Event Notification Report for September 08, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/07/2010 - 09/08/2010
Power Reactor
Event Number: 46234
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: MI
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/08/2010
Notification Time: 11:00 [ET]
Event Date: 09/08/2010
Event Time: 07:47 [EDT]
Last Update Date: 09/08/2010
Notification Time: 11:00 [ET]
Event Date: 09/08/2010
Event Time: 07:47 [EDT]
Last Update Date: 09/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTINE LIPA (R3DO)
CHRISTINE LIPA (R3DO)
| 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 |
OFFSITE NOTIFICATION DUE TO BODY DISCOVERED IN THE OWNER CONTROLLED AREA
"At 0747 hours on September 8, 2010, a body was discovered on the beach along the Owner Controlled Area at the Cook Nuclear Plant.
"Local law enforcement agencies have been notified. It is expected that a press release will be issued from local law enforcement.
"The NRC Senior Resident Inspector was notified. Plant operation was not impacted by the event. The fatality did not occur on site.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies and expected media involvement related to the discovery."
Although unconfirmed, the licensee believes that the body belongs to a person that went missing on the lake last week. The licensee notified Lake Township, Berrien County Sheriffs Office, Federal Bureau of Investigation and the U.S. Coast Guard. Either Berrien County or Lake Township will be issuing a press release.
"At 0747 hours on September 8, 2010, a body was discovered on the beach along the Owner Controlled Area at the Cook Nuclear Plant.
"Local law enforcement agencies have been notified. It is expected that a press release will be issued from local law enforcement.
"The NRC Senior Resident Inspector was notified. Plant operation was not impacted by the event. The fatality did not occur on site.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies and expected media involvement related to the discovery."
Although unconfirmed, the licensee believes that the body belongs to a person that went missing on the lake last week. The licensee notified Lake Township, Berrien County Sheriffs Office, Federal Bureau of Investigation and the U.S. Coast Guard. Either Berrien County or Lake Township will be issuing a press release.
Power Reactor
Event Number: 46235
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: EDWARD NIELSEN
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: FL
Unit: [] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: EDWARD NIELSEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/08/2010
Notification Time: 15:52 [ET]
Event Date: 09/08/2010
Event Time: 13:45 [EDT]
Last Update Date: 09/08/2010
Notification Time: 15:52 [ET]
Event Date: 09/08/2010
Event Time: 13:45 [EDT]
Last Update Date: 09/08/2010
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):
ROBERT HAAG (R2DO)
ROBERT HAAG (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 4 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DURING MAINTENANCE ON A REACTOR PROTECTION SYSTEM RELAY
"At 1345 [EDT] on 9/8/10, Turkey Point Unit 4 automatically tripped during the repair of a failed Turbine Stop Valve Relay which inputs into the Reactor Protection System. During the replacement of this relay, the logic condition was met causing a Reactor Trip and Turbine Trip.
"At the time of the trip, reactor power was 100%. Auxiliary Feedwater was automatically initiated when Steam Generator levels lowered below the actuation setpoint. Steam Generator levels are now stable at their normal band and Auxiliary Feedwater is now secured.
"Additionally, the Source Range Detectors did not automatically energize and were manually energized and are operating correctly.
"Unit 4 has been stabilized in Mode 3 on normal off-site power. This event is reportable per 10CFR50.72(b)(2)(iv)(B) - actuation of the Reactor Protection System with the reactor critical and 10CFR50.72(b)(3)(iv)(A) - valid actuation of an ESF system (AFW)."
The trip was characterized as uncomplicated. All rods fully inserted. No relief valves lifted during the transient. Normal feedwater has been re-established to the steam generators and decay heat is being removed via the turbine bypass valves to the condenser. The unit is in a normal shutdown electrical lineup. There was no impact on Unit 3.
The license has notified the NRC Resident Inspector.
"At 1345 [EDT] on 9/8/10, Turkey Point Unit 4 automatically tripped during the repair of a failed Turbine Stop Valve Relay which inputs into the Reactor Protection System. During the replacement of this relay, the logic condition was met causing a Reactor Trip and Turbine Trip.
"At the time of the trip, reactor power was 100%. Auxiliary Feedwater was automatically initiated when Steam Generator levels lowered below the actuation setpoint. Steam Generator levels are now stable at their normal band and Auxiliary Feedwater is now secured.
"Additionally, the Source Range Detectors did not automatically energize and were manually energized and are operating correctly.
"Unit 4 has been stabilized in Mode 3 on normal off-site power. This event is reportable per 10CFR50.72(b)(2)(iv)(B) - actuation of the Reactor Protection System with the reactor critical and 10CFR50.72(b)(3)(iv)(A) - valid actuation of an ESF system (AFW)."
The trip was characterized as uncomplicated. All rods fully inserted. No relief valves lifted during the transient. Normal feedwater has been re-established to the steam generators and decay heat is being removed via the turbine bypass valves to the condenser. The unit is in a normal shutdown electrical lineup. There was no impact on Unit 3.
The license has notified the NRC Resident Inspector.
Hospital
Event Number: 46236
Rep Org: VA MEDICAL CENTER JACKSON
Licensee: DEPARTMENT OF VETERAN AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS E. HUSTON
HQ OPS Officer: VINCE KLCO
Licensee: DEPARTMENT OF VETERAN AFFAIRS
Region: 4
City: JACKSON State: MS
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: THOMAS E. HUSTON
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2010
Notification Time: 14:00 [ET]
Event Date: 09/08/2010
Event Time: 00:00 [CDT]
Last Update Date: 09/09/2010
Notification Time: 14:00 [ET]
Event Date: 09/08/2010
Event Time: 00:00 [CDT]
Last Update Date: 09/09/2010
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):
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)
CHRISTINE LIPA (R3DO)
ANGELA MCINTOSH (FSME)
MEDICAL DOSE DIFFERENT THAN PRESCRIBED DOSE
The following information was received by e-mail from a program manager with the U.S. Department of Veterans Affairs, Veterans Health Administration (VHA), National Health Physics Program (NHPP):
" [The VHA is] notifying the NRC of 11 medical events at G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi. These medical events occurred for Iodine-125 permanent prostate seed implant brachytherapy.
"As historical information, 10 medical events were reported to NRC on earlier dates for prostate seed implants at this medical center under NRC Event Report No. 44522.
"Following up on those medical event reports, VHA initiated a comprehensive external review and reanalysis of post-treatment dose parameters for all prostate seed implants performed at the medical center.
"Upon evaluation of updated dose information generated by the external review, medical center staff, working with NHPP, discovered on September 8, 2010, that 11 additional medical events need to be reported.
"10 of the 11 events were based on updated D90 values (considered to be final values) for the planned treatment site being 80% or less than the prescribed dose. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(1)(i).
"1 of the 11 events was based on absorbed dose to a tissue other than the treatment site exceeding the expected dose by 50% or more. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(3).
"As additional information, medical center staff, working with NHPP, has determined that 4 of the 10 previously reported medical events under NRC Event Number 44522 could be retracted because updated D90 values (considered to be final values) from the external review are above 80% of the prescribed dose. If retraction of these 4 events is pursued, NHPP will discuss the dose information with NRC Region III prior to notifying the NRC Operations Center of the retractions.
"NHPP will ensure that the medical center follows NRC requirements for notification of the referring physician and patient for these medical events. The patients involved in the medical events have been tracked by the medical center and the clinical outcomes for the patients have been verified to be consistent with expected clinical outcomes for successful prostate seed implants.
"A 15-day written report of these medical events will be submitted to NRC Region III.
"[The VHA] will notify the NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events.
"In summary, [VHA is] confirming a total of 17 medical events for the medical center. 11 medical events are reported today (10 based on a low dose to treatment site; 1 based on elevated dose to other organs and tissues). 6 medical events were reported previously under NRC Event No. 44522. 4 of the 10 medical events previously reported under NRC Event No. 44522 no longer meet criteria as medical events and might later be retracted.
"Additional Information:
"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.
"Address of permittee involved in this event: G.V. (Sonny) Montgomery VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.
"VHA permit number of permittee involved in event: Permit No. 23-08786-01."
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 e-mail from a program manager with the U.S. Department of Veterans Affairs, Veterans Health Administration (VHA), National Health Physics Program (NHPP):
" [The VHA is] notifying the NRC of 11 medical events at G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi. These medical events occurred for Iodine-125 permanent prostate seed implant brachytherapy.
"As historical information, 10 medical events were reported to NRC on earlier dates for prostate seed implants at this medical center under NRC Event Report No. 44522.
"Following up on those medical event reports, VHA initiated a comprehensive external review and reanalysis of post-treatment dose parameters for all prostate seed implants performed at the medical center.
"Upon evaluation of updated dose information generated by the external review, medical center staff, working with NHPP, discovered on September 8, 2010, that 11 additional medical events need to be reported.
"10 of the 11 events were based on updated D90 values (considered to be final values) for the planned treatment site being 80% or less than the prescribed dose. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(1)(i).
"1 of the 11 events was based on absorbed dose to a tissue other than the treatment site exceeding the expected dose by 50% or more. This circumstance is interpreted as meeting the definition of a medical event per 10 CFR 35.3045(a)(3).
"As additional information, medical center staff, working with NHPP, has determined that 4 of the 10 previously reported medical events under NRC Event Number 44522 could be retracted because updated D90 values (considered to be final values) from the external review are above 80% of the prescribed dose. If retraction of these 4 events is pursued, NHPP will discuss the dose information with NRC Region III prior to notifying the NRC Operations Center of the retractions.
"NHPP will ensure that the medical center follows NRC requirements for notification of the referring physician and patient for these medical events. The patients involved in the medical events have been tracked by the medical center and the clinical outcomes for the patients have been verified to be consistent with expected clinical outcomes for successful prostate seed implants.
"A 15-day written report of these medical events will be submitted to NRC Region III.
"[The VHA] will notify the NRC Project Manager, Cassandra Frazier (NRC Region III), of these medical events.
"In summary, [VHA is] confirming a total of 17 medical events for the medical center. 11 medical events are reported today (10 based on a low dose to treatment site; 1 based on elevated dose to other organs and tissues). 6 medical events were reported previously under NRC Event No. 44522. 4 of the 10 medical events previously reported under NRC Event No. 44522 no longer meet criteria as medical events and might later be retracted.
"Additional Information:
"Department of Veterans Affairs has a Master Materials License (MML) from the NRC: License No. 03-23853-01VA. Permits are issued under the MML to VA facilities. The VA submits reports to the NRC through the VHA's National Health Physics Program office located in North Little Rock, AR.
"Address of permittee involved in this event: G.V. (Sonny) Montgomery VA Medical Center, 1500 East Woodrow Wilson Drive, Jackson, Mississippi 39216.
"VHA permit number of permittee involved in event: Permit No. 23-08786-01."
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.