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Event Notification Report for September 7, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/06/2004 - 09/07/2004

** EVENT NUMBERS **


41008 41023

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General Information or Other Event Number: 41008
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: AURORA State: WI
County:
License #: 09-1017-01
Agreement: Y
Docket:
NRC Notified By: PAUL CALEB
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/02/2004
Notification Time: 11:20 [ET]
Event Date: 08/31/2004
Event Time: 14:00 [CDT]
Last Update Date: 09/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
LINDA GERSEY (NMSS)

Event Text

WISCONSIN AGREEMENT STATE REPORT: SOURCE FAILED TO RETRACT

"On the evening of August 31, 2004 during a mammosite treatment utilizing a Varian HDR unit, the source failed to retract upon completion of the treatment time. The licensee's RSO/AMP had to enter the treatment room and retract the source manually.

"The licensee subsequently contacted Varian for assistance. A service representative from Varian arrived at Aurora Baycare Medical Center on Wednesday, Sept. 1, 2004. The Varian service representative found nothing wrong with the HDR unit. However, approximately 2 cm of the connecting catheter had 'buckled' (appeared melted and twisted), possibly restricting source movement. The licensee has contacted the catheter manufacturer for assistance in analyzing the catheter to determine what may have caused it to buckle.

"Preliminary dose indications by the licensee indicate that the patient received an additional amount of dose to the skin while the source was being retracted. The licensee reported that the most probable estimate of the additional skin dose is 1.0 Gy."

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Power Reactor Event Number: 41023
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: R. SWEENEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/06/2004
Notification Time: 12:44 [ET]
Event Date: 09/06/2004
Event Time: 11:50 [EDT]
Last Update Date: 09/06/2004
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
Person (Organization):
BENOIT DESAI (R2)
MICHAEL CASE (NRR)
RICHARD WESSMAN (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 97 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP FOLLOWING PARTIAL LOSS OF OFFSITE POWER

"At approximately 1150 [EDT], CR3 Site experienced a 230KV 'B' Buss loss. The resultant loss of power was a loss of both non-vital 4160V busses. All RCPs tripped and a reactor trip occurred. The plant is stable on natural circulation cooling.

"This report is based on the Reactor Protection System Actuation and Specified System Actuation (Emergency Feedwater)."

The "B" ESF 4160KV Bus deenergized resulting in an autostart of the "B" EDG, as expected. Natural Circulation has been confirmed with both Steam Generators [SGs] receiving Emergency Feedwater [EFW] via both the Turbine-Driven and Diesel-Driven EFW Pumps. The SGs are using the Atmospheric Dumps to remove decay heat. There was no known SG tube leakage prior to the transient. The cause for the partial loss of offsite power is under investigation.

The licensee informed the NRC Resident Inspector.

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