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Event Notification Report for September 11, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/10/2003 - 09/11/2003

** EVENT NUMBERS **


40136 40137 40141 40143 40145 40146 40147

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General Information or Other Event Number: 40136
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LITTLE COMPANY OF MARY HOSPITAL
Region: 4
City: TORRANCE State: CA
County:
License #: 090503
Agreement: Y
Docket:
NRC Notified By: KATHLEEN KAUFMAN
HQ OPS Officer: RICH LAURA
Notification Date: 09/05/2003
Notification Time: 14:44 [EST]
Event Date: 09/04/2003
Event Time: 08:00 [PDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHARLES MARSCHALL (R4)
TOM ESSIG (NMSS)

Event Text

CALIFORNIA AGREEMENT STATE REPORT ON MEDICAL EVENT

"On September 4, 2003, two patients were scheduled for prostate brachytherapy implants. The first was suppose to be implanted with Iodine 125 and the second with Palladium 103. In anticipation of these procedures both the Palladium 103 and Iodine 125 were brought to the surgical suite.

"The first implant procedure was started and after two strands of Palladium 103 had been implanted it was discovered that an error had been made because the patient was scheduled to be implanted with Iodine 125. The treatment plan had been performed for Iodine 125. The decision was made to continue with the implanting of the Palladium 103 after a new treatment plan was performed. Based on the new plan the appropriate number of Palladium 103 seeds were implanted delivering the prescribed dose. Initial report from (DELETED) was that the patient was scheduled for 7:30 AM, so the event most likely occurred around 8:00 AM. Specific details will be included in his full report to follow. Because the treatment planning equipment was already in the surgical suits, the new plan could be developed with little delay. Specific time frame delays to follow in the full report.

"The second patient, scheduled for Palladium 103 was in the same day surgery suite and had not been prepped nor given an IV. He was rescheduled for another day, as they did not have enough Palladium 103 for both patients."

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General Information or Other Event Number: 40137
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HBC/TERRACON
Region: 4
City: NEW CASEY State: TX
County:
License #: L05268
Agreement: Y
Docket:
NRC Notified By: HELEN WATKINS
HQ OPS Officer: RICH LAURA
Notification Date: 09/05/2003
Notification Time: 18:47 [EST]
Event Date: 09/04/2003
Event Time: [CDT]
Last Update Date: 09/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHARLES MARSCHALL (R4)
JANET SCHLUETER (NMSS)

Event Text

TEXAS AGREEMENT STATE REPORT ON STOLEN GAUGE

"A nuclear gauge was stolen during the night from a pickup truck parked at a residence. The chain and lock were cut and the gauge was taken. We are unaware of whether other items were taken. The technician became aware the gauge was missing when he arrived at a jobsite at about 5:30 am on 09/05/2003. The field service manager looked around the neighborhood and at local pawn shops but did not locate the gauge. The Licensee is considering a public announcement and the offering of a reward. The Agency is investigating the incident."

The gauge is a Troxler 3430, serial # 17272, with 39.2 milliCuries of Am-241 (serial # 47-12694) and 6 milliCuries of Cs-137 (serial # 50-6643).

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General Information or Other Event Number: 40141
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NORTHRIDGE HOSPITAL
Region: 4
City: VAN NUYS State: CA
County:
License #: 0041
Agreement: Y
Docket:
NRC Notified By: KATHLEEN KAUFMAN
HQ OPS Officer: NATHAN SANFILIPPO
Notification Date: 09/08/2003
Notification Time: 19:01 [EST]
Event Date: 09/08/2003
Event Time: 09:30 [PDT]
Last Update Date: 09/08/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
JANET SCHLUETER (NMSS)

Event Text

AGREEMENT STATE REPORT - IRIDIUM 192 SOURCE FAILED TO RETRACT

The following was received via fax from the California Radiation Control office:

"At about 9:30 a.m. on 09-08-03, an Ir-192 source (4.6 Ci [Curie]) failed to retract following a patient treatment. The source became stuck in the transfer tube. The physicist started his stopwatch, entered the room and attempted to manually retract the source. Manual retract failed. The physicist called the physician, who was waiting outside the room. The physician entered the room and disconnected the apparatus from the patient and dropped the transfer tube into a lead pig. The physicist and physician moved the patient out of the room. The physicist stopped the watch and it showed that 2 minutes had elapsed. The physicist surveyed the patient and obtained no measurement above background. The physicist re-entered the room and performed a radiation survey, and found the hot spot along the transfer tube to be in the pig. The pig measured 10 mR [millirem] /hr at 3 feet. The room was locked and posted until arrival of the manufacturer's representative, who also was unable to make the source retract. The manufacturer's representative placed the transfer tube into a shipping container and shipped it back to the manufacturer for further investigation. Doses to the patient, physicist and physician were estimated as follows: patient skin dose (10cm from source for 2 minutes) = 9 rem; physicist for 2 minutes = 45 mrem [millirem]; physician 125 mrem [millirem] whole body and 15 rem extremity."

The device used was a Nucleotron MicroSelectron HDR [High Dose Rate] model number 31324 (Serial Number D36A4476).

The malfunction of the device is under investigation.

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General Information or Other Event Number: 40143
Rep Org: EDERER, LLC
Licensee: EDERER, LLC
Region: 4
City: SEATTLE State: WA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOE HOFF
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/10/2003
Notification Time: 12:13 [EST]
Event Date: 09/10/2003
Event Time: [PDT]
Last Update Date: 09/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
LINDA HOWELL (R4)
JACK FOSTER (NRR)
MONTE PHILLIPS (R3)

Event Text

POTENTIAL SAFETY HAZARD INVOLVING CRANE EMERGENCY DRUM BRAKE

"Subject: 10 CFR, Part 21 notification of potential safety related nonconforming condition.

"This letter serves to notify the Commission of a potential safety related noncompliance in a delivered component as defined in 10 CFR, Part 21.

"Condition:

"On Friday, Aug. 15, 2003 the Duane Arnold Energy Center (DAEC) notified Ederer that during routine testing of the X-SAM® Single Failure Proof Safety System on Ederer crane S/N F1475, the emergency drum brake would not set consistently. DAEC said the condition was being evaluated in accordance with their 10 CFR, Part 21 reporting procedure. DAEC also said they had re-adjusted the system so it was functioning correctly for use.
Ederer reviewed the information provided by DAEC and sent a letter to them on Wednesday, Aug. 20, 2003, which recommended the crane not be used for any safety-related or critical lifts until the X-SAM® Safety System has been thoroughly examined and verified to be in satisfactory operating condition.

"Evaluation:

"The crane had been in service since 1983 and this was the first instance where the system did not function correctly. Ederer's Design Engineer for the system traveled to DAEC Saturday Aug. 23, 2003 and examined and tested the system. It was determined that accumulated wear over the life of the assembly resulted in increased friction such that the cable would not slide freely and brake reaction setting force could no longer overcome the resistance of the cable. This resulted in the inconsistent operation of the emergency drum brake noted by DAEC.

"Ederer has requested DAEC send the old cable assembly back to us for a more complete examination. If that examination provides any different results, a supplemental report will be submitted.

"If allowed to remain uncorrected, this condition constitutes a 'safety hazard' because, in the event of the failure of another component, the loss of the safety function could result in a significant reduction in the degree of protection provided by the crane safety system.

"Corrective Action:

"1.) Ederer notified the other affected user (Point Beach) with the same type of system and advised them not to use their crane for any safety-related or critical lifts until the condition had been evaluated.

"2.) Ederer replaced the cable assembly and retested the system at DAEC on Sunday, Aug 24, 2003.

"3.) Even though the Point Beach system was functioning normally, Ederer went to site and replaced the cable assembly and retested the system on Monday, Sept. 1, 2003.

"4.) Ederer has set a recommended replacement life for this component of 10 years. This is based on 50% of the shortest known useful life of 20 years.

"Conclusion:

"Ederer considers this condition to be reportable in accordance with 10 CFR, Part 21, Section 21.3(m). Nuclear plants using this equipment were identified and notified, and the components replaced. There have been no previous similar conditions reported. There was no adverse effect on plant safety or on the health and safety of the public as a result of this condition.

"In summary, Ederer has notified affected users, notified the NRC and taken appropriate corrective action.

"Any questions regarding this report or other Ederer cranes should be directed to: Jim Nelson, Account Manager for Cranes, at jnelson@ederer.par.com. Please provide the following information; customer name, contact person, email address, telephone number, facility, and crane serial number."

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Power Reactor Event Number: 40145
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GERRY GOSMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/10/2003
Notification Time: 19:32 [EST]
Event Date: 09/10/2003
Event Time: 17:40 [CDT]
Last Update Date: 09/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
73.71(b)(1) - SAFEGUARDS REPORTS
Person (Organization):
MONTE PHILLIPS (R3)

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

Event Text

1-HR SECURITY REPORT INVOLVING UNESCORTED ACCESS AUTHORIZATION

Vital Area unescorted access inappropriately granted. Immediate compensatory measures taken upon discovery. The licensee informed the NRC Resident Inspector. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 40146
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: CHET DESMARAIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/10/2003
Notification Time: 21:02 [EST]
Event Date: 09/10/2003
Event Time: 17:46 [CDT]
Last Update Date: 09/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MONTE PHILLIPS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION DUE TO A POTENTIAL BREAK IN FIRE PROTECTION WATER SYSTEM

"Potential break of Fire Water Main in Admin Bldg could cause both divisions of Safe Shutdown equipment to be inoperable by flooding the battery rooms for #11 & 12 125VDC Batteries. Vulnerable section of piping has been isolated to eliminate the flooding concern. Fire Protection compensatory actions have been established in accordance with the site Fire Protection Program."

The licensee informed the NRC resident inspector.

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Power Reactor Event Number: 40147
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DON ROLAND
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/11/2003
Notification Time: 02:40 [EST]
Event Date: 09/11/2003
Event Time: 00:40 [EDT]
Last Update Date: 09/11/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MOHAMED SHANBAKY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 63 Power Operation

Event Text

OFFSITE NOTIFICATION MADE TO PENNSYLVANIA EMERGENCY MANAGEMENT AGENCY (PEMA)

"At 2314 EDT on 9/10/03 a fire was reported at the Unit 1B Reactor Feed Pump. The Fire Brigade was activated and the fire was extinguished at 2322 (8 minutes after identification). To support removal of the feed pump from service reactor power was reduced to 63%. Due to notifying the Pennsylvania Emergency Management Agency (PEMA) and other outside agencies, this event is being reported under 10CFR50.72(b)(2)(xi)."

The NRC Resident Inspector was notified by the Licensee.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012