Event Notification Report for March 09, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/08/2005 - 03/09/2005
EVENT NUMBERS
41483414754147741473
Hospital
Event Number: 41483
Rep Org: ST. JOHNS MERCY MEDICAL CENTER
Licensee: ST. JOHNS MERCY MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00794-03
Agreement: N
Docket:
NRC Notified By: ROBERT F. TURCO, RSO
HQ OPS Officer: JOHN MacKINNON
Licensee: ST. JOHNS MERCY MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-00794-03
Agreement: N
Docket:
NRC Notified By: ROBERT F. TURCO, RSO
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/11/2005
Notification Time: 17:24 [ET]
Event Date: 03/09/2005
Event Time: 08:35 [CST]
Last Update Date: 03/11/2005
Notification Time: 17:24 [ET]
Event Date: 03/09/2005
Event Time: 08:35 [CST]
Last Update Date: 03/11/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MARK RING (R3)
LAWRENCE KOKAJKO (NMSS)
MARK RING (R3)
LAWRENCE KOKAJKO (NMSS)
INCORRECT DOSE GIVEN TO AN INFANT
A 5 month old infant was to have received 0.5 millicuries of technetium-99 myoview sulfur colloid but instead received 11.6 millicuries of technetium-99 myoview sulfur colloid. Person did not look at the label when measuring the dose to be given to the 5 month old infant. Calculated whole body dose to the infant ranges from 1.0 to 10 rem (most likely between 5.2 and 10 rem whole body dose to the infant) . No adverse reaction to the infant due to receiving 11.6 millicuries of technetium-99 myoview sulfur colloid. Physician has talked to the parents of the infant. Licensee looking into what corrective actions to take in order to prevent this same incident from happening in the future.
A written report will be issued.
A 5 month old infant was to have received 0.5 millicuries of technetium-99 myoview sulfur colloid but instead received 11.6 millicuries of technetium-99 myoview sulfur colloid. Person did not look at the label when measuring the dose to be given to the 5 month old infant. Calculated whole body dose to the infant ranges from 1.0 to 10 rem (most likely between 5.2 and 10 rem whole body dose to the infant) . No adverse reaction to the infant due to receiving 11.6 millicuries of technetium-99 myoview sulfur colloid. Physician has talked to the parents of the infant. Licensee looking into what corrective actions to take in order to prevent this same incident from happening in the future.
A written report will be issued.
Power Reactor
Event Number: 41475
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/09/2005
Notification Time: 16:40 [ET]
Event Date: 03/09/2005
Event Time: 13:04 [CST]
Last Update Date: 03/09/2005
Notification Time: 16:40 [ET]
Event Date: 03/09/2005
Event Time: 13:04 [CST]
Last Update Date: 03/09/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
TROY PRUETT (R4)
TROY PRUETT (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 |
OFFSITE NOTIFICATION DUE TO INVESTIGATION OF INADVERTENT SIREN ACTIVATION
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"On Tuesday 3/8, a local radio station carried a message about inadvertent siren soundings on the previous weekend. Neither the Arkansas Department of Health (ADH) staff nor ANO EP staff received any notifications relative to the inadvertent sounding or the number or location of the sirens. The ADH considers the sirens to be operable. A possible cause was reported as loss of electric service in some areas. ANO has some history that indicates power surges may cause inadvertent actuation of the sirens."
The licensee has notified the NRC Resident Inspector.
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"On Tuesday 3/8, a local radio station carried a message about inadvertent siren soundings on the previous weekend. Neither the Arkansas Department of Health (ADH) staff nor ANO EP staff received any notifications relative to the inadvertent sounding or the number or location of the sirens. The ADH considers the sirens to be operable. A possible cause was reported as loss of electric service in some areas. ANO has some history that indicates power surges may cause inadvertent actuation of the sirens."
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 41477
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: MIKE MCBREARTY
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: MIKE MCBREARTY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/09/2005
Notification Time: 20:36 [ET]
Event Date: 03/09/2005
Event Time: 00:00 [PST]
Last Update Date: 03/18/2005
Notification Time: 20:36 [ET]
Event Date: 03/09/2005
Event Time: 00:00 [PST]
Last Update Date: 03/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TROY PRUETT (R4)
TROY PRUETT (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
PLANNED LOSS OF THE EMERGENCY RESPONSE DATA SYSTEM
The following information was obtained from the licensee via e-mail (licensee text in quotes):
"On Thursday, March 10, 2005 San Onofre Nuclear Generating Station, Unit 2, will remove a portion of the Safety Parameter Display System (SPDS) and the Emergency Response Data System (ERDS) from service for a planned upgrade to ensure long-term reliability and improve the human-machine interface. This work is expected to complete within seven days.
"The SPDS emergency assessment function at San Onofre is implemented by a combination of the Qualified Safety Parameter Display System (QSPDS) and the Critical Function Monitoring System (CFMS). The QSPDS portion, which provides emergency assessment capability to plant operators in the control room, will remain functional. The CFMS portion, which receives input from the QSPDS, implements the ERDS and communicates data to the Technical Support Center and Emergency Offsite Facility. Only the CFMS and ERDS are impacted by this upgrade.
"This planned CFMS outage is being reported in accordance with 10CFR50.72(b)(3)(xiii) as a courtesy notification even though only a portion of the SPDS will be removed from service and preplanned compensatory measures will be in place for the duration of the work.
"At the time of this report, Unit 2 and Unit 3 were operating at about 79 percent and 99 percent power, respectively.
"The NRC Resident Inspectors will be notified of this occurrence and will be provided with a copy of this report."
Should an emergency event occur, the licensee intends to transmit emergency response data to the NRC via facsimile and voice via the emergency notification system. No electronic data will be sent to the NRC Operations Center for the outage duration.
* * * UPDATE FROM CLAY WILLIAMS TO HOWIE CROUCH ON MARCH 18, 2005 @ 1551 EST * * *
"The CFMS upgrade work was completed on March 17, 2005 at 2310 PST. The SPDS and ERDS have been returned to service."
The licensee has notified the NRC Resident Inspector. Notified R4DO (Farnholtz).
The following information was obtained from the licensee via e-mail (licensee text in quotes):
"On Thursday, March 10, 2005 San Onofre Nuclear Generating Station, Unit 2, will remove a portion of the Safety Parameter Display System (SPDS) and the Emergency Response Data System (ERDS) from service for a planned upgrade to ensure long-term reliability and improve the human-machine interface. This work is expected to complete within seven days.
"The SPDS emergency assessment function at San Onofre is implemented by a combination of the Qualified Safety Parameter Display System (QSPDS) and the Critical Function Monitoring System (CFMS). The QSPDS portion, which provides emergency assessment capability to plant operators in the control room, will remain functional. The CFMS portion, which receives input from the QSPDS, implements the ERDS and communicates data to the Technical Support Center and Emergency Offsite Facility. Only the CFMS and ERDS are impacted by this upgrade.
"This planned CFMS outage is being reported in accordance with 10CFR50.72(b)(3)(xiii) as a courtesy notification even though only a portion of the SPDS will be removed from service and preplanned compensatory measures will be in place for the duration of the work.
"At the time of this report, Unit 2 and Unit 3 were operating at about 79 percent and 99 percent power, respectively.
"The NRC Resident Inspectors will be notified of this occurrence and will be provided with a copy of this report."
Should an emergency event occur, the licensee intends to transmit emergency response data to the NRC via facsimile and voice via the emergency notification system. No electronic data will be sent to the NRC Operations Center for the outage duration.
* * * UPDATE FROM CLAY WILLIAMS TO HOWIE CROUCH ON MARCH 18, 2005 @ 1551 EST * * *
"The CFMS upgrade work was completed on March 17, 2005 at 2310 PST. The SPDS and ERDS have been returned to service."
The licensee has notified the NRC Resident Inspector. Notified R4DO (Farnholtz).
Power Reactor
Event Number: 41473
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: BILL GOTT
Region: 4 State: AR
Unit: [] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: RICHARD HARRIS
HQ OPS Officer: BILL GOTT
Notification Date: 03/09/2005
Notification Time: 09:36 [ET]
Event Date: 03/09/2005
Event Time: 05:37 [CST]
Last Update Date: 03/15/2005
Notification Time: 09:36 [ET]
Event Date: 03/09/2005
Event Time: 05:37 [CST]
Last Update Date: 03/15/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
TROY PRUETT (R4)
TROY PRUETT (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Standby | 0 | Hot Standby |
PRESSURIZER HEATER SLEEVE LEAKAGE
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"ANO (Arkansas Nuclear One) Unit 2 shutdown on 3/9/05 at approximately 0038 [CST] to begin the 2R17 refueling outage. While performing the Mode 3 Hot Shutdown Walk down on ANO Unit 2, evidence of leakage was discovered around three (3) pressurizer heater sleeves. The amount of leakage was minor since no indication of moisture was present and the build up of boric acid was minimal. Investigations are underway as to the repair of the affected nozzles."
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 03/12/05 @ 2255 BY JAMES CRABILL TO CHAUNCEY GOULD * * *
The following information was obtained from the licensee via facsimile (licensee text in quotes):
" ANO Unit 2 shutdown on 3-9-05 at approximately 0038 to begin the 2R17 refueling outage. While performing the Mode 3 Hot Shutdown Walk down on ANO Unit 2, evidence of leakage was discovered around three (3) pressurizer Heater Sleeves. The amount of leakage was minor since no indication of moisture was present and the build up of boric acid was minimal. Investigations are underway as to the repair of the affected nozzles.
"Update on 3/12/2005 @ 2140: During the followup inspection performed on 3-12-2005, eight pressurizer heater nozzles had evidence of boric acid leakage at the annulus between the nozzle and pressurizer. One plug was also discovered with evidence of boric acid leakage. The nozzle at this location was plugged during the late 1980's."
The reactor is presently in cold shutdown.
The NRC Resident Inspector was notified.
* * * UPDATE FROM J. CRABILL TO M. RIPLEY 2220 EST 03/15/05 * * *
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"Following decontamination activities performed on 3-15-2005, 1 [one] additional pressurizer heater nozzle had evidence of leakage at the annulus between the nozzle and pressurizer."
The licensee notified the NRC Resident Inspector. Notified R4 DO (T. Farnholtz)
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"ANO (Arkansas Nuclear One) Unit 2 shutdown on 3/9/05 at approximately 0038 [CST] to begin the 2R17 refueling outage. While performing the Mode 3 Hot Shutdown Walk down on ANO Unit 2, evidence of leakage was discovered around three (3) pressurizer heater sleeves. The amount of leakage was minor since no indication of moisture was present and the build up of boric acid was minimal. Investigations are underway as to the repair of the affected nozzles."
The licensee notified the NRC Resident Inspector.
* * * UPDATE ON 03/12/05 @ 2255 BY JAMES CRABILL TO CHAUNCEY GOULD * * *
The following information was obtained from the licensee via facsimile (licensee text in quotes):
" ANO Unit 2 shutdown on 3-9-05 at approximately 0038 to begin the 2R17 refueling outage. While performing the Mode 3 Hot Shutdown Walk down on ANO Unit 2, evidence of leakage was discovered around three (3) pressurizer Heater Sleeves. The amount of leakage was minor since no indication of moisture was present and the build up of boric acid was minimal. Investigations are underway as to the repair of the affected nozzles.
"Update on 3/12/2005 @ 2140: During the followup inspection performed on 3-12-2005, eight pressurizer heater nozzles had evidence of boric acid leakage at the annulus between the nozzle and pressurizer. One plug was also discovered with evidence of boric acid leakage. The nozzle at this location was plugged during the late 1980's."
The reactor is presently in cold shutdown.
The NRC Resident Inspector was notified.
* * * UPDATE FROM J. CRABILL TO M. RIPLEY 2220 EST 03/15/05 * * *
The following information was obtained from the licensee via facsimile (licensee text in quotes):
"Following decontamination activities performed on 3-15-2005, 1 [one] additional pressurizer heater nozzle had evidence of leakage at the annulus between the nozzle and pressurizer."
The licensee notified the NRC Resident Inspector. Notified R4 DO (T. Farnholtz)