Event Notification Report for September 27, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/26/2010 - 09/27/2010
EVENT NUMBERS
46286462844628146282
General Information or Other
Event Number: 46286
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: OH02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: ERIC SIMPSON
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: OH02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/28/2010
Notification Time: 15:01 [ET]
Event Date: 09/27/2010
Event Time: 00:00 [EDT]
Last Update Date: 11/09/2010
Notification Time: 15:01 [ET]
Event Date: 09/27/2010
Event Time: 00:00 [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STEVE ORTH (R3DO)
KEVIN HSUEH (FSME)
STEVE ORTH (R3DO)
KEVIN HSUEH (FSME)
OHIO AGREEMENT STATE REPORT - 95% MEDICAL UNDERDOSAGE DUE TO EQUIPMENT FAILURE
The following report was received from the State of Ohio via email:
"On September 27, 2010, the Gamma Knife gave a Fatal Error and terminated treatment to a patient. The error appears to be a failed computer disc drive. The safety system of the Gamma Knife functioned as designed, moving the patient out of the treatment machine and closing the Gamma Knife doors. The patient was safely removed from the treatment room. A service representative was immediately contacted and repair of the Gamma Knife is in progress.
"It is intended to give the remaining dose from the plan to the patient once the Gamma Knife is repaired."
The device in question is a Leksell, Model Perfexion Gamma Knife unit [S/N MV010], which contains a 13,824 Ci Co-60 source. The intended dose was 1400 rad. The delivered dose was 71.5 rad. The target organ was the brain. There is no effect on the patient.
Ohio report #: OH100021.
* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *
"On 11/9/10 the problem was diagnosed as faulty computer on unit. Computer was replaced and fully tested on 9/28/10. Patient remained in hospital overnight on 9/27/10 and received remainder of treatment on 9/28/10. No adverse effects anticipated due to delay in completing treatment. Licensee has contacted the manufacturer to review this incident for applicability to other units."
Ohio Item Number 100021
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 report was received from the State of Ohio via email:
"On September 27, 2010, the Gamma Knife gave a Fatal Error and terminated treatment to a patient. The error appears to be a failed computer disc drive. The safety system of the Gamma Knife functioned as designed, moving the patient out of the treatment machine and closing the Gamma Knife doors. The patient was safely removed from the treatment room. A service representative was immediately contacted and repair of the Gamma Knife is in progress.
"It is intended to give the remaining dose from the plan to the patient once the Gamma Knife is repaired."
The device in question is a Leksell, Model Perfexion Gamma Knife unit [S/N MV010], which contains a 13,824 Ci Co-60 source. The intended dose was 1400 rad. The delivered dose was 71.5 rad. The target organ was the brain. There is no effect on the patient.
Ohio report #: OH100021.
* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *
"On 11/9/10 the problem was diagnosed as faulty computer on unit. Computer was replaced and fully tested on 9/28/10. Patient remained in hospital overnight on 9/27/10 and received remainder of treatment on 9/28/10. No adverse effects anticipated due to delay in completing treatment. Licensee has contacted the manufacturer to review this incident for applicability to other units."
Ohio Item Number 100021
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: 46284
Facility: NUCLEAR FUEL SERVICES INC.
Region: 2 State: TN
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: JOHN KNOKE
Region: 2 State: TN
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
NAVAL REACTOR FUEL CYCLE
LEU SCRAP RECOVERY
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/28/2010
Notification Time: 12:50 [ET]
Event Date: 09/27/2010
Event Time: 13:41 [EDT]
Last Update Date: 09/28/2010
Notification Time: 12:50 [ET]
Event Date: 09/27/2010
Event Time: 13:41 [EDT]
Last Update Date: 09/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
MARK LESSER (R2DO)
JAMES RUBENSTONE (NMSS)
FUELS GROUP Email
MARK LESSER (R2DO)
JAMES RUBENSTONE (NMSS)
FUELS GROUP Email
UNUSUAL BUILDUP OF MATERIAL IN ALUMINUM CENTRIFUGE AREA
"During the unloading of centrifuges in the Building 333 U-Aluminum centrifuge area, a crusty buildup of material (~1/8" thick) was observed on the inside of the centrifuge 'jacket' that contains the centrifuge bowl. The buildup was also observed on the underside of the centrifuge lid ('cake pan'). This level of material buildup was unusual and had not been previously observed. It should be noted that some dusting or spattering had been previously observed. The system is designed with drains on the bottom that are designed to prevent the accumulation of liquid within the centrifuge 'jacket'. There is also a requirement to inspect the 'jacket' when solution is observed draining from the overflows. This was considered an unanalyzed or improperly analyzed condition because the mechanism for buildup of this extent was not considered in the safety analysis (i.e. there was no indication of buildup provided by the overflows).
"The following corrective actions were taken: 1) operations in the affected area were suspended; 2) the area was posted to maintain the integrity of the as-found conditions; 3) the area was inspected by safety personnel; 4) the issue was entered into the internal Problem Identification, Resolution, and Correction System (PIRCS); 5) an Unusual Incident Evaluation was performed; 6) calculations were performed with bounding conditions; 7) photographs were taken of the equipment; 8) the system was scanned to determine U-235 mass (~46 grams U-235); 9) material samples were taken and delivered to the laboratory for analysis; and 10) an investigation has been initiated."
There were no control or control system failures. There were no actual or potential safety consequences to workers, the public, or the environment. No degradations or failures have been identified. The system is currently in a safe and stable condition. An investigation has been initiated.
The licensee has notified the NRC Resident Inspector.
"During the unloading of centrifuges in the Building 333 U-Aluminum centrifuge area, a crusty buildup of material (~1/8" thick) was observed on the inside of the centrifuge 'jacket' that contains the centrifuge bowl. The buildup was also observed on the underside of the centrifuge lid ('cake pan'). This level of material buildup was unusual and had not been previously observed. It should be noted that some dusting or spattering had been previously observed. The system is designed with drains on the bottom that are designed to prevent the accumulation of liquid within the centrifuge 'jacket'. There is also a requirement to inspect the 'jacket' when solution is observed draining from the overflows. This was considered an unanalyzed or improperly analyzed condition because the mechanism for buildup of this extent was not considered in the safety analysis (i.e. there was no indication of buildup provided by the overflows).
"The following corrective actions were taken: 1) operations in the affected area were suspended; 2) the area was posted to maintain the integrity of the as-found conditions; 3) the area was inspected by safety personnel; 4) the issue was entered into the internal Problem Identification, Resolution, and Correction System (PIRCS); 5) an Unusual Incident Evaluation was performed; 6) calculations were performed with bounding conditions; 7) photographs were taken of the equipment; 8) the system was scanned to determine U-235 mass (~46 grams U-235); 9) material samples were taken and delivered to the laboratory for analysis; and 10) an investigation has been initiated."
There were no control or control system failures. There were no actual or potential safety consequences to workers, the public, or the environment. No degradations or failures have been identified. The system is currently in a safe and stable condition. An investigation has been initiated.
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 46281
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: ERIC SIMPSON
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/27/2010
Notification Time: 12:23 [ET]
Event Date: 09/27/2010
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2010
Notification Time: 12:23 [ET]
Event Date: 09/27/2010
Event Time: 00:00 [EDT]
Last Update Date: 09/27/2010
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):
MEL GRAY (R1DO)
MEL GRAY (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
OFFSITE NOTIFICATION - LOSS OF ONE EMERGENCY RESPONSE SIREN
"One of the 37 Prompt Notification System sirens surrounding the James A. FitzPatrick (JAF) /Nine Mile Point (NMP) sites spuriously activated at 0848 for a period of 3-5 minutes. This has been confirmed by siren report back system software and siren repair personnel. A member of the public called to report the activation to the Oswego County 911 Dispatch Center. The Dispatch Center notified Oswego County Emergency Management Office. County personnel took action to cancel the activation using the remote activation control system, notified the licensee emergency preparedness personnel, and dispatched a siren repair crew. Siren repair personnel have isolated the siren and are troubleshooting to determine the cause. No press releases are currently planned by either Oswego County or the licensees."
The licensee notified the NRC Resident Inspector.
"One of the 37 Prompt Notification System sirens surrounding the James A. FitzPatrick (JAF) /Nine Mile Point (NMP) sites spuriously activated at 0848 for a period of 3-5 minutes. This has been confirmed by siren report back system software and siren repair personnel. A member of the public called to report the activation to the Oswego County 911 Dispatch Center. The Dispatch Center notified Oswego County Emergency Management Office. County personnel took action to cancel the activation using the remote activation control system, notified the licensee emergency preparedness personnel, and dispatched a siren repair crew. Siren repair personnel have isolated the siren and are troubleshooting to determine the cause. No press releases are currently planned by either Oswego County or the licensees."
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 46282
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: BENJAMIN GEISS
HQ OPS Officer: ERIC SIMPSON
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: BENJAMIN GEISS
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/27/2010
Notification Time: 12:24 [ET]
Event Date: 09/27/2010
Event Time: 08:48 [EDT]
Last Update Date: 09/27/2010
Notification Time: 12:24 [ET]
Event Date: 09/27/2010
Event Time: 08:48 [EDT]
Last Update Date: 09/27/2010
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):
MEL GRAY (R1DO)
MEL GRAY (R1DO)
| 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 - LOSS OF ONE EMERGENCY RESPONSE SIREN
"One of the 37 Prompt Notification System sirens surrounding the James A. FitzPatrick (JAF) /Nine Mile Point (NMP) sites spuriously activated at 0848 for a period of 3-5 minutes. This has been confirmed by siren report back system software and siren repair personnel. A member of the public called to report the activation to the Oswego County 911 Dispatch Center. The Dispatch Center notified Oswego County Emergency Management Office. County personnel took action to cancel the activation using the remote activation control system, notified the Licensee Emergency Preparedness personnel, and dispatched a siren repair crew. Siren repair personnel have isolated the siren and are performing troubleshooting to determine the cause. No press releases are currently planned by either Oswego County or the licensees."
The licensee notified the NRC Resident Inspector.
"One of the 37 Prompt Notification System sirens surrounding the James A. FitzPatrick (JAF) /Nine Mile Point (NMP) sites spuriously activated at 0848 for a period of 3-5 minutes. This has been confirmed by siren report back system software and siren repair personnel. A member of the public called to report the activation to the Oswego County 911 Dispatch Center. The Dispatch Center notified Oswego County Emergency Management Office. County personnel took action to cancel the activation using the remote activation control system, notified the Licensee Emergency Preparedness personnel, and dispatched a siren repair crew. Siren repair personnel have isolated the siren and are performing troubleshooting to determine the cause. No press releases are currently planned by either Oswego County or the licensees."
The licensee notified the NRC Resident Inspector.