Event Notification Report for August 14, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/13/2007 - 08/14/2007
EVENT NUMBERS
4356543566435674372746029
Power Reactor
Event Number: 43565
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: DAVID DUNCAN
HQ OPS Officer: JOHN KNOKE
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: DAVID DUNCAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/14/2007
Notification Time: 13:22 [ET]
Event Date: 08/14/2007
Event Time: 12:51 [EDT]
Last Update Date: 08/14/2007
Notification Time: 13:22 [ET]
Event Date: 08/14/2007
Event Time: 12:51 [EDT]
Last Update Date: 08/14/2007
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):
JAMNES CAMERON (R3)
JAMNES CAMERON (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SUPPORT CENTER UNAVAILABLE FOR EMERGENCY USE
"Fermi 2 removed the Technical Support Center (TSC) heating ventilation and air conditioning system from operation to facilitate preventive maintenance activities on August 14, 2007. During this work, the facility will not be available for emergency use. Fermi is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event TSC activation is necessary, the EOF will be utilized. Activation and use of the EOF as a backup for the TSC is included in Fermi's Radiological Emergency Response Preparedness Plan, and drills have been held performing both the TSC and EOF functions from the EOF. Fermi will notify the NRC upon completion of this work, which is scheduled for Wednesday August 15, 2007."
The licensee will notify the NRC Resident Inspector.
* * * UPDATE PROVIDED BY JEFF GROFF TO JEFF ROTTON AT 2342 EDT ON 08/14/07 * * *
"Preventive Maintenance activities on the TSC HVAC system have been complete. The TSC is now available for use."
The licensee notified the NRC Resident Inspector. Notified R3DO (J. Cameron)
"Fermi 2 removed the Technical Support Center (TSC) heating ventilation and air conditioning system from operation to facilitate preventive maintenance activities on August 14, 2007. During this work, the facility will not be available for emergency use. Fermi is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event TSC activation is necessary, the EOF will be utilized. Activation and use of the EOF as a backup for the TSC is included in Fermi's Radiological Emergency Response Preparedness Plan, and drills have been held performing both the TSC and EOF functions from the EOF. Fermi will notify the NRC upon completion of this work, which is scheduled for Wednesday August 15, 2007."
The licensee will notify the NRC Resident Inspector.
* * * UPDATE PROVIDED BY JEFF GROFF TO JEFF ROTTON AT 2342 EDT ON 08/14/07 * * *
"Preventive Maintenance activities on the TSC HVAC system have been complete. The TSC is now available for use."
The licensee notified the NRC Resident Inspector. Notified R3DO (J. Cameron)
General Information or Other
Event Number: 43566
Rep Org: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ERIC NOVACEK
HQ OPS Officer: JEFF ROTTON
Licensee: ROSEMOUNT NUCLEAR INSTRUMENTS, INC
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ERIC NOVACEK
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/14/2007
Notification Time: 14:40 [ET]
Event Date: 08/14/2007
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2007
Notification Time: 14:40 [ET]
Event Date: 08/14/2007
Event Time: 00:00 [CDT]
Last Update Date: 08/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
CHARLES R. OGLE (R2)
VINCENT GADDY (R4)
VERN HODGE (NRR)
CHARLES R. OGLE (R2)
VINCENT GADDY (R4)
VERN HODGE (NRR)
ROSEMEOUNT 1154 PRESSURE TRANSMITTER CALIBRATION PROBLEM
The supplier provided the following information via facsimile:
Pursuant to 10 CFR Part 21, section 21.21(b) Rosemount Nuclear Instruments, Inc. [RNII] is writing to inform NRC that a total of ten (10) Model 1154 and 1154 Series H output range code 4 pressure transmitters whose model code includes special option suffix N0026 or N0079 may not calibrate at all of the published values [9 shipped to 2 utility sites in the United States].
"During evaluation of two returned Model 1154 output range code 4 pressure transmitters with special option suffix N0026, the cause of the customer-reported calibration problem was isolated to the amplifier circuit card assembly (CCA). Upon replacement of the amplifier CCAs the two affected transmitters calibrated and functioned normally.
"During root cause analysis it was observed that a single resistor (R316) on each affected amplifier CCA had an incorrect resistance value. The R316 resistor enables a standard upper range limit (URL) of a transmitter with output range code four to be increased from 150 inches water to 210 inches water in combination with a minimum span of 75 inches water. This R316 resistor allows the transmitter to achieve performance specifications, calibration ranges, and spans as indicated by the special option drawing.
"To meet site specific application requirements transmitters may be field recalibrated to different upper and lower range values and/or spans. Model 1154 and 1154 Series H transmitters with special option suffix N0026 or N0079 and amplifier CCAs whose R316 resistors were not replaced during the sub-assembly process, will have incorrect resistance values and may not calibrate to all upper and lower range values and/or spans published for the applicable special option. However, if an affected transmitter has been successfully calibrated, having the incorrect resistance value will not adversely affect transmitter performance during normal operation or accident conditions.
"The manufacturing records for the two returned Model 1154 transmitters (with amplifier CCAs with part number 01154-0001-0006) were carefully reviewed. The sub-assembly traveler lacked the required material traceability information, indicating that the R316 resistors were not replaced. In an abundance of caution RNII carefully reviewed all sub assembly travelers for part number 01154-000l-0006. No other discrepancies were found.
"The corrective action which has been taken; the name of the individual or organization responsible for that action; and the length of time taken to complete that action:
"(a) RNII verified all transmitters in production and finished goods with applicable special options utilizing 01154-0001-0006 amplifier CCA's contained the correct board and resistor. No discrepancies were found. (Complete: 7/24/2007)
"(b) RNII evaluated all 01154 CCA's in production to ensure they contained the correct resistor. No discrepancies were found. (Complete: 7/20/07)
"(c) RNII examined all manufacturing paperwork for 01154-0001-0006 amplifier CCAs built and shipped prior to 7/24/2007. No additional discrepancies were found. (Complete: 7/25/2007)
"(d) An internal corrective action request was initiated. All corrective actions will be completed by 8/15/07.
"The end user is advised to determine the impact of this potential non-conformance on its plant operations and safety and take action as deemed necessary. RNII can supply replacement 01154-0001-0006 amplifier CCAs which can be installed per section five of the product manual or the transmitter can be returned to RNII for rework. If it is determined that return of affected transmitter(s) is required, RNII should be contacted to facilitate the return process."
Plants affected: Saint Lucie (6 received) , and Waterford 3 (3 received).
The supplier provided the following information via facsimile:
Pursuant to 10 CFR Part 21, section 21.21(b) Rosemount Nuclear Instruments, Inc. [RNII] is writing to inform NRC that a total of ten (10) Model 1154 and 1154 Series H output range code 4 pressure transmitters whose model code includes special option suffix N0026 or N0079 may not calibrate at all of the published values [9 shipped to 2 utility sites in the United States].
"During evaluation of two returned Model 1154 output range code 4 pressure transmitters with special option suffix N0026, the cause of the customer-reported calibration problem was isolated to the amplifier circuit card assembly (CCA). Upon replacement of the amplifier CCAs the two affected transmitters calibrated and functioned normally.
"During root cause analysis it was observed that a single resistor (R316) on each affected amplifier CCA had an incorrect resistance value. The R316 resistor enables a standard upper range limit (URL) of a transmitter with output range code four to be increased from 150 inches water to 210 inches water in combination with a minimum span of 75 inches water. This R316 resistor allows the transmitter to achieve performance specifications, calibration ranges, and spans as indicated by the special option drawing.
"To meet site specific application requirements transmitters may be field recalibrated to different upper and lower range values and/or spans. Model 1154 and 1154 Series H transmitters with special option suffix N0026 or N0079 and amplifier CCAs whose R316 resistors were not replaced during the sub-assembly process, will have incorrect resistance values and may not calibrate to all upper and lower range values and/or spans published for the applicable special option. However, if an affected transmitter has been successfully calibrated, having the incorrect resistance value will not adversely affect transmitter performance during normal operation or accident conditions.
"The manufacturing records for the two returned Model 1154 transmitters (with amplifier CCAs with part number 01154-0001-0006) were carefully reviewed. The sub-assembly traveler lacked the required material traceability information, indicating that the R316 resistors were not replaced. In an abundance of caution RNII carefully reviewed all sub assembly travelers for part number 01154-000l-0006. No other discrepancies were found.
"The corrective action which has been taken; the name of the individual or organization responsible for that action; and the length of time taken to complete that action:
"(a) RNII verified all transmitters in production and finished goods with applicable special options utilizing 01154-0001-0006 amplifier CCA's contained the correct board and resistor. No discrepancies were found. (Complete: 7/24/2007)
"(b) RNII evaluated all 01154 CCA's in production to ensure they contained the correct resistor. No discrepancies were found. (Complete: 7/20/07)
"(c) RNII examined all manufacturing paperwork for 01154-0001-0006 amplifier CCAs built and shipped prior to 7/24/2007. No additional discrepancies were found. (Complete: 7/25/2007)
"(d) An internal corrective action request was initiated. All corrective actions will be completed by 8/15/07.
"The end user is advised to determine the impact of this potential non-conformance on its plant operations and safety and take action as deemed necessary. RNII can supply replacement 01154-0001-0006 amplifier CCAs which can be installed per section five of the product manual or the transmitter can be returned to RNII for rework. If it is determined that return of affected transmitter(s) is required, RNII should be contacted to facilitate the return process."
Plants affected: Saint Lucie (6 received) , and Waterford 3 (3 received).
Other Nuclear Material
Event Number: 43567
Rep Org: ENGINEERING CONSULTANT SERVICES
Licensee: ENGINEERING CONSULTANT SERVICES
Region: 1
City: ROANOKE State: VA
County:
License #: 45-25534-01
Agreement: N
Docket:
NRC Notified By: SETH REYNOLDS
HQ OPS Officer: JEFF ROTTON
Licensee: ENGINEERING CONSULTANT SERVICES
Region: 1
City: ROANOKE State: VA
County:
License #: 45-25534-01
Agreement: N
Docket:
NRC Notified By: SETH REYNOLDS
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/14/2007
Notification Time: 17:17 [ET]
Event Date: 08/14/2007
Event Time: 17:10 [EDT]
Last Update Date: 08/14/2007
Notification Time: 17:17 [ET]
Event Date: 08/14/2007
Event Time: 17:10 [EDT]
Last Update Date: 08/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAUL KROHN (R1)
JOSEPH HOLONICH (FSME)
PAUL KROHN (R1)
JOSEPH HOLONICH (FSME)
TROXLER MOISTURE DENSITY GAUGE DAMAGED ON CONSTRUCTION SITE
At 1710 EDT on 08/14/07, a Troxler moisture density gauge, model 3430, serial number 36254, was in use at a construction worksite on VA Route 460. A large piece of construction equipment was backing up and while the gauge technician attempted to get the vehicle driver's attention, the vehicle ran over the Troxler gauge. The 8 millicurie Cs-137 source was extended and after the damage could only be retracted to within 4 inches of the gauge case. The technician kept the extended source in the ground and controlled access to the area. The gauge technician called the NRC Operations Center for assistance.
R1DO (Paul Krohn) and FSME EO (Holonich) were notified and briefed by the licensee technician on what assistance was required. During the conference call the RSO was notified and the company was dispatching personnel to the scene to assist.
* * * UPDATE PROVIDED BY CURTIS HOWELL TO JEFF ROTTON AT 1953 EDT ON 08/14/07 * * *
The licensee was able to retract the source and close the shutter door. No significant personnel exposure was received. The area has been opened for unrestricted access.
Notified R1DO (Krohn) and FSME EO (Holonich).
At 1710 EDT on 08/14/07, a Troxler moisture density gauge, model 3430, serial number 36254, was in use at a construction worksite on VA Route 460. A large piece of construction equipment was backing up and while the gauge technician attempted to get the vehicle driver's attention, the vehicle ran over the Troxler gauge. The 8 millicurie Cs-137 source was extended and after the damage could only be retracted to within 4 inches of the gauge case. The technician kept the extended source in the ground and controlled access to the area. The gauge technician called the NRC Operations Center for assistance.
R1DO (Paul Krohn) and FSME EO (Holonich) were notified and briefed by the licensee technician on what assistance was required. During the conference call the RSO was notified and the company was dispatching personnel to the scene to assist.
* * * UPDATE PROVIDED BY CURTIS HOWELL TO JEFF ROTTON AT 1953 EDT ON 08/14/07 * * *
The licensee was able to retract the source and close the shutter door. No significant personnel exposure was received. The area has been opened for unrestricted access.
Notified R1DO (Krohn) and FSME EO (Holonich).
Hospital
Event Number: 43727
Rep Org: ONCOLOGY INSTITUTE OF GREATER LAFAY
Licensee: ONCOLOGY INSTITUTE OF GREATER LAFAYETTE
Region: 3
City: LAFAYETTE State: IN
County:
License #: 13-32087-01
Agreement: N
Docket:
NRC Notified By: PHIL DITTMER
HQ OPS Officer: JOE O'HARA
Licensee: ONCOLOGY INSTITUTE OF GREATER LAFAYETTE
Region: 3
City: LAFAYETTE State: IN
County:
License #: 13-32087-01
Agreement: N
Docket:
NRC Notified By: PHIL DITTMER
HQ OPS Officer: JOE O'HARA
Notification Date: 10/17/2007
Notification Time: 11:39 [ET]
Event Date: 08/14/2007
Event Time: 00:00 [EDT]
Last Update Date: 10/17/2007
Notification Time: 11:39 [ET]
Event Date: 08/14/2007
Event Time: 00:00 [EDT]
Last Update Date: 10/17/2007
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):
KENNETH RIEMER (R3)
GREG MORELL (FSME)
KENNETH RIEMER (R3)
GREG MORELL (FSME)
POTENTIAL MEDICAL EVENT
A patient received a series of 3 vaginal cylinder HDR treatments on 08/14/07, 08/28/07, and 09/11/07 at the Arnett Cancer Care Center [also known as the Oncology Institute of Greater Lafayette which is the name on their license]. The treatment was planned with a source spacing of 5 millimeters. The electronic transfer of source spacing from the planned console to the treatment console did not function properly and the source spacing information was entered into the treatment console manually and inadvertently a source spacing of 2.5 millimeters was used. The dose distribution was different than planned due to the spacing difference, but the overall dose was correct. The prescribed dose per fraction was 700 cGray using an Ir-192 source with 13 dwell positions spaced 5 millimeters apart.
The physician has been notified and does not believe that there will be any adverse effects to the patient. At this time the patient has not been notified, but the licensee is attempting to contact her to inform her that the overall dose was delivered differently that planned.
The licensee has taken corrective action to set the device default spacing at 5 millimeters and they will be revising their procedures to prevent reoccurrence. An inspection by the NRC Region 3 Inspector (Bob Gattone) on 10/16/07 discovered the source spacing error.
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.
A patient received a series of 3 vaginal cylinder HDR treatments on 08/14/07, 08/28/07, and 09/11/07 at the Arnett Cancer Care Center [also known as the Oncology Institute of Greater Lafayette which is the name on their license]. The treatment was planned with a source spacing of 5 millimeters. The electronic transfer of source spacing from the planned console to the treatment console did not function properly and the source spacing information was entered into the treatment console manually and inadvertently a source spacing of 2.5 millimeters was used. The dose distribution was different than planned due to the spacing difference, but the overall dose was correct. The prescribed dose per fraction was 700 cGray using an Ir-192 source with 13 dwell positions spaced 5 millimeters apart.
The physician has been notified and does not believe that there will be any adverse effects to the patient. At this time the patient has not been notified, but the licensee is attempting to contact her to inform her that the overall dose was delivered differently that planned.
The licensee has taken corrective action to set the device default spacing at 5 millimeters and they will be revising their procedures to prevent reoccurrence. An inspection by the NRC Region 3 Inspector (Bob Gattone) on 10/16/07 discovered the source spacing error.
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.
General Information or Other
Event Number: 46029
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: TETRA TECH
Region: 4
City: KANSAS CITY State: KS
County:
License #: 22-C250-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: DONG HWA PARK
Licensee: TETRA TECH
Region: 4
City: KANSAS CITY State: KS
County:
License #: 22-C250-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/18/2010
Notification Time: 17:13 [ET]
Event Date: 08/14/2007
Event Time: 00:00 [CDT]
Last Update Date: 06/18/2010
Notification Time: 17:13 [ET]
Event Date: 08/14/2007
Event Time: 00:00 [CDT]
Last Update Date: 06/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)
WILLIAM JONES (R4DO)
BRUCE WATSON (FSME)
AGREEMENT STATE REPORT - POTENTIALLY DAMAGED TROXLER
The State of Kansas provided the following information via facsimile:
"During the course of an inspection performed on 10/31/2007, it was discovered that Tetra-Tech had a gauge damaged in an accident at a temporary jobsite on 8/1/2007. The gauge was leak tested and shipped back to the manufacturer (Troxler) and refurbished and then returned to Tetra-Tech. Tetra-Tech did not notify the State of the damaged gauge and was issued a citation via the Inspection letter dated 11/15/2007. Terra-Tech responded in a letter dated 12/26/2007 and that was accompanied by several pictures of the damaged gauge. Based on the licensee's description and the photos the gauge was only superficially damaged with only a slight dent being visible on one end of the gauge. Had KDHE [Kansas Department of Health and Environment] been notified at the time of the accident on 8/14/2007 and been sent pictures, no response would have been required. The licensee understands, based on their letter, the need to communicate with KOHE regarding future incidents. No further action is required.
"This item was determined during the State of Kansas IMPEP [Integrated Materials Performance Evaluation Program] inspection conducted the week of June 14, 2010, that this event was reportable under 10CFR30.50(b)(2). An electronic update to the NMED database will follow."
KS Event No.: KS070010
The State of Kansas provided the following information via facsimile:
"During the course of an inspection performed on 10/31/2007, it was discovered that Tetra-Tech had a gauge damaged in an accident at a temporary jobsite on 8/1/2007. The gauge was leak tested and shipped back to the manufacturer (Troxler) and refurbished and then returned to Tetra-Tech. Tetra-Tech did not notify the State of the damaged gauge and was issued a citation via the Inspection letter dated 11/15/2007. Terra-Tech responded in a letter dated 12/26/2007 and that was accompanied by several pictures of the damaged gauge. Based on the licensee's description and the photos the gauge was only superficially damaged with only a slight dent being visible on one end of the gauge. Had KDHE [Kansas Department of Health and Environment] been notified at the time of the accident on 8/14/2007 and been sent pictures, no response would have been required. The licensee understands, based on their letter, the need to communicate with KOHE regarding future incidents. No further action is required.
"This item was determined during the State of Kansas IMPEP [Integrated Materials Performance Evaluation Program] inspection conducted the week of June 14, 2010, that this event was reportable under 10CFR30.50(b)(2). An electronic update to the NMED database will follow."
KS Event No.: KS070010