Event Notification Report for September 07, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/06/2011 - 09/07/2011
EVENT NUMBERS
47254472474724847276
Agreement State
Event Number: 47254
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS REGIONAL CANCER CENTER
Region: 3
City: WASAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: MARK PAULSON
HQ OPS Officer: VINCE KLCO
Licensee: ASPIRUS REGIONAL CANCER CENTER
Region: 3
City: WASAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: MARK PAULSON
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2011
Notification Time: 16:26 [ET]
Event Date: 09/07/2011
Event Time: 12:00 [CDT]
Last Update Date: 09/09/2011
Notification Time: 16:26 [ET]
Event Date: 09/07/2011
Event Time: 12:00 [CDT]
Last Update Date: 09/09/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTINE LIPA (R3DO)
PAUL MICHALAK (FSME)
CHRISTINE LIPA (R3DO)
PAUL MICHALAK (FSME)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING AN UNDERDOSAGE
"Wisconsin Department of Health Services (DHS) received notification by phone call from the licensee on September 8, 2011 about a medical event involving I-125 permanent prostate seed implants. During a standard review conducted September 7, 2011 of a post seed implant report the Authorized Medical Physicist determined that the dose delivered differed from the prescribed dose by 20% or more. Specifically it was found that only 76% (110 Gy) of the prescribed dose was delivered to 90% of the CTV for an implant completed on July 22, 2011. The licensee had established the dose based criteria that by post-operation CT, prostate D90 values are < 80% or >130% for classifying medical events. The licensee has notified the Authorized User, referring physician and will notify the patient during a scheduled examine the week of September 11, 2011. There is no expected immediate harm to the patient and the Authorized User and referring physician will discuss with the patient to determine if supplemental radiation (implant or external beam) will be done. DHS conducted an investigating of this medical event on September 9, 2011 by sending a special inspection team. The preliminarily conclusion after reviewing the licensee's procedures and discussion with the Authorized User and Authorized Medical Physicist is that the under dose was directly caused by edema of the prostate, i.e. post implant procedure swelling."
Wisconsin Event Number: WI110014
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.
"Wisconsin Department of Health Services (DHS) received notification by phone call from the licensee on September 8, 2011 about a medical event involving I-125 permanent prostate seed implants. During a standard review conducted September 7, 2011 of a post seed implant report the Authorized Medical Physicist determined that the dose delivered differed from the prescribed dose by 20% or more. Specifically it was found that only 76% (110 Gy) of the prescribed dose was delivered to 90% of the CTV for an implant completed on July 22, 2011. The licensee had established the dose based criteria that by post-operation CT, prostate D90 values are < 80% or >130% for classifying medical events. The licensee has notified the Authorized User, referring physician and will notify the patient during a scheduled examine the week of September 11, 2011. There is no expected immediate harm to the patient and the Authorized User and referring physician will discuss with the patient to determine if supplemental radiation (implant or external beam) will be done. DHS conducted an investigating of this medical event on September 9, 2011 by sending a special inspection team. The preliminarily conclusion after reviewing the licensee's procedures and discussion with the Authorized User and Authorized Medical Physicist is that the under dose was directly caused by edema of the prostate, i.e. post implant procedure swelling."
Wisconsin Event Number: WI110014
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: 47247
Facility: COOK
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RANDY ROSE
HQ OPS Officer: BILL HUFFMAN
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RANDY ROSE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/07/2011
Notification Time: 12:14 [ET]
Event Date: 09/07/2011
Event Time: 08:54 [EDT]
Last Update Date: 09/07/2011
Notification Time: 12:14 [ET]
Event Date: 09/07/2011
Event Time: 08:54 [EDT]
Last Update Date: 09/07/2011
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):
CHRISTINE LIPA (R3DO)
CHRISTINE LIPA (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP FOLLOWING MAIN TURBINE TRIP FROM 100% POWER
"On Sept 7, 2011, at 0854, DC Cook Unit 1 reactor automatically tripped due to a trip of the main turbine. The cause of the main turbine trip is still under investigation.
"This event is reportable under 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation, as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report.
"The DC Cook Sr. Resident NRC Inspector has been notified.
"The electrical grid is stable and Unit 1 is being supplied by offsite power. All control rods fully inserted. Decay heat is being removed via steam dumps to the main condenser. Preliminary evaluation indicates all plant systems functioned normally following the reactor trip. DC Cook Unit 1 remains stable in Mode 3 while conducting the post trip review."
"On Sept 7, 2011, at 0854, DC Cook Unit 1 reactor automatically tripped due to a trip of the main turbine. The cause of the main turbine trip is still under investigation.
"This event is reportable under 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation, as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report.
"The DC Cook Sr. Resident NRC Inspector has been notified.
"The electrical grid is stable and Unit 1 is being supplied by offsite power. All control rods fully inserted. Decay heat is being removed via steam dumps to the main condenser. Preliminary evaluation indicates all plant systems functioned normally following the reactor trip. DC Cook Unit 1 remains stable in Mode 3 while conducting the post trip review."
Fuel Cycle Facility
Event Number: 47248
Facility: B&W NUCLEAR OPERATING GROUP, INC.
Region: 2 State: VA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: JOHN CARTER
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: VA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: JOHN CARTER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/07/2011
Notification Time: 13:12 [ET]
Event Date: 09/07/2011
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2011
Notification Time: 13:12 [ET]
Event Date: 09/07/2011
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DANIEL RICH (R2DO)
FUELS OUO GROUP
ABY MOHSENI (NMSS)
DANIEL RICH (R2DO)
FUELS OUO GROUP
ABY MOHSENI (NMSS)
FITNESS FOR DUTY REPORT RELATED TO INTRODUCTION OF ALCOHOL INTO PROTECTED AREA
The licensee reported a fitness-for-duty violation due to an employee who inadvertently brought alcohol into the protected area. The violation was self-reported by the individual involved. The employee is being tested under the FFD program and his access has been denied pending outcome of an investigation. Contact the HOO for additional details
The licensee reported a fitness-for-duty violation due to an employee who inadvertently brought alcohol into the protected area. The violation was self-reported by the individual involved. The employee is being tested under the FFD program and his access has been denied pending outcome of an investigation. Contact the HOO for additional details
Agreement State
Event Number: 47276
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: FLOWSERVE US INC.
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0121-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: DONALD NORWOOD
Licensee: FLOWSERVE US INC.
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0121-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/18/2011
Notification Time: 13:42 [ET]
Event Date: 09/07/2011
Event Time: 00:00 [EDT]
Last Update Date: 09/18/2011
Notification Time: 13:42 [ET]
Event Date: 09/07/2011
Event Time: 00:00 [EDT]
Last Update Date: 09/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ART BURRITT (R1DO)
ADELAIDE GIANTELLI (FSME)
ART BURRITT (R1DO)
ADELAIDE GIANTELLI (FSME)
AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY CAMERA LOCKING MECHANISM
The following information was received via e-mail:
"On September 7, 2011, the licensee discovered a failure of the locking mechanism of a QSA 880-Delta radiography exposure device. This is a 30-day notification event. Device: 880 Delta. S/N: D7822.
"During the installation of the 880 camera, it was discovered that the locking mechanism would not return to the 'Stored / Locked' position. While investigating the malfunction, it was determined that possibly one of the springs in the locking mechanism was bad. The manufacturer (QSA Global / Sentinel) was called and the malfunction was explained and it was requested that the camera be sent back for further investigation and correction of the malfunction.
"This camera did not have a radioactive source in it or attached to the drive cable at the time of the malfunction discovery. This is a brand new 880 Delta camera and has not had a radioactive source in it. The source to be installed in the camera is being stored in a 650L changer, serial number 2168 and secured in [the licensee's] radiography booth.
"The RSO was the only person in the radiography booth when the malfunction was discovered and no potential exposure occurred.
"Updates will be provided through NMED.
North Carolina Incident Number: NC 11-48
The following information was received via e-mail:
"On September 7, 2011, the licensee discovered a failure of the locking mechanism of a QSA 880-Delta radiography exposure device. This is a 30-day notification event. Device: 880 Delta. S/N: D7822.
"During the installation of the 880 camera, it was discovered that the locking mechanism would not return to the 'Stored / Locked' position. While investigating the malfunction, it was determined that possibly one of the springs in the locking mechanism was bad. The manufacturer (QSA Global / Sentinel) was called and the malfunction was explained and it was requested that the camera be sent back for further investigation and correction of the malfunction.
"This camera did not have a radioactive source in it or attached to the drive cable at the time of the malfunction discovery. This is a brand new 880 Delta camera and has not had a radioactive source in it. The source to be installed in the camera is being stored in a 650L changer, serial number 2168 and secured in [the licensee's] radiography booth.
"The RSO was the only person in the radiography booth when the malfunction was discovered and no potential exposure occurred.
"Updates will be provided through NMED.
North Carolina Incident Number: NC 11-48