
Power Reactor
Event Number: 43518
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM A GOLDEN
HQ OPS Officer: JASON KOZAL
Region: 2 State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM A GOLDEN
HQ OPS Officer: JASON KOZAL
Notification Date: 07/24/2007
Notification Time: 22:05 [ET]
Event Date: 07/24/2007
Event Time: 16:45 [CDT]
Last Update Date: 07/24/2007
Notification Time: 22:05 [ET]
Event Date: 07/24/2007
Event Time: 16:45 [CDT]
Last Update Date: 07/24/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOEL MUNDAY (R2)
JOEL MUNDAY (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH PRESSURE COOLANT INJECTION INOPERABLE DUE TO FAILED POWER SUPPLY
"At 1645 on 7/24/07 during the transfer to the Normal Power Supply of the 3A 250 RMQV Board upon completion of scheduled maintenance. Unit 3 High Pressure Coolant Injection system received a 120 VAC Power Failure and was declared inoperable. 120VAC HPCI power is supplied by the Unit 3 ECCS Div 2 Analog Trip Unit Inverter. The Inverter lost power during the 250vdc board transfer and was not able to be restored to service.
"Investigation is still continuing on the failure of the Div 2 ECCS Inverter.
"This event is reportable as an 8-hour Non-Emergency Notification in accordance with 10 CFR 50.72 (b)(3)(v)(B) as; 'Any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to: Remove Residual Heat' ; and 10 CFR 50.72 (b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to; mitigate the consequences of an accident.'
"This event also requires a 60 day written report in accordance with 10 CFR 50.73 (a)(2)(v)(B) and 10 CFR 50.73 (a)(2)(v)(D).
"NRC EVENT # 43518 was reported to Mr. Kozal and the NRC Resident (C. Stancil) was notified at 1925 CDST on 07/24/07."
"At 1645 on 7/24/07 during the transfer to the Normal Power Supply of the 3A 250 RMQV Board upon completion of scheduled maintenance. Unit 3 High Pressure Coolant Injection system received a 120 VAC Power Failure and was declared inoperable. 120VAC HPCI power is supplied by the Unit 3 ECCS Div 2 Analog Trip Unit Inverter. The Inverter lost power during the 250vdc board transfer and was not able to be restored to service.
"Investigation is still continuing on the failure of the Div 2 ECCS Inverter.
"This event is reportable as an 8-hour Non-Emergency Notification in accordance with 10 CFR 50.72 (b)(3)(v)(B) as; 'Any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to: Remove Residual Heat' ; and 10 CFR 50.72 (b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the Safety Function of structures or systems that are needed to; mitigate the consequences of an accident.'
"This event also requires a 60 day written report in accordance with 10 CFR 50.73 (a)(2)(v)(B) and 10 CFR 50.73 (a)(2)(v)(D).
"NRC EVENT # 43518 was reported to Mr. Kozal and the NRC Resident (C. Stancil) was notified at 1925 CDST on 07/24/07."
Power Reactor
Event Number: 43515
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: JEFF ROTTON
Region: 3 State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE INGALLS
HQ OPS Officer: JEFF ROTTON
Notification Date: 07/24/2007
Notification Time: 10:40 [ET]
Event Date: 07/24/2007
Event Time: 02:56 [CDT]
Last Update Date: 07/30/2007
Notification Time: 10:40 [ET]
Event Date: 07/24/2007
Event Time: 02:56 [CDT]
Last Update Date: 07/30/2007
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):
RICHARD SKOKOWSKI (R3)
RICHARD SKOKOWSKI (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 |
TECHNICAL SUPPORT CENTER VENTILATION INOPERABLE
"During performance of the Technical Support Center (TSC) Ventilation System Operability Test, an outside air damper failed to close causing a failure of the TSC Ventilation System to attain the required 0.125 inches water column positive pressure. If an emergency condition occurs during the time the repairs are being made, plans are to utilize the TSC as long as radiological conditions allow. Procedure F3-6 ACTIVATION AND OPERATION OF THE TSC, section 7.6, directs TSC management to relocate TSC activities to a radiological safe area if necessary."
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 07/30/07 AT 1449 EDT FROM MARK LOOSBROCK TO MACKINNON * * *
Technical Support Center (TSC) Ventilation System is now operable. R3DO (Steve Orth) notified.
The NRC Resident Inspector was notified of this event update by the licensee.
"During performance of the Technical Support Center (TSC) Ventilation System Operability Test, an outside air damper failed to close causing a failure of the TSC Ventilation System to attain the required 0.125 inches water column positive pressure. If an emergency condition occurs during the time the repairs are being made, plans are to utilize the TSC as long as radiological conditions allow. Procedure F3-6 ACTIVATION AND OPERATION OF THE TSC, section 7.6, directs TSC management to relocate TSC activities to a radiological safe area if necessary."
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 07/30/07 AT 1449 EDT FROM MARK LOOSBROCK TO MACKINNON * * *
Technical Support Center (TSC) Ventilation System is now operable. R3DO (Steve Orth) notified.
The NRC Resident Inspector was notified of this event update by the licensee.
Hospital
Event Number: 43516
Rep Org: LESTER COX MEDICAL CENTER
Licensee: LESTER COX MEDICAL CENTER
Region: 3
City: SPRINGFIELD State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: JOHN PACYNIAK
HQ OPS Officer: JASON KOZAL
Licensee: LESTER COX MEDICAL CENTER
Region: 3
City: SPRINGFIELD State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: JOHN PACYNIAK
HQ OPS Officer: JASON KOZAL
Notification Date: 07/24/2007
Notification Time: 14:15 [ET]
Event Date: 07/24/2007
Event Time: 10:00 [CDT]
Last Update Date: 07/24/2007
Notification Time: 14:15 [ET]
Event Date: 07/24/2007
Event Time: 10:00 [CDT]
Last Update Date: 07/24/2007
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):
RICHARD SKOKOWSKI (R3)
CINDY FLANNERY (FSME)
RICHARD SKOKOWSKI (R3)
CINDY FLANNERY (FSME)
MEDICAL EVENT - ADMINISTERED DOSE LESS THAN PRESCRIBED DOSE
The treatment consisted of 3 fractionated high dose rate (HDR) brachytherapy procedures. The dose was prescribed by the physician at 5 millimeters from the surface of the cylinder, however, the dose was calculated at the surface of the cylinder. The HDR brachytherapy was administered at 5 millimeters as prescribed. Due to the discrepancy between the prescribed and calculated dose an under dose of the patient of over 4 Grays (Gy) resulted. The prescription was for an administration of 15 Gy. Only 10.3 Gy was administered. The physician is planning to add one more fraction to complete the intended treatment of 15 Gy. The patient will be informed of this misadministration.
The licensee indicated that they will verify the prescription and the film prior to administration to insure consistency between the two. Additionally, when the dose distribution is plotted, the licensee will overlay the cylinder over the dose distribution to visually verify the dose.
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.
The treatment consisted of 3 fractionated high dose rate (HDR) brachytherapy procedures. The dose was prescribed by the physician at 5 millimeters from the surface of the cylinder, however, the dose was calculated at the surface of the cylinder. The HDR brachytherapy was administered at 5 millimeters as prescribed. Due to the discrepancy between the prescribed and calculated dose an under dose of the patient of over 4 Grays (Gy) resulted. The prescription was for an administration of 15 Gy. Only 10.3 Gy was administered. The physician is planning to add one more fraction to complete the intended treatment of 15 Gy. The patient will be informed of this misadministration.
The licensee indicated that they will verify the prescription and the film prior to administration to insure consistency between the two. Additionally, when the dose distribution is plotted, the licensee will overlay the cylinder over the dose distribution to visually verify the dose.
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.