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Event Notification Report for March 1, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/28/2005 - 03/01/2005

** EVENT NUMBERS **


41438 41449 41450 41451 41452

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General Information or Other Event Number: 41438
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BAYSTATE HEALTH SYSTEMS
Region: 1
City: SPRINGFIELD State: MA
County:
License #: 60-0095
Agreement: Y
Docket: 02-5457
NRC Notified By: MIKE WHALEN (VIA FAX)
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/24/2005
Notification Time: 12:41 [ET]
Event Date: 01/07/2005
Event Time: 10:35 [EST]
Last Update Date: 02/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
CHARLES MILLER (NMSS)

Event Text

AGREEMENT STATE MEDICAL EVENT

The following report was received from the Massachusetts Department of Public Health and Radiation Control via facsimile:

"Endocrinologist ordered thyroid uptake study on a patient - dose to be 17 uCi of I-131. The Central Booking Department scheduled the patient to arrive in the Nuclear Medicine Department for an I-131 'total body scan.' On 1/4/05, CNMT 1 received the appointment roster form for 1/7/05, posted it on exam scheduling bulletin board, and placed the order for a total body scan - which is generally 3.7 mCi of I-131 - without looking at the diagnosis. Total body scan ordered on roster was reviewed by Nuclear Medicine Physician and checked off for that day's activity. On the day of the exam, CNMT 2 retrieved the paper work and administered the 3.7 mCi, I-131 whole body scan. Patient sent home and came back 2 days later for thyroid scan. The imaging CNMT 3 noted that the thyroid scan did not look as expected, thus, reviewed all the paperwork and discovered that the wrong procedure (and dose) was administered. The Nuclear Medicine Physician and the RSO were then immediately notified by the CNMT 3, who in turn, notified the prescribing Endocrinologist. The Nuclear Medicine Physician then notified the patient (on 1/7/05) and the Department Administration. A summary report will be sent to the patient which will include notification that a formal report has been submitted to the Massachusetts Radiation Control Program.

"The patient ultimately received 3.6 mCi of I-131, had a thyroid uptake of 70% which resulted in a thyroid dose of 13,111 rads and a TEDE of 2.6 rads. This dose will be taken into consideration when the patient is treated next for hyperthyroidism."

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Other Nuclear Material Event Number: 41449
Rep Org: FOX CHASE CANCER CENTER
Licensee: FOX CHASE CANCER CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 37-02766-01
Agreement: N
Docket:
NRC Notified By: KAREN SHEEHAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/28/2005
Notification Time: 15:35 [ET]
Event Date: 02/25/2005
Event Time: 11:11 [EST]
Last Update Date: 02/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DANIEL HOLODY (R1)
PAM HENDERSON (R1)
SCOTT MOORE (NMSS)

Event Text

DELIVERY OF RADIOACTIVE PHOSPHORUS (P-32) TO UNAUTHORIZED INDIVIDUAL BY FED-EX

The Radiation Safety Officer (RSO) for the Fox Chase Cancer Center reported that a shipment of P-32 (3.2 millicuries based on a 2/24/05 calculated decay) was received by her that had been opened by an unknown and unauthorized individual. She stated that she had been expecting the shipment of P-32 from M.P Biomedical of Irvine CA to arrive at the Fox Chase facility on Friday 2/25/05. The RSO stated that when she received the package on 2/28/05, there was clear evidence that the package had been opened and resealed. She stated that the P-32 contents were undamaged and nothing was missing. In addition, a survey of the package showed no contamination.

The RSO tracked the history of the package through Fed-Ex and determined that the package had been delivered to someone else (Contact the Headquarters Operations Officer for the name of the person) on 2/25/05 at 11:11a.m. The delivery location was listed as the address previously used by Fox Chase (although a different address it is still at the same building location). The RSO was unable to find anyone in the Fox Chase building by the name documented in the Fed-Ex tracking system.

The licensee believes that this is reportable since the P-32 was unaccounted for and apparently possessed by an unauthorized individual for some period of time after 11:11a.m. on 2/25/05 such that an exposure could have resulted to persons in an unrestricted area.

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Power Reactor Event Number: 41450
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SCOTT FRUIN
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2005
Notification Time: 17:27 [ET]
Event Date: 02/28/2005
Event Time: 02:06 [CST]
Last Update Date: 02/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
ANNE MARIE STONE (R3)
CYNTHIA CARPENTER (NRR)
KRISS KENNEDY (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby

Event Text

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION - UNUSUAL EVENT

The following information was provided by the licensee via fax (licensee text in quotes):

"At 1535 [CST] hours on 2/28/05, Byron Station determined that an emergency classification for an Unusual Event was not declared previously at 0206 [CST] on 2/28/05. The missed Unusual Event classification was due to a RCS dose equivalent I-131 value for Byron Unit 1 exceeding the EAL threshold value of >1.0 microCuries/gm [Iodine] for EAL MU7. An RCS iodine sample was taken at 0106 hours on 2/28/05 during shutdown activities for the B1R13 refueling outage. The sample was analyzed and reported back to the Operations shift at 0206 hours with a value of 1.07 microCuries/gm[Iodine]. This sample has been reconfirmed. At 0206 on 2/28/05, Byron Unit 1 was not in the mode of applicability for the RCS coolant activity Technical Specification 3.4.16. It was not recognized at that time that the EAL threshold value was exceeded until 1535 hours on 2/28/05. Note that a subsequent RCS sample taken at 0930 on 2/28/05 determined that the EAL threshold value is no longer exceeded and the current value remains less than the threshold. Byron Unit 1 has been operating the current cycle with an estimated 1-3 leaking fuel rods and special limitations were implemented by the site during shutdown.

"This notification is being made in accordance with the requirements of 10 CFR 50.72(a) for a missed declaration of an Unusual Event for RCS dose EQ I-131 exceeding the EAL threshold value of 1.0 microCuries/gm[Iodine] during shutdown activities for the Byron Unit 1 refueling outage. This issue has been placed in the Byron Corrective Action Program."

The licensee will notify the NRC Resident Inspector, State and Local agencies.

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Power Reactor Event Number: 41451
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: STEVE SMITH
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2005
Notification Time: 19:52 [ET]
Event Date: 02/28/2005
Event Time: 14:57 [MST]
Last Update Date: 02/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHUCK CAIN (R4)

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 Y 100 Power Operation 100 Power Operation

Event Text

MAJOR LOSS OF SIREN COVERAGE WITHIN THE EMERGENCY PLANNING ZONE

The following information was provided by the licensee via facsimile (licensee text in quotes):

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On February 28, 2005 at approximately 14:57 Mountain Standard Time, the Palo Verde Emergency Preparedness Program Manager was notified of vandalism to a single siren (#42) that resulted in the siren being inoperable. Based on evidence from previous testing, the vandalism has been established to have occurred sometime between 15:00, Friday, 02/25/2005 and 03:00, Saturday, 02/26/2005. The affected siren is estimated to impact approximately 116 members of the population (7.3%) in the emergency planning zone (EPZ) within 5 miles. Palo Verde's reporting criterion is a loss of capability to inform greater than 5% of the population within 5 miles (or 10% within 5 to 10 miles) for greater than 1 hour. This call is being placed due to the relatively large segment of the population affected, and the uncertainty of the length of time that will be needed to restore the siren to operable condition. The Palo Verde Emergency Plan (section 6.6.2.1) has a contingency for dispatching Maricopa County Sheriff's Office (MCSO) vehicles with loud speakers to alert persons within the affected area(s) when sirens are inoperable.

"There are no events in progress that require siren operation.

"The NRC Resident Inspector has been notified of the siren failure and this ENS call."

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Power Reactor Event Number: 41452
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BOB PACE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/01/2005
Notification Time: 02:51 [ET]
Event Date: 03/01/2005
Event Time: 00:43 [EST]
Last Update Date: 03/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DANIEL HOLODY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 15 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR SCRAM FROM 15% POWER DUE TO HIGH TURBINE VIBRATION

"MANUAL REACTOR SCRAM DUE TO HIGH TURBINE GENERATOR VIBRATION DURING A PLANNED UNIT 1 POWER REDUCTION TO MODE 2 TO PERFORM MAINTENANCE TO REPLACE THE VENT LINE PIPING ON 11 MSR DRAIN TANK. THE MANUAL REACTOR SCRAM WAS INTIATED PER AOP-7E, SECTION V, "HIGH TURBINE VIBRATION" TRIP CRITERIA WHEN BEARING #5 EXCEEDED 12 MILS VIBRATION. THIS EVENT MEETS NUREG-1022 REV. 2, SECTION 3.2.6 "SYSTEM ACTUATION" PART 50.72(B)(2)(IV)(B) "ANY EVENT OR CONDITION THAT RESULTS IN ACTUATION OF Tf-IE REACTOR PROTECTION SYSTEM (RPS) WHEN THE REACTOR IS CRITICAL EXCEPT WHEN THE ACTUATION RESULTS FROM AND IS PART OF A PRE-PLANNED SEQUENCE DURING TESTING OR REACTOR OPERATION."

ALL RODS FULLY INSERTED AND NO ECCS OR RELIEF VALVE ACTUATIONS OCCURRED. HEAT SINK IS
THE CONDENSER AND TURBINE BYPASS VALVES


THE NRC RESIDENT INSPECTOR WAS NOTIFIED.

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