Event Notification Report for January 02, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/01/2013 - 01/02/2013
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State
Event Number: 48647
Rep Org: RESEARCH MEDICAL CENTER
Licensee: RESEARCH MEDICAL CENTER
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-18625-01
Agreement: N
Docket:
NRC Notified By: STEPHEN SLACK
HQ OPS Officer: CHARLES TEAL
Licensee: RESEARCH MEDICAL CENTER
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-18625-01
Agreement: N
Docket:
NRC Notified By: STEPHEN SLACK
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/03/2013
Notification Time: 10:22 [ET]
Event Date: 01/02/2013
Event Time: 11:47 [CST]
Last Update Date: 01/03/2013
Notification Time: 10:22 [ET]
Event Date: 01/02/2013
Event Time: 11:47 [CST]
Last Update Date: 01/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
FSME EVENT RESOURCE (EMAI)
RICHARD SKOKOWSKI (R3DO)
FSME EVENT RESOURCE (EMAI)
RADIOISOTOPE ADMINISTERED TO THE INCORRECT PATIENT
While conducting a radiopharmaceutical stress test the dose was administered to the incorrect patient. The isotope was 11 mCi of Tc-99m. The patient is not expected to experience any adverse effects as a result of this treatment.
* * * UPDATE AT 1440 EST ON 01/03/13 FROM STEPHEN SLACK TO S. SANDIN * * *
The licensee is retracting this report after a discussion with NRC Region III (Gattone) which concluded that the event did not meet the reporting criteria as a medical event.
Notified R3DO (Skokowski) and FSME Events Resource via email.
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.
While conducting a radiopharmaceutical stress test the dose was administered to the incorrect patient. The isotope was 11 mCi of Tc-99m. The patient is not expected to experience any adverse effects as a result of this treatment.
* * * UPDATE AT 1440 EST ON 01/03/13 FROM STEPHEN SLACK TO S. SANDIN * * *
The licensee is retracting this report after a discussion with NRC Region III (Gattone) which concluded that the event did not meet the reporting criteria as a medical event.
Notified R3DO (Skokowski) and FSME Events Resource via email.
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: 48643
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: RONE ENGINEERING SERVICES LTD
Region: 4
City: DALLAS State: TX
County:
License #: 02356
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Licensee: RONE ENGINEERING SERVICES LTD
Region: 4
City: DALLAS State: TX
County:
License #: 02356
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/02/2013
Notification Time: 17:46 [ET]
Event Date: 01/02/2013
Event Time: 00:00 [CST]
Last Update Date: 01/02/2013
Notification Time: 17:46 [ET]
Event Date: 01/02/2013
Event Time: 00:00 [CST]
Last Update Date: 01/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)
RAY AZUA (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
MEXICO (EMAI)
AGREEMENT STATE REPORT - MISSING TROXLER
The following was received from the State of Texas via email:
"On January 2, 2013, the Agency [State of Texas] was notified by the licensee's Radiation Safety Officer (RSO) that a Troxler model 3430 containing an 8 millicurie cesium - 137 source and a 40 millicurie americium - 241/beryllium source could not be located. The licensee's records indicated that the gauge had been returned by their technician and locked in the storage area on December 31, 2012. The licensee's tracking system, which tracks the location of their vehicles, confirmed that the truck used by the technician had been returned to the licensee's location at the close of business on December 31. The licensee conducted an inventory of all of its gauges and this was the only gauge missing. The RSO stated that the storage area had no signs of tampering. The RSO stated that they had interviewed the technician assigned to use the gauge, but the technician did not provide any information useful to recover the gauge. The RSO stated that they were in the process of notifying the police of the theft. The RSO stated that the offering of a reward would be discussed with company management. The RSO stated that the gauge was locked inside of a transportation case and that the operating rod was locked in the shielded position. The RSO stated that he did not believe there was any risk of exposure to a member of the general public. Additional information will be provided as it is received in accordance with SA-300.
"Texas Incident Number: I-9030"
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 was received from the State of Texas via email:
"On January 2, 2013, the Agency [State of Texas] was notified by the licensee's Radiation Safety Officer (RSO) that a Troxler model 3430 containing an 8 millicurie cesium - 137 source and a 40 millicurie americium - 241/beryllium source could not be located. The licensee's records indicated that the gauge had been returned by their technician and locked in the storage area on December 31, 2012. The licensee's tracking system, which tracks the location of their vehicles, confirmed that the truck used by the technician had been returned to the licensee's location at the close of business on December 31. The licensee conducted an inventory of all of its gauges and this was the only gauge missing. The RSO stated that the storage area had no signs of tampering. The RSO stated that they had interviewed the technician assigned to use the gauge, but the technician did not provide any information useful to recover the gauge. The RSO stated that they were in the process of notifying the police of the theft. The RSO stated that the offering of a reward would be discussed with company management. The RSO stated that the gauge was locked inside of a transportation case and that the operating rod was locked in the shielded position. The RSO stated that he did not believe there was any risk of exposure to a member of the general public. Additional information will be provided as it is received in accordance with SA-300.
"Texas Incident Number: I-9030"
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
Power Reactor
Event Number: 48644
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: DONALD WALLS
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: AR
Unit: [] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: DONALD WALLS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/02/2013
Notification Time: 18:42 [ET]
Event Date: 01/02/2013
Event Time: 13:08 [CST]
Last Update Date: 01/02/2013
Notification Time: 18:42 [ET]
Event Date: 01/02/2013
Event Time: 13:08 [CST]
Last Update Date: 01/02/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RAY AZUA (R4DO)
RAY AZUA (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 87 | Power Operation |
INADVERTENT ACTUATION OF SAFETY INJECTION, CONTAINMENT COOLING AND CONTAINMENT ISOLATION SIGNALS
"At 1308 hours [CST] on January 2, 2013, Arkansas Nuclear One Unit 2 (ANO-2) experienced an inadvertent safety injection actuation signal (SIAS), containment cooling actuation signal (CCAS) and containment isolation actuation signal (CIAS) during matrix testing on 'C' channel plant protective system (PPS). All components actuated as designed for the stated actuation signals.
"After verification that the actuation signal was not valid the high pressure safety injection (HPSI) pumps and low pressure safety injection (LPSI) pumps were secured and their hand switches placed in pull-to-lock as directed by the abnormal operating procedure for inadvertent SIAS at 1312 hours. The HPSI and LPSI pumps were the restored to normal standby condition and available for automatic operation at 1352 hours.
"The unit did down power to approximately 87% power when all three coolant charging pumps ran with suction aligned to the boric acid makeup tanks. The unit currently remains in mode 1. SIAS, CCAS, and CIAS have been reset. The cause of the inadvertent actuation signals is under investigation. The NRC Resident Inspector has been informed."
Unit 2 entered Technical Specification 3.0.3 for approximately 40 minutes while the LPSI and HPSI pumps were in pull-to-lock.
"At 1308 hours [CST] on January 2, 2013, Arkansas Nuclear One Unit 2 (ANO-2) experienced an inadvertent safety injection actuation signal (SIAS), containment cooling actuation signal (CCAS) and containment isolation actuation signal (CIAS) during matrix testing on 'C' channel plant protective system (PPS). All components actuated as designed for the stated actuation signals.
"After verification that the actuation signal was not valid the high pressure safety injection (HPSI) pumps and low pressure safety injection (LPSI) pumps were secured and their hand switches placed in pull-to-lock as directed by the abnormal operating procedure for inadvertent SIAS at 1312 hours. The HPSI and LPSI pumps were the restored to normal standby condition and available for automatic operation at 1352 hours.
"The unit did down power to approximately 87% power when all three coolant charging pumps ran with suction aligned to the boric acid makeup tanks. The unit currently remains in mode 1. SIAS, CCAS, and CIAS have been reset. The cause of the inadvertent actuation signals is under investigation. The NRC Resident Inspector has been informed."
Unit 2 entered Technical Specification 3.0.3 for approximately 40 minutes while the LPSI and HPSI pumps were in pull-to-lock.