United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2005 > March 24

Event Notification Report for March 24, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/23/2005 - 03/24/2005

** EVENT NUMBERS **


41344 41501 41507 41516

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41344
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: FREDERICK SMITH
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/19/2005
Notification Time: 05:54 [ET]
Event Date: 01/19/2005
Event Time: 02:37 [EST]
Last Update Date: 03/23/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANNE MARIE STONE (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE DUE TO AN UNANALYZED CONDITION

"The environmental temperature of the tornado missile enclosure for the Emergency Diesel Generators during an accident condition when all three testable rupture disks open is expected to exceed the limiting temperature for the structural concrete. A detailed analysis of the capability of the tornado missile enclosure concrete to meet that standard cited in the USAR section 3.8.3.3.7 has not been located. At 0237 on 19 January 2005, Division 1,2 & 3 Diesel Generators were declared inoperable. Actions of Technical Specification 3.8.2 were directed and compliance verified."


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


* * * UPDATE ON 03/23/05 @ 1524 BY KEN MEADE TO CHAUNCEY GOULD * * * RETRACTION

The following information was provided by the licensee by fax:

"An 8-hour notification was made on January 19, 2005, in accordance with 10CFR50.72(b)(3)(ii)(B), for an unanalyzed condition and 10CFR50.72(b)(3)(v)(D), for the loss of the accident mitigation safety function. This report was made after declaring division 1, 2, and 3 diesel generators inoperable because the tornado missile enclosure concrete analysis demonstrating compliance with USAR section 3.8.3.3.7 could not be located. Compensatory measures were taken to protect the concrete and vent lines in the area while an analysis was performed."

"The required analysis was performed by a contract engineering firm. On March 23, 2005, the analysis was owner accepted with comments for incorporation into the final report. None of the comments affected the conclusion of the analysis. This analysis confirmed that the concrete enclosure, as originally designed, supported operability of the diesel generators and their support subsystems."

"Modifications are being implemented to improve the design margin of the safety related enclosure under accident conditions with the testable rupture disks open. These design modifications are improvements and were not required for past diesel generator operability."

"Since the operability of the diesel generators and their support subsystems were not affected, there was no unanalyzed condition that significantly degraded plant safety, nor was there a loss of safety function. Since there was no reportable condition, ENF 41344 is retracted."


The NRC Resident Inspector was notified.

Notified RDO (Kozak)

To top of page
General Information or Other Event Number: 41501
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M008-1
Agreement: Y
Docket:
NRC Notified By: A. SCROGGS (E-MAIL)
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/18/2005
Notification Time: 11:30 [ET]
Event Date: 03/17/2005
Event Time: 12:00 [PST]
Last Update Date: 03/18/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM FARNHOLTZ (R4)
TOM ESSIG (NMSS)

Event Text

ARGEEMENT STATE MEDICAL EVENT

The following information was provided by the State via e-mail (State text in quotes):

"At 2 PM on March 17, 2005, the Swedish Medical Center, Radiation Safety Officer reported that an incident occurred at 12 PM, March 17, due to a clogged filter in the i.v. tubing used to administer an Iodine 131 radioisotope. The clog occurred during the procedure and prevented the administration of the total prescribed dose.

"The dosimetric protocol of the I-131 administration requires a 'cold' infusion of AntiB Antibody prior to radioisotope administration. This cold administration needs to pass through a 0.22 micron filter. The manufacturer's protocol states that the radioisotope should also be administered through the filter. The protocol further indicates that if the filter clogs, that the remainder of the radioisotope is administered without the presence of the filter.

"When the filter clogged, the nuclear medicine technologist first attempted to flush the clog with saline and then bypass the filter to complete the administration. After the administration it was determined by dose calibrator that 43.7 MBq (1.18 mCi) of I-131 was trapped in the tubing behind the filter. The actual administered activity was about 146.2 MBq (3.95 mCi) of the prescribed 185 MBq (5 mCi) dose.

"Corrective Actions: Since the preliminary investigation indicates the cause of the misadministration was due to clogging of the filter, the Radiation Safety Officer has recommended immediately bypassing the filter during administration instead of attempting to unclog it. The RSO plans to contact the vendor to get a protocol clarification and will include that information in the formal written report."

To top of page
General Information or Other Event Number: 41507
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MARIETTA MEMORIAL HOSPITAL
Region: 3
City: MARIETTA State: OH
County:
License #: 02120850007
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/21/2005
Notification Time: 08:50 [ET]
Event Date: 03/11/2005
Event Time: 13:00 [EST]
Last Update Date: 03/21/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3)
JOHN HICKEY (NMSS)

Event Text

POSSIBLE MEDICAL MISADMINISTRATION

A prostate implant patient at Marietta Memorial Hospital was to have received 98 Iodine-125 seeds, 0.310 millicuries per seed, but instead received 83 iodine-125 seeds and 15 palladium-103 seeds, 1.2 millicuries each (palladium-103 is accelerator produced). The patient received 98% of the planned dose. The holders for the iodine-125 seeds and the palladium-103 seeds are similar in shape and size. The State of Ohio Bureau of Radiation Protection received the above information on 03/16/05 around 1300 hours. The Ohio Bureau of Radiation Protection is investigating this event.

To top of page
Power Reactor Event Number: 41516
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: JIM RUSSELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/23/2005
Notification Time: 22:29 [ET]
Event Date: 03/23/2005
Event Time: 19:56 [EST]
Last Update Date: 03/23/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DAVID AYRES (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
4 N Y 20 Power Operation 0 Hot Standby

Event Text

REACTOR MANUALLY TRIPPED FROM 20% POWER DURING LOAD REDUCTION.

Unit 4 reactor was manually tripped from 20 percent power per 4 - GOP - 103 "Power Operation to Hot Standby" (normal shutdown procedure), during a load reduction to take the unit off line. The reason for the load reduction was an oil leak of approximately 100 drops per minute on the "4B" steam generator feed pump. The reactor was tripped when directed by 4 - GOP - 103. All rods fully inserted, no relief valves lifted, and all other systems functioned normally.

The licensee notified the NRC Resident Inspector.

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