Event Notification Report for February 08, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/07/2011 - 02/08/2011
Agreement State
Event Number: 46602
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: REX HOSPITAL
Region: 1
City: Raleigh State: NC
County:
License #: 092-0160-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOHN SHOEMAKER
Licensee: REX HOSPITAL
Region: 1
City: Raleigh State: NC
County:
License #: 092-0160-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/08/2011
Notification Time: 13:51 [ET]
Event Date: 02/08/2011
Event Time: 00:00 [EST]
Last Update Date: 02/08/2011
Notification Time: 13:51 [ET]
Event Date: 02/08/2011
Event Time: 00:00 [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - UNDER DOSE RECEIVED DURING BRACHYTHERAPY PROCEDURE
The following information was received from the State of North Carolina via email:
"A patient undergoing a HDR [High Dose Rate] brachytherapy procedure received an under dose on three fractions.
"The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site.
"The patient has been notified and they are trying to contact the prescribing physician to notify him."
An investigation has been initiated to determine the cause of this event and corrective actions.
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 from the State of North Carolina via email:
"A patient undergoing a HDR [High Dose Rate] brachytherapy procedure received an under dose on three fractions.
"The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site.
"The patient has been notified and they are trying to contact the prescribing physician to notify him."
An investigation has been initiated to determine the cause of this event and corrective actions.
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: 46603
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAN HUNT
HQ OPS Officer: JOHN SHOEMAKER
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAN HUNT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/08/2011
Notification Time: 15:06 [ET]
Event Date: 02/08/2011
Event Time: 08:00 [CST]
Last Update Date: 02/08/2011
Notification Time: 15:06 [ET]
Event Date: 02/08/2011
Event Time: 08:00 [CST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ERIC DUNCAN (R3DO)
ERIC DUNCAN (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 97 | Power Operation | 97 | Power Operation |
UNANALYZED EVENT COULD INITIATE HIGH PRESSURE CORE SPRAY AND OVERFILL THE REACTOR PRESSURE VESSEL
"During the performance of a Fire Protection self assessment, it was discovered that a calculation for the safe shutdown analysis has an assumed action for an operator to locally depress the internal breaker trip plunger to trip the High Pressure Core Spray (HPCS) pump in response to a fire in the main control room. However, due to personnel safety concerns related to potential arc flashing events associated with this action, the remote shutdown procedure was revised to locally close the HPCS injection valve (1E22F004) in lieu of depressing the internal breaker trip plunger.
"During engineering's review of this procedure and supporting calculation, it was determined that the HPCS system could be initiated due to concurrent fire induced hot short cable damage to the two automatic initiation logic instrument cables routed in the same raceway in the area. In this event, even if the HPCS breaker could be tripped or the HPCS injection valve could be closed locally, HPCS would continue to fill the reactor pressure vessel (RPV) and flood the main steam lines. Once pressure reaches the setpoint for the Main Steam Safety Relief Valves (MSSRVs), they would lift and discharge mixed-phase water through the discharge line to the suppression pool. This conservatively postulated scenario would place the MSSRVs and their associated tailpipes in an unanalyzed condition for the stresses expected during the two-phase flow event.
"While it is not expected that a failure of the MSSRV discharge line will occur, a confirmatory analysis will be performed. Compensatory measures for Multiple Spurious Operations have been determined to be adequate until the analysis is complete."
The licensee added additional fire zone surveillance to operator plant walk downs and will investigate to determine further corrective actions.
The license has notified the NRC Senior Resident Inspector.
"During the performance of a Fire Protection self assessment, it was discovered that a calculation for the safe shutdown analysis has an assumed action for an operator to locally depress the internal breaker trip plunger to trip the High Pressure Core Spray (HPCS) pump in response to a fire in the main control room. However, due to personnel safety concerns related to potential arc flashing events associated with this action, the remote shutdown procedure was revised to locally close the HPCS injection valve (1E22F004) in lieu of depressing the internal breaker trip plunger.
"During engineering's review of this procedure and supporting calculation, it was determined that the HPCS system could be initiated due to concurrent fire induced hot short cable damage to the two automatic initiation logic instrument cables routed in the same raceway in the area. In this event, even if the HPCS breaker could be tripped or the HPCS injection valve could be closed locally, HPCS would continue to fill the reactor pressure vessel (RPV) and flood the main steam lines. Once pressure reaches the setpoint for the Main Steam Safety Relief Valves (MSSRVs), they would lift and discharge mixed-phase water through the discharge line to the suppression pool. This conservatively postulated scenario would place the MSSRVs and their associated tailpipes in an unanalyzed condition for the stresses expected during the two-phase flow event.
"While it is not expected that a failure of the MSSRV discharge line will occur, a confirmatory analysis will be performed. Compensatory measures for Multiple Spurious Operations have been determined to be adequate until the analysis is complete."
The licensee added additional fire zone surveillance to operator plant walk downs and will investigate to determine further corrective actions.
The license has notified the NRC Senior Resident Inspector.
Agreement State
Event Number: 46600
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: J LEEK ASSOCIATES, INC.
Region: 1
City: Edenton State: NC
County:
License #: 021-1612-0G
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSON
HQ OPS Officer: JOHN SHOEMAKER
Licensee: J LEEK ASSOCIATES, INC.
Region: 1
City: Edenton State: NC
County:
License #: 021-1612-0G
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/08/2011
Notification Time: 11:19 [ET]
Event Date: 02/08/2011
Event Time: 00:00 [EST]
Last Update Date: 02/08/2011
Notification Time: 11:19 [ET]
Event Date: 02/08/2011
Event Time: 00:00 [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - LOST GAS CHROMATOGRAPH SOURCE
The following information was received via facsimile:
"On December 9, 2010, North Carolina Radiation Protection Section (NCRPS) received a phone call from the Radiation Safety Officer (RSO) of J. Leek Associates, Inc. (JLA). The RSO stated that he needed to register a new Ni-63 gas chromatograph (GC) source because the old Ni-63 source had been lost. The lost source was used in a model GC-14A PSE, Shimadzu GC. The serial number of the lost source was 608335.
"NCRPS initiated an investigation and performed an inspection on December 14, 2010. The missing source could not be located during the inspection. Three violations were issued by NCRPS to JLA in a Notice of Violation (NOV) letter dated December 21, 2010. The three violations were:
"1. Loss of Ni-63, activity-10 mCi, Serial Number 608335.
"2. Failure to perform inventory every six months.
"3. Failure to perform leak test every six months.
"JLA responded to the NOV on January 20, 2011. NCRPS is currently reviewing the JLA file for escalated enforcement actions and penalty assessment. This incident has been closed."
NCRPS believes the source may have been lost in the trash and not stolen.
NCRPS Incident No.: 11-06.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was received via facsimile:
"On December 9, 2010, North Carolina Radiation Protection Section (NCRPS) received a phone call from the Radiation Safety Officer (RSO) of J. Leek Associates, Inc. (JLA). The RSO stated that he needed to register a new Ni-63 gas chromatograph (GC) source because the old Ni-63 source had been lost. The lost source was used in a model GC-14A PSE, Shimadzu GC. The serial number of the lost source was 608335.
"NCRPS initiated an investigation and performed an inspection on December 14, 2010. The missing source could not be located during the inspection. Three violations were issued by NCRPS to JLA in a Notice of Violation (NOV) letter dated December 21, 2010. The three violations were:
"1. Loss of Ni-63, activity-10 mCi, Serial Number 608335.
"2. Failure to perform inventory every six months.
"3. Failure to perform leak test every six months.
"JLA responded to the NOV on January 20, 2011. NCRPS is currently reviewing the JLA file for escalated enforcement actions and penalty assessment. This incident has been closed."
NCRPS believes the source may have been lost in the trash and not stolen.
NCRPS Incident No.: 11-06.
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf