Event Notification Report for December 04, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/03/2010 - 12/04/2010
EVENT NUMBERS
46460464554645647819
Hospital
Event Number: 46460
Rep Org: OAKWOOD ANNAPOLIS HOSPITAL
Licensee: OAKWOOD ANNAPOLIS HOSPITAL
Region: 3
City: WAYNE State: MI
County:
License #: 21-11457-02
Agreement: N
Docket:
NRC Notified By: PIYUSH PANDYA
HQ OPS Officer: VINCE KLCO
Licensee: OAKWOOD ANNAPOLIS HOSPITAL
Region: 3
City: WAYNE State: MI
County:
License #: 21-11457-02
Agreement: N
Docket:
NRC Notified By: PIYUSH PANDYA
HQ OPS Officer: VINCE KLCO
Notification Date: 12/06/2010
Notification Time: 14:49 [ET]
Event Date: 12/04/2010
Event Time: 10:30 [EST]
Last Update Date: 12/06/2010
Notification Time: 14:49 [ET]
Event Date: 12/04/2010
Event Time: 10:30 [EST]
Last Update Date: 12/06/2010
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):
ROBERT DALEY (R3DO)
ANGELA MCINTOSH (FSME)
ROBERT DALEY (R3DO)
ANGELA MCINTOSH (FSME)
DELIVERED DOSE GREATER THAN PRESCRIBED DOSE
"A patient was scheduled for a Tc-99m Myoview diagnostic cardiac resting perfusion study on 12/04/2010. Prescribed dosage was 10 mCi as noted on the departmental Prescribed Dosage List. These dosages are delivered as unit dose quantities along with Tc-99m in bulk quantity.
"Technetium-99m was delivered in bulk quantity in a syringe at approximately 0600 [EST] as 150 mCi calibrated for 1200 [EST]. At approximately 0900 [EST] a MAA kit was made by withdrawing 64 mCi from the bulk allotment.
"The nuclear medicine technologist inadvertently picked up the syringe at approximately 1030 [EST] containing Tc-99m as pertechnetate in bulk quantity (124.5 mCi) and without confirmatory assay in the dose calibrator injected the patient.
"As per 10 CFR 35.3045 (a)(1), the dose delivered differs from the prescribed dose by greater than 5 rem effective dose equivalent (EDE). However the upper large intestine (ULI) dose does not differ by more than 50 rads from the dose to be delivered from the prescribed dosage as follows:
Prescribed Dosage (10 mCi) EDE: 0.481 rem
Administered Dosage (31.4 mCi) EDE: 5.988 rem (Difference = 5.507 rem)
ULI Dose from Prescribed Dosage (10 mCi) 2.109 rads
ULI Dose From Administered Dosage (124.5 mCi) 26.257 rads (Difference = 24.148 rads)
"As per 10 CFR 35.3045 (a)(1)(ii), the administered dosage (124.5 mCi) differs from the prescribed dosage (10 mCi) by greater than the limit of 20%."
The physician determined there was no adverse impact on the patient.
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 was scheduled for a Tc-99m Myoview diagnostic cardiac resting perfusion study on 12/04/2010. Prescribed dosage was 10 mCi as noted on the departmental Prescribed Dosage List. These dosages are delivered as unit dose quantities along with Tc-99m in bulk quantity.
"Technetium-99m was delivered in bulk quantity in a syringe at approximately 0600 [EST] as 150 mCi calibrated for 1200 [EST]. At approximately 0900 [EST] a MAA kit was made by withdrawing 64 mCi from the bulk allotment.
"The nuclear medicine technologist inadvertently picked up the syringe at approximately 1030 [EST] containing Tc-99m as pertechnetate in bulk quantity (124.5 mCi) and without confirmatory assay in the dose calibrator injected the patient.
"As per 10 CFR 35.3045 (a)(1), the dose delivered differs from the prescribed dose by greater than 5 rem effective dose equivalent (EDE). However the upper large intestine (ULI) dose does not differ by more than 50 rads from the dose to be delivered from the prescribed dosage as follows:
Prescribed Dosage (10 mCi) EDE: 0.481 rem
Administered Dosage (31.4 mCi) EDE: 5.988 rem (Difference = 5.507 rem)
ULI Dose from Prescribed Dosage (10 mCi) 2.109 rads
ULI Dose From Administered Dosage (124.5 mCi) 26.257 rads (Difference = 24.148 rads)
"As per 10 CFR 35.3045 (a)(1)(ii), the administered dosage (124.5 mCi) differs from the prescribed dosage (10 mCi) by greater than the limit of 20%."
The physician determined there was no adverse impact on the patient.
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.
Power Reactor
Event Number: 46455
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: CHRIS SMOLINSKI
HQ OPS Officer: BILL HUFFMAN
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: CHRIS SMOLINSKI
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/04/2010
Notification Time: 14:13 [ET]
Event Date: 12/04/2010
Event Time: 11:28 [EST]
Last Update Date: 12/04/2010
Notification Time: 14:13 [ET]
Event Date: 12/04/2010
Event Time: 11:28 [EST]
Last Update Date: 12/04/2010
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):
WAYNE SCHMIDT (R1DO)
WAYNE SCHMIDT (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 |
TONE ALERT EMERGENCY NOTIFICATION SYSTEM INOPERABLE
"At 1142 (EST) on December 4, 2010, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1028 (EST).
"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).
"The County Alert Sirens which also function as part of the Public Prompt Notification System remain operable.
"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.
"The event has been entered into the corrective action program and the resident inspector has been briefed .
"At 1258 (EST) on December 4, 2010, Oswego County Emergency Management notified JAF that the Tone Alert Radio System has been restored effective at 1255 (EST) ."
"At 1142 (EST) on December 4, 2010, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1028 (EST).
"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).
"The County Alert Sirens which also function as part of the Public Prompt Notification System remain operable.
"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.
"The event has been entered into the corrective action program and the resident inspector has been briefed .
"At 1258 (EST) on December 4, 2010, Oswego County Emergency Management notified JAF that the Tone Alert Radio System has been restored effective at 1255 (EST) ."
Power Reactor
Event Number: 46456
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JIM VAUGHN
HQ OPS Officer: VINCE KLCO
Region: 1 State: NY
Unit: [1] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JIM VAUGHN
HQ OPS Officer: VINCE KLCO
Notification Date: 12/04/2010
Notification Time: 14:37 [ET]
Event Date: 12/04/2010
Event Time: 11:42 [EST]
Last Update Date: 12/04/2010
Notification Time: 14:37 [ET]
Event Date: 12/04/2010
Event Time: 11:42 [EST]
Last Update Date: 12/04/2010
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):
WAYNE SCHMIDT (R1DO)
WAYNE SCHMIDT (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 |
TONE ALERT EMERGENCY NOTIFICATION SYSTEM INOPERABLE
"On Saturday, December 04, 2010 at 1142 [EST], the NYS Warning Point informed NMP [Nine Mile Point] via the RECS [Radiological Emergency Communications System] line that the EAS/Tone system was out of service for greater than one hour as of 1128 [EST].
"10CFR 50.72(b)(3)(xiii) requires reporting within 8 hours when a significant portion of the emergency communications system has been lost. Site Emergency Procedures define a loss of EAS/Tone for greater than 1 hour as a significant loss of emergency communications.
"The EAS/Tone Alert system was returned to service on December 4, 2010 at 1255 [EST].
"The event has been entered into the corrective action program,"
The licensee notified the NRC Resident Inspector.
"On Saturday, December 04, 2010 at 1142 [EST], the NYS Warning Point informed NMP [Nine Mile Point] via the RECS [Radiological Emergency Communications System] line that the EAS/Tone system was out of service for greater than one hour as of 1128 [EST].
"10CFR 50.72(b)(3)(xiii) requires reporting within 8 hours when a significant portion of the emergency communications system has been lost. Site Emergency Procedures define a loss of EAS/Tone for greater than 1 hour as a significant loss of emergency communications.
"The EAS/Tone Alert system was returned to service on December 4, 2010 at 1255 [EST].
"The event has been entered into the corrective action program,"
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 47819
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID BROOKINS
HQ OPS Officer: CHARLES TEAL
Region: 2 State: FL
Unit: [3] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID BROOKINS
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/10/2012
Notification Time: 12:42 [ET]
Event Date: 12/04/2010
Event Time: 00:00 [EDT]
Last Update Date: 04/10/2012
Notification Time: 12:42 [ET]
Event Date: 12/04/2010
Event Time: 00:00 [EDT]
Last Update Date: 04/10/2012
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):
KATHLEEN O'DONOHUE (R2DO)
KATHLEEN O'DONOHUE (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Refueling | 0 | Refueling |
| 4 | N | Y | 100 | Power Operation | 100 | Power Operation |
HABITABILITY REQUIREMENT NOT MET DUE TO MAINTENANCE ON THE TSC
"Portions of the Turkey Point Technical Support Center (TSC) Heating Ventilation and Air Conditioning System (HVAC) were deenergized for maintenance for the periods of 12/4/10 to 7/13/11 and 10/10/11 to 10/28/11 (prior Event Notification 47387, made on 10/28/11, for the 10/10-28/11 period was retracted by FPL on 12/14/11).
"For the period 10/10/11 to 10/28/11, an Equipment Clearance Order (ECO) deenergized the TSC HVAC dampers in the non-emergency position while the ECO was in effect. The ECO was put into effect on 10/10/11. The ECO was released at 1630 [EDT] on 10/28/2011 and functionally tested restoring TSC ventilation recirculation capability.
"For the period 12/4/10 to 7/13/11, a similar ECO deenergized all but one of the TSC HVAC dampers in the non-emergency position while the ECO was in effect. The normal air inlet damper was stuck in the closed (emergency) position during this period. The ECO was put into effect on 12/4/10 and released on 7/13/11.
"Compensatory measures were not put into effect during either period that the TSC HVAC dampers were deenergized. Accordingly, FPL [Florida Power and Light] cannot conclude that the TSC would have remained continuously habitable for 30 days under every postulated design basis accident scenario as required by NRC standards. However, the alternate Turkey Point TSC remained available at all times."
The licensee has notified the NRC Resident Inspector.
"Portions of the Turkey Point Technical Support Center (TSC) Heating Ventilation and Air Conditioning System (HVAC) were deenergized for maintenance for the periods of 12/4/10 to 7/13/11 and 10/10/11 to 10/28/11 (prior Event Notification 47387, made on 10/28/11, for the 10/10-28/11 period was retracted by FPL on 12/14/11).
"For the period 10/10/11 to 10/28/11, an Equipment Clearance Order (ECO) deenergized the TSC HVAC dampers in the non-emergency position while the ECO was in effect. The ECO was put into effect on 10/10/11. The ECO was released at 1630 [EDT] on 10/28/2011 and functionally tested restoring TSC ventilation recirculation capability.
"For the period 12/4/10 to 7/13/11, a similar ECO deenergized all but one of the TSC HVAC dampers in the non-emergency position while the ECO was in effect. The normal air inlet damper was stuck in the closed (emergency) position during this period. The ECO was put into effect on 12/4/10 and released on 7/13/11.
"Compensatory measures were not put into effect during either period that the TSC HVAC dampers were deenergized. Accordingly, FPL [Florida Power and Light] cannot conclude that the TSC would have remained continuously habitable for 30 days under every postulated design basis accident scenario as required by NRC standards. However, the alternate Turkey Point TSC remained available at all times."
The licensee has notified the NRC Resident Inspector.