Event Notification Report for April 13, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/12/2012 - 04/13/2012
Agreement State
Event Number: 47841
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PINNACLE HEALTH HOSPITALS
Region: 1
City: CAMP HILL State: PA
County:
License #: PA-0037
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: PINNACLE HEALTH HOSPITALS
Region: 1
City: CAMP HILL State: PA
County:
License #: PA-0037
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2012
Notification Time: 10:53 [ET]
Event Date: 04/13/2012
Event Time: 00:00 [EDT]
Last Update Date: 04/17/2012
Notification Time: 10:53 [ET]
Event Date: 04/13/2012
Event Time: 00:00 [EDT]
Last Update Date: 04/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - RADIOTHERAPY UNDERDOSE
The following report was received via fax:
"On April 13, 2012, a patient was to receive a prescribed dose of 100 mCi of iodine-131 (I-131) for thyroid cancer. Two capsules of I-131 were received from the radiopharmacy in a single vial which was assayed to assure proper dose prior to administering to the patient. The patient was given the contents of the vial for treatment and the treatment was considered complete. The Nuclear Medicine staff prepared the remaining container for return to the radiopharmacy on Monday April 16, 2012. The radiopharmacy picked up the I-131 container and returned it to their facility. Upon inspection of the returned package, the radiopharmacy discovered that one of the two capsules intended for the treatment remained lodged in the vial. The radiopharmacy informed Tristan and the RSO at 12:30 EDT on Monday April 16, 2012. The patient received 50 mCi of the intended 100 mCi dose.
"Patient and referring physician are in the process of being notified. The [PA] Department [of Radiation Protection] plans to do a reactive inspection on April 17, 2012."
PA Event ID: PA120013
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 via fax:
"On April 13, 2012, a patient was to receive a prescribed dose of 100 mCi of iodine-131 (I-131) for thyroid cancer. Two capsules of I-131 were received from the radiopharmacy in a single vial which was assayed to assure proper dose prior to administering to the patient. The patient was given the contents of the vial for treatment and the treatment was considered complete. The Nuclear Medicine staff prepared the remaining container for return to the radiopharmacy on Monday April 16, 2012. The radiopharmacy picked up the I-131 container and returned it to their facility. Upon inspection of the returned package, the radiopharmacy discovered that one of the two capsules intended for the treatment remained lodged in the vial. The radiopharmacy informed Tristan and the RSO at 12:30 EDT on Monday April 16, 2012. The patient received 50 mCi of the intended 100 mCi dose.
"Patient and referring physician are in the process of being notified. The [PA] Department [of Radiation Protection] plans to do a reactive inspection on April 17, 2012."
PA Event ID: PA120013
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.
Agreement State
Event Number: 47839
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: CLOSE THE LOOP, INC.
Region: 1
City: HEBRON State: KY
County:
License #: 401-865-430
Agreement: Y
Docket:
NRC Notified By: CHRISTOPHER KEFFER
HQ OPS Officer: JOHN SHOEMAKER
Licensee: CLOSE THE LOOP, INC.
Region: 1
City: HEBRON State: KY
County:
License #: 401-865-430
Agreement: Y
Docket:
NRC Notified By: CHRISTOPHER KEFFER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/16/2012
Notification Time: 14:22 [ET]
Event Date: 04/13/2012
Event Time: 07:00 [CDT]
Last Update Date: 04/16/2012
Notification Time: 14:22 [ET]
Event Date: 04/13/2012
Event Time: 07:00 [CDT]
Last Update Date: 04/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)
LOST STATIC ELIMINATOR
The licensee notified the Kentucky Department of Public Health and Safety, Radiation Health Branch on April 16, 2012 at 1135 (CDT) of a missing static eliminator. The static eliminator was discovered to be missing by an oncoming operator on April 13, 2012 at 0700 (CDT). An operator on the previous shift reported the device to be in place. The Director of Facility Operations was not in the office on April 13, 2012 and was not made aware of the missing device until April 16, 2012 at 0715 (CDT). The licensee initiated a search for the device on April 16, 2012 at 0715 (CDT) but has been unsuccessful in locating the device. The licensee plans to continue searching for the device. The licensee does not suspect tampering or theft and no exposures to personnel have occurred or are expected at this time. The device is a Model P-2021 Static Eliminator, Serial # A2HU670, with a 10 mCi Po-210 source.
Kentucky Radiation Health Branch Report number KY120007.
No other notifications have been made by the licensee.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
The licensee notified the Kentucky Department of Public Health and Safety, Radiation Health Branch on April 16, 2012 at 1135 (CDT) of a missing static eliminator. The static eliminator was discovered to be missing by an oncoming operator on April 13, 2012 at 0700 (CDT). An operator on the previous shift reported the device to be in place. The Director of Facility Operations was not in the office on April 13, 2012 and was not made aware of the missing device until April 16, 2012 at 0715 (CDT). The licensee initiated a search for the device on April 16, 2012 at 0715 (CDT) but has been unsuccessful in locating the device. The licensee plans to continue searching for the device. The licensee does not suspect tampering or theft and no exposures to personnel have occurred or are expected at this time. The device is a Model P-2021 Static Eliminator, Serial # A2HU670, with a 10 mCi Po-210 source.
Kentucky Radiation Health Branch Report number KY120007.
No other notifications have been made by the licensee.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
Power Reactor
Event Number: 47834
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOHN RIDINGER
HQ OPS Officer: JOHN KNOKE
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: JOHN RIDINGER
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/13/2012
Notification Time: 19:31 [ET]
Event Date: 04/13/2012
Event Time: 15:25 [CDT]
Last Update Date: 04/13/2012
Notification Time: 19:31 [ET]
Event Date: 04/13/2012
Event Time: 15:25 [CDT]
Last Update Date: 04/13/2012
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):
KATHLEEN O'DONOHUE (R2DO)
KATHLEEN O'DONOHUE (R2DO)
| 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 |
| 3 | N | N | 0 | Refueling | 0 | Refueling |
UNANALYZED CONDITION IMPACTING EMERGENCY DIESEL GENERATOR LOADING
"On March 14, 2012, it was determined that in the event of an Appendix R fire, fire damage to cables in certain fire areas could cause a Residual Heat Removal Service Water System (RHRSW) pump to spuriously start, overload EDG A and B, and render them inoperable during certain Appendix R fires. This was reported as an unanalyzed condition (Ref. EN #47764).
"An extent of condition analysis was completed on April 13, 2012. From this analysis it was determined that EDG A, D, 3EC, and 3ED could exceed the maximum rated loading due to the potential for an automatic or spurious start of RHRSW Pumps B3 and D3 that supply Emergency Equipment Cooling Water (EECW) to essential safety equipment.
"The following are the Fire Areas (FA) affected:
EDG A in FA 21
EDG D for FA 2-3 and 9
EDG 3EC in FA 1-1, 1-3, and 20, and
EDG 3ED in FA 1-1, 1-3, 1-4, and 20.
"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). This is also reportable as a 60 day written report IAW 10 CFR 50.73(a)(2)(ii)(B). This event was entered into the licensee's Corrective Action Program as PER 536176.
"The NRC Resident Inspector has been notified of this event."
"On March 14, 2012, it was determined that in the event of an Appendix R fire, fire damage to cables in certain fire areas could cause a Residual Heat Removal Service Water System (RHRSW) pump to spuriously start, overload EDG A and B, and render them inoperable during certain Appendix R fires. This was reported as an unanalyzed condition (Ref. EN #47764).
"An extent of condition analysis was completed on April 13, 2012. From this analysis it was determined that EDG A, D, 3EC, and 3ED could exceed the maximum rated loading due to the potential for an automatic or spurious start of RHRSW Pumps B3 and D3 that supply Emergency Equipment Cooling Water (EECW) to essential safety equipment.
"The following are the Fire Areas (FA) affected:
EDG A in FA 21
EDG D for FA 2-3 and 9
EDG 3EC in FA 1-1, 1-3, and 20, and
EDG 3ED in FA 1-1, 1-3, 1-4, and 20.
"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B). This is also reportable as a 60 day written report IAW 10 CFR 50.73(a)(2)(ii)(B). This event was entered into the licensee's Corrective Action Program as PER 536176.
"The NRC Resident Inspector has been notified of this event."