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Event Notification Report for August 09, 2011

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
08/08/2011 - 08/09/2011

EVENT NUMBERS
471374715849079

Power Reactor
Event Number: 47137
Facility: GINNA
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: REX REISSNER
HQ OPS Officer: VINCE KLCO
Notification Date: 08/09/2011
Notification Time: 16:25 [ET]
Event Date: 08/09/2011
Event Time: 12:30 [EDT]
Last Update Date: 08/09/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RAY POWELL (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation
Event Text
INADVERTENT ACTUATION OF AN EMERGENCY SIREN

"[There was an] inadvertent actuation of siren 46 due to water intrusion into the control box. The door was knocked open by a falling tree branch. Power to the siren has been isolated to prevent re-occurrence. Repair is scheduled for August 10, 2011"

The licensee notified both Wayne and Monroe counties and the NRC Resident Inspector.


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 47158
Rep Org: CHRISTIANA CARE
Licensee: CHRISTIANA CARE
Region: 1
City: NEWARK   State: DE
County:
License #: 0712153-02
Agreement: N
Docket:
NRC Notified By: JOSEPH SOLGE
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/16/2011
Notification Time: 14:47 [ET]
Event Date: 08/09/2011
Event Time: 00:00 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)
Event Text
DOSE DIFFERENT THAN PRESCRIBED

A patient was scheduled to receive three separate treatments for pancreatic cancer containing Yttrium-90. Each dose was to contain 10.5 milliCuries of Yttrium-90 for a total of 31.5 milliCuries. Cardinal Health (the producer of the treatment) provided the entire dose of 31.5 milliCurie in a single syringe. The physician verified the receipt of the syringe and administered it to the patient.

When the patient was scheduled to return on 8/16/11 for the second treatment Cardinal Health realized that they had provided the entire dose instead of three separate doses of 10.5 milliCuries. Cardinal Health notified Christiana Care of the error.

The treating physician and patient have been notified. No adverse health effects are expected.

* * * RETRACTION FROM JOESPH SOLGE TO JOHN SHOEMAKER AT 1009 EDT ON 11/01/11 * * *

The original directive was correct in regard to the dose administered, therefore this event is being retracted.

Notified the R1DO (Perry) and FSME (McIntosh).

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.


Non-Agreement State
Event Number: 49079
Rep Org: CLIFF'S NATURAL RESOURCES
Licensee: CLIFF'S NATURAL RESOURCES
Region: 3
City: ISHPEMING   State: MI
County:
License #: 21-26748-01
Agreement: N
Docket:
NRC Notified By: JEREMY LAAKSO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/30/2013
Notification Time: 06:49 [ET]
Event Date: 08/09/2011
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
STEVE ORTH (R3DO)
FSME EVENTS RESOURCE (E-MA)
Event Text
PROCESS GAUGE SHUTTER WILL NOT CLOSE

The shutter on a process gauge used to measure iron ore density was discovered to be stuck open on 08/09/11 during a routine 6-month check. The gauge is in a remote location which is not easily accessible by personnel. The licensee has procedurally restricted access to the site and stated that it planned to have the gauge repaired when other process equipment in the vicinity of the gauge required maintenance or repair.

During a recent NRC Regional inspection, the inspector became aware of this condition. The licensee was informed the event should have been reported to the NRC Operations Center when it was discovered. The gauge in question is a Kay Ray with a 200 millicurie Cs-137 source.