Event Notification Report for May 26, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/25/2010 - 05/26/2010
Power Reactor
Event Number: 45957
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ANDREW WISNIEWSKI
HQ OPS Officer: VINCE KLCO
Region: 1 State: VT
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ANDREW WISNIEWSKI
HQ OPS Officer: VINCE KLCO
Notification Date: 05/26/2010
Notification Time: 17:25 [ET]
Event Date: 05/26/2010
Event Time: 15:26 [EDT]
Last Update Date: 05/26/2010
Notification Time: 17:25 [ET]
Event Date: 05/26/2010
Event Time: 15:26 [EDT]
Last Update Date: 05/26/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES DWYER (R1DO)
JAMES DWYER (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A | Y | 72 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM WHILE INCREASING POWER
"At 1526 on 5/26/2010, while operators were increasing power with reactor recirculation flow, an RPS (Reactor Protection System) actuation occurred in both channels and all control rods inserted. RPV (Reactor Pressure Vessel) level decreased to 114.5 inches (Low level setpoint is less than 127 inches). Following the scram, the PCIS (Primary Containment Isolation System) groups 2, 3, 4 and 5 received actuation signals and all open valves isolated. Both trains of standby gas treatment system actuated.
"Plant actions taken included entering procedures OT-3100, Reactor Scram on RPS Actuation and EOP-1, RPV Control on Low Level Signal. The EOP-1 was exited per shift manager direction because of no emergency. The operators stabilized the plant and reset both RPS and PCIS. An investigation into the cause of the scram is continuing."
Electrical power is being supplied from offsite sources through the startup transformers.
The licensee notified the NRC Resident Inspector.
"At 1526 on 5/26/2010, while operators were increasing power with reactor recirculation flow, an RPS (Reactor Protection System) actuation occurred in both channels and all control rods inserted. RPV (Reactor Pressure Vessel) level decreased to 114.5 inches (Low level setpoint is less than 127 inches). Following the scram, the PCIS (Primary Containment Isolation System) groups 2, 3, 4 and 5 received actuation signals and all open valves isolated. Both trains of standby gas treatment system actuated.
"Plant actions taken included entering procedures OT-3100, Reactor Scram on RPS Actuation and EOP-1, RPV Control on Low Level Signal. The EOP-1 was exited per shift manager direction because of no emergency. The operators stabilized the plant and reset both RPS and PCIS. An investigation into the cause of the scram is continuing."
Electrical power is being supplied from offsite sources through the startup transformers.
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 46009
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: REDACTED
Region: 1
City: REDACTED State: NY
County: REDACTED
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: VINCE KLCO
Licensee: REDACTED
Region: 1
City: REDACTED State: NY
County: REDACTED
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: VINCE KLCO
Notification Date: 06/15/2010
Notification Time: 10:44 [ET]
Event Date: 05/26/2010
Event Time: 00:00 [EDT]
Last Update Date: 06/15/2010
Notification Time: 10:44 [ET]
Event Date: 05/26/2010
Event Time: 00:00 [EDT]
Last Update Date: 06/15/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)
DANIEL HOLODY (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - POTENTIAL IMPROPER RADIATION DOSE
The following information was received by facsimile:
"A misadministration involving the implantation of radioactive seeds into the prostate (permanent brachytherapy) was reported to [the New York State Department of Health] office on May 28, 2010. The patient, a 58 year old male diagnosed with prostate cancer, Gleason score of 6, PSA of 3.8, was implanted on May 26, 2010. The prescribed dose was 145 Gy, to be delivered using Iodine-125 seeds, with an activity of approximately 0.36 mCi/seed. The patient was implanted with 112 seeds. A significant number of seeds (22) were placed outside the prostate gland, inferior to the gland (5.4 cm) and in the perineum. According to the medical physicist's calculations, the implanted area of the prostate received a D90 of 140 Gy.
"The initial indication is that the misplacement is a result of misidentification of the prostate by the radiation oncologist who performed the procedure. Ultrasound and C-arm fluoroscopy systems were used to aid with positioning the seeds. It appears that the patient's colon was not properly prepared, which caused poor ultrasound imaging. In addition, a Foley catheter was not inserted into the bladder, which made bladder localization difficult. A post implant confirmatory fluoroscopic image was obtained and the radiation oncologist observed that the sources were outside of the prostate area. On May 28, 2010, a post implant CT scan was performed which confirmed the seed locations and allowed for a calculation of the DVH [Dose-Volume Histogram] to the perineum of 10.0 Gy. The medical record has been requested and will be sent out for an expert review."
New York Event Report ID No: NYDOH-10-01
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 following information was received by facsimile:
"A misadministration involving the implantation of radioactive seeds into the prostate (permanent brachytherapy) was reported to [the New York State Department of Health] office on May 28, 2010. The patient, a 58 year old male diagnosed with prostate cancer, Gleason score of 6, PSA of 3.8, was implanted on May 26, 2010. The prescribed dose was 145 Gy, to be delivered using Iodine-125 seeds, with an activity of approximately 0.36 mCi/seed. The patient was implanted with 112 seeds. A significant number of seeds (22) were placed outside the prostate gland, inferior to the gland (5.4 cm) and in the perineum. According to the medical physicist's calculations, the implanted area of the prostate received a D90 of 140 Gy.
"The initial indication is that the misplacement is a result of misidentification of the prostate by the radiation oncologist who performed the procedure. Ultrasound and C-arm fluoroscopy systems were used to aid with positioning the seeds. It appears that the patient's colon was not properly prepared, which caused poor ultrasound imaging. In addition, a Foley catheter was not inserted into the bladder, which made bladder localization difficult. A post implant confirmatory fluoroscopic image was obtained and the radiation oncologist observed that the sources were outside of the prostate area. On May 28, 2010, a post implant CT scan was performed which confirmed the seed locations and allowed for a calculation of the DVH [Dose-Volume Histogram] to the perineum of 10.0 Gy. The medical record has been requested and will be sent out for an expert review."
New York Event Report ID No: NYDOH-10-01
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.
Agreement State
Event Number: 46890
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: BED BATH AND BEYOND
Region: 1
City: PLAINVIEW State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Licensee: BED BATH AND BEYOND
Region: 1
City: PLAINVIEW State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 05/26/2010
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 05/26/2010
Event Time: 00:00 [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)
AGREEMENT STATE REPORT - POTENTIALLY DAMAGED TRITIUM SIGN
The following information was received via fax:
"Event location: 401 South Oyster Bay Road. Plainview, NY, 11803
"[On] 7/15/10, [Bed Bath and Beyond] BBB reported that Shaw Group, Inc. visited Bed Bath and Beyond to package their tritium exit signs for removal. They discovered two signs with letters that did not illuminate. Neither sign showed evidence of damage to the tubes. Both signs were packaged and secured in an electrical room. On June 15, 2010, a Shaw Representative took surveys of the floor and space where the sign was located. All results were below 1000 dpm per 100 square centimeters. Bed Bath & Beyond plans to send the damaged signs to Shield Source, Inc (SSI) and will provide a report within 30 days of the transfer of the damaged signs.
"A letter received [on] July 30, 2010, showing that the lights were returned to Shield Source, Inc. Incident is closed.
New York Event Report ID Number: NY - 11 - 07
The following information was received via fax:
"Event location: 401 South Oyster Bay Road. Plainview, NY, 11803
"[On] 7/15/10, [Bed Bath and Beyond] BBB reported that Shaw Group, Inc. visited Bed Bath and Beyond to package their tritium exit signs for removal. They discovered two signs with letters that did not illuminate. Neither sign showed evidence of damage to the tubes. Both signs were packaged and secured in an electrical room. On June 15, 2010, a Shaw Representative took surveys of the floor and space where the sign was located. All results were below 1000 dpm per 100 square centimeters. Bed Bath & Beyond plans to send the damaged signs to Shield Source, Inc (SSI) and will provide a report within 30 days of the transfer of the damaged signs.
"A letter received [on] July 30, 2010, showing that the lights were returned to Shield Source, Inc. Incident is closed.
New York Event Report ID Number: NY - 11 - 07