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Event Notification Report for January 31, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/28/2005 - 01/31/2005

** EVENT NUMBERS **


41358 41360 41362 41363

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General Information or Other Event Number: 41358
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: RIVERSIDE METHODIST HOSPITAL
Region: 3
City: COLUMBUS State: OH
County:
License #: OH- 021202500
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/26/2005
Notification Time: 12:13 [ET]
Event Date: 01/24/2005
Event Time: [EST]
Last Update Date: 01/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3)
SANDRA WASTLER (NMSS)

Event Text

AGREEMENT STATE REPORT OF ADMINISTRATION OF RADIOACTIVE IODINE TO A PREGNANT PATIENT

The following information is a preliminary report provided to the Ohio Department of Health Bureau of Radiation Protection concerning a patient at the Riverside Methodist Hospital in Columbus, Ohio that was administered radioactive iodine while pregnant.

"It has been brought to our attention that a patient that had been treated for hyperthyroidism at our facility was in fact pregnant at the time of the administration. The patient had an uptake study performed on 11/2/04 (205 microcuries of I-123 sodium iodine) pursuant to a diagnosis of hyperthyroidism. The patient was administered 12.7 millicuries of I-131 sodium iodine on 11/16/04 as treatment. The patient was counseled by the Authorized User prior to the administration and received written consent from the patient that she was not or could not be pregnant at that time. A pregnancy test was not performed to confirm or deny this fact.

"The fact that the patient was pregnant was brought to our attention when she saw her family practice physician (who was the referring physician for the uptake and hyperthyroidism treatment procedures) for complaints of abdominal pain. A radiograph of the abdomen was taken and the pregnancy discovered. This occurred sometime within the past week. The fact that the patient was pregnant was relayed to the Authorized User, who, in conjunction with the referring physician, referred the patient to a prenatal specialist to determine the age of the fetus. The specialist determined the delivery date to be 4/25/05, which meant the age of the fetus at the time of the I-131 administration was 17 weeks. This determination was made on January 24, 2005, and the RSO's staff called the [Ohio Department of Health] to report the event after gathering information for a dosimetry study at approximately 10 AM, 25 January, 2005.

"The dosimetry estimate for the fetus was approximately 2.0432 rad to the whole fetus and 22,400 rad to the fetal thyroid from both the I-123 and I-131 administrations. It should be noted that the patient underwent a CT angiogram on 9/24/04 (fetal age 8 weeks), but that this dose and the abdominal x-ray taken last week were not added to the fetal whole body dose since specific technique factors were not available for these studies which were performed elsewhere.

"The patient will be notified of the treatment plan for the continuation of the pregnancy today or tomorrow, once the prenatal specialist receives the dosimetry estimate the RSO provided the Authorized User. The referring physician has been in close contact with the Authorized User throughout this process."

The Ohio Department of Health considers this an "Abnormal Occurrence" and will be conducting an investigation commencing this Friday (1/28/05).


Ohio Dept of Health Report # 2005-001

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General Information or Other Event Number: 41360
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CORRADINO GROUP
Region: 1
City: WEST PALM BEACH State: FL
County:
License #: 2770-1
Agreement: Y
Docket:
NRC Notified By: C. ADAMS (VIA E-MAIL)
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/26/2005
Notification Time: 18:00 [ET]
Event Date: 01/26/2005
Event Time: [EST]
Last Update Date: 01/26/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
THOMAS DECKER (R2)
LARRY CAMPER (NMSS)
JOHN KINNEMAN (R1)
MCDONALD (DHS)
RUTLEDGE (DHS)

Event Text

AGREEMENT STATE REPORT PROVIDING INFORMATION ABOUT AN EVENT OF MEDIA INTEREST

The Florida Bureau of Radiation Control provided the following report via e-mail to the NRC:

"[The] West Palm Beach Fire Department received a call about an electrical fire at [a West Palm Beach business] location. There was not an active fire [when the Fire Department reached the incident site] but an electrical smell [was] in the air. While in the [incident] building location, the FPD radiation dosimeters [worn by the Fire Department responders] indicated a [radioactive] source in a storage locker. [Based on the detected radiation], a one city block was evacuated and an area around the site of ten city blocks was sealed off. "

[The licensee was authorized to posses Troxler type gauges at the site for its business activities which were stored at the location where the Fire Department had responded.]

"Investigators [from the Florida Bureau of Radiation Control] arrived on scene and noted proper signage on the door [of the incident location] for a temporary work site [storing Troxler type gauges]. Licensee representatives opened [the] storage container [with the Troxler type gauges] to verify that the gauges were inside [and intact]. The emergency is in the process of being terminated. The [State] of Florida will continue its investigation."

There was never any actual fire or release of any radioactive material during the course of this event.

Florida Report FL05-016

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Power Reactor Event Number: 41362
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: GUY McCALLUM
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/27/2005
Notification Time: 21:12 [ET]
Event Date: 01/27/2005
Event Time: 18:30 [EST]
Last Update Date: 01/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS DECKER (R2)

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

Event Text

SINGLE FAILURE IDENTIFIED THAT COULD PREVENT RE-ENERGIZING BOTH ES BUSSES


"On January 27, 2005, Crystal River - Unit 3 (CR-3) discovered an installation subject to a single failure that could prevent both Emergency Diesel Generators (EDGS) and both offsite power sources from supplying power to their respective Engineered Safeguards (ES) Busses. This is a condition contrary to 10CFR50.72 (b)(3)(ii)(B).

"The installation involves the 4.16 Kv supply breakers from the offsite power transformer (OPT) and the Back-up Engineered Safeguards Transformer (BEST) which are the two required offsite power sources. From the OPT, one breaker supplies the 'A' ES Bus and a second breaker supplies the 'B' ES Bus. From the BEST, one breaker supplies the 'A' ES Bus and a second breaker supplies the 'B' ES Bus. A traditional (non-nuclear) design for such pairs of supply breakers includes current transformers that are connected to each other for each phase and a watt hour meter from those connections to monitor power. These circuits were installed around 1990 to support the coordination of the new 230 Kv breakers to supply the OPT and the coordination with the 230 Kv supply breakers for the new BEST.

"Should a failure of the wire connecting the current transformers or the watthour meter occur such that the ES Bus supply breakers' lockout relays are actuated, all breakers supplying and receiving power via the ES Busses would be opened and locked out. The result is that neither EDG nor the offsite power source would be able to automatically supply power to its respective ES Bus.

"CR-3 is currently disconnecting and isolating the watthour meters and removing the connection between the respective breakers' current transformers."

Licensee entered Tech Spec 3.8.9.1 at 1830 hours based on single failure but considers both ES busses operable.

The NRC Resident Inspector was notified of this event by the licensee.

*** Update on 01/28/05 at 1655 EST from Guy McCallum to MacKinnon ****

"On January 28, 2005, Crystal River - Unit 3 (CR-3) corrected the single failure vulnerability associated with the Engineered Safeguards (ES) Busses.

"A permanent modification which removed the single failure vulnerability for the offsite power transformer (OPT) was completed at (0152), and the modification for the Back-up Engineered Safeguards Transformer (BEST) was completed at (0644). R2DO (T. Decker) notified.

The NRC Resident Inspector was notified of this event by the licensee.

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Power Reactor Event Number: 41363
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: EDDIE BYARS
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/30/2005
Notification Time: 04:52 [ET]
Event Date: 01/30/2005
Event Time: 04:10 [EST]
Last Update Date: 01/30/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS DECKER (R2)

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

LOSS OF EMERGENCY SIREN CAPABILITY DUE TO ADVERSE WEATHER

"Loss of greater than 25% EWSS [Early Warning Siren System] due to ice storm."

The majority of the sirens were lost in Fairfield and Newberry Counties. The licensee had no estimated time for restoration.

The licensee informed state/local agencies and the NRC Resident Inspector.

* * * Update on 01/30/05 at 1536 hours by Albert Harris to MacKinnon * * *

At 0900 hours 84% of the EWSS was returned to service. At 1430 hours EWSS was declared operable after 98% of the system was returned to service. R2DO (T. Decker) notified.


The licensee informed the state/local agencies and the NRC Resident Inspector.

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