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Event Notification Report for April 5, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/04/2005 - 04/05/2005

** EVENT NUMBERS **


41542 41554 41556 41560 41561 41562

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 41542
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LOWELL GENERAL HOSPITAL
Region: 1
City: LOWELL State: MA
County:
License #: 44-0060
Agreement: Y
Docket: 02-5396
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/29/2005
Notification Time: 12:46 [ET]
Event Date: 01/17/2005
Event Time: 12:00 [EST]
Last Update Date: 04/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
TOM ESSIG (NMSS)

Event Text

MEDICAL MISADMINISTRATION - WRONG TREATMENT SITE

The State provided the following NMED information:

"On 1/18/05, the licensee reported to the Agency a teletherapy misadministration that occurred on 1/17/05. The situation was described as 'the treatment field was displaced by six cm when the therapist set the central axis of the field at the tattoo marking the bottom of the field'. An area of 15 cm x 6 cm (treatment site) received dose when the plan called for that tissue to receive no dose. The dose was one day's treatment of 180 cGy. The treatment monitor units and energy were correct, the error was entirely an issue of field placement."

The Regulation Code cited is 105 CFR 120.502 (4) (a). The intended dose to the patient was 180 cGy, however, only 90 cGy was given to the wrong treatment site (15 cm x 6 cm area). Per the treating physician, no corrective action is needed. The hospital retrained staff to ensure confirming proper positioning of therapy prior to treatment.

"Event type Description: MD2 - Wrong Treatment Site.

"Cause description: The therapist did not correctly align the treatment field with the patient's treatment alignment tattoo."

"The Agency considers this event closed."

* * * UPDATE FROM STATE (TONY CARPENITO) TO M. RIPLEY AT 0953 EST 04/04/05 * * *

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

"The device used to deliver the radiation treatment was a LINEAR ACCELERATOR."

Notified R1 DO (Noggle) and NMSS EO (T. Essig)

* * * RETRACTION FROM STATE (TONY CARPENITO) TO M. RIPLEY AT 1130 EST 04/04/05 * * *

Based on a discussion with the NMSS EO (T. Essig) and the State (T. Carpenito), this notification is retracted because the device used to deliver the radiation treatment is not regulated by NRC.

Notified R1 DO (Noggle) and NMSS EO (T. Essig)

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General Information or Other Event Number: 41554
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: FUGRO CONSULTANTS
Region: 4
City: PASADENA State: TX
County:
License #: L04322
Agreement: Y
Docket:
NRC Notified By: KAREN VERSER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/31/2005
Notification Time: 16:21 [ET]
Event Date: 01/18/2005
Event Time: [CST]
Last Update Date: 03/31/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
ELMO COLLINS (NMSS)

Event Text

AGREEMENT STATE - OVEREXPOSURE

The following information was provided by the Texas Department of State Health Services via E-mail (state text in quotes):

"Radiography was conducted at both field and fixed locations during the December [2004] monitoring period. The badge of [the radiographer trainee] was the only high badge for the Licensee during the monitoring period. The Radiography Trainer claims that his pocket dosimeter and alarming rate meter showed no unusual activity during the monitoring period. All exposure devices were leak tested December 30, 2004, with no leakage in excess of applicable limits being exceeded - no leakage. The Radiographer Trainer was on two crews during the monitoring period. Both other crew members had normal exposures for the monitoring period. No explanation for a possible source of exposure to the badge was offered by the Licensee or the wearer of the badge. The Licensee was cited for violating the Deep dose annual exposure limits for calendar year 2004."

The trainee was seen by a physician however, the blood work results are not yet available. As corrective action, the licensee has notified all radiographers to carefully monitor their pocket dosimeters and alarming rate meters, and to keep their personal monitoring badges away from sources of radiation.

The four cameras used contained Ir-192 (72.4 Ci, 81.5 Ci, 34.1 Ci, and 39.4 Ci). Total dose received by the radiographer trainee was 11.885 REM DDE for December 2004 and 12.771 REM DDE for the annual monitoring period.

Texas Incident # I-8199.

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General Information or Other Event Number: 41556
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEAM COOPERHEAT - MQS
Region: 4
City: ALVIN State: TX
County:
License #: L00087
Agreement: Y
Docket:
NRC Notified By: GLENN CORBIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/31/2005
Notification Time: 16:33 [ET]
Event Date: 02/21/2005
Event Time: 18:55 [CST]
Last Update Date: 03/31/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
ELMO COLLINS (NMSS)

Event Text

AGREEMENT STATE - RADIOGRAPHIC SOURCE PARTIALLY DISCONNECTED FROM CAMERA

The following information was provided via E-mail by the Texas Department of State Health Services (DSHS) (state text in quotes):

"On February 21,2005 at the Motiva Enterprise facility located in Port Arthur, Texas an event took place that prevented the return of a radiography source to the shielded position via normal operations. The unauthorized retrieval of the source was done without proper license condition authorization. All dosimeters have been processed and no overexposures have occurred as a result of the retrieval. Additionally, a verbal notification was made to DSHS, and followed by written report received 03/21/05.

"The Operating and Emergency procedures to be employed in an incident of this type were reviewed for full understanding by all staff involved in Radiographic operations."

The source was Ir-192 (150 Ci) from a SPEC Model G-60; AEA Model 969.

Texas Incident # I-8224

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Power Reactor Event Number: 41560
Facility: LASALLE
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: HAROLD VINYARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/04/2005
Notification Time: 13:19 [ET]
Event Date: 02/07/2005
Event Time: 07:56 [CST]
Last Update Date: 04/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
KENNETH O'BRIEN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

INVALID SPECIFIED SYSTEM ACTUATION

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"This telephone notification is provided in accordance with 10 CFR 50.73(a)(1), to report an invalid actuation reportable under 10 CFR 50.73(a)(2)(iv)(A).

"On February 7, 2005, at 0756 [CST], with Unit 2 in Mode 3 'Hot Shutdown' in preparation for the 2005 refueling outage, the 2A Reactor Protection System (RPS) bus unexpectedly de-energized during performance of LOS-RP-W1, 'Manual Scram Instrumentation.' As a result, an RPS Bus A half scram and Division 1 Primary Containment Isolation System (PCIS) isolations were received, including the isolation of shutdown cooling. All affected containment isolation valves closed as designed.

"An inspection found that the 2A RPS MG set output breaker had opened. RPS Bus A was transferred to its alternate feed, and the associated containment isolations were reset. Shutdown cooling was restored at 0845 hours on February 7, 2005.

"Troubleshooting found that the 2A RPS MG set voltage regulator had failed. The voltage regulator was replaced and successfully tested, and the 2A RPS MG set was returned to service. Laboratory testing of the failed voltage regulator circuit board found that a solder joint had failed on load-dropping resistor R8, which caused the excitation output voltage to decrease sharply. This resulted in a trip of the 2A RPS MG set output breaker on low voltage.

"The apparent cause of the failed solder joint was a manufacturing defect. Corrective actions include visual inspections of RPS MG set voltage regulatory circuit boards in the field and in the storeroom, and the development of enhanced receipt inspection requirements.

"This event is reportable under 10 CFR 50.73(a)(2)(iv)(A) as an invalid actuation of containment isolation valves in more than one system."

The licensee has notified the NRC Resident Inspector.

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Hospital Event Number: 41561
Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County: LANCASTER
License #: 37-11866-04
Agreement: N
Docket:
NRC Notified By: TONY MONTAGNESE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/04/2005
Notification Time: 15:01 [ET]
Event Date: 09/30/2003
Event Time: [EST]
Last Update Date: 04/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
Person (Organization):
JAMES NOGGLE (R1)
JOHN HICKEY (NMSS)

Event Text

MEDICAL EVENT NOTIFICATION

In September, 2003, a patient at Lancaster General Hospital's Health Campus was undergoing Co-60 gamma knife treatment. In preparation for the treatment, the patient was immobilized to ensure that the gamma knife was accurately aimed at the treatment site. During the treatment, the patient became uncomfortable and asked to move. He was told to move only his legs, but he shifted his body. As a result, the patient shifted 7cm away from the gamma knife. Licensee was unable to calculate dose to unintended site. There were no adverse effects to the patient.

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Power Reactor Event Number: 41562
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DUANE HAAS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/04/2005
Notification Time: 19:51 [ET]
Event Date: 04/04/2005
Event Time: 16:07 [CST]
Last Update Date: 04/04/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KENNETH O'BRIEN (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 85 Power Operation 85 Power Operation

Event Text

MINIMUM SWITCHYARD VOLTAGE REQUIREMENTS NOT MET

The following information was obtained from the licensee via facsimile (licensee text in quotes):

"On April 4, 2005, at 1607 hours [CDT], Quad Cities was notified that the switchyard voltage was below that required to ensure that offsite power would remain available following a design basis accident. Both sources of off site power were declared inoperable. The appropriate Technical Specification required actions were taken for both units. The ability of the Emergency Diesel Generators to perform their design function is not affected by this condition. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function given the predicted post-LOCA switchyard voltage.

"This notification report is similar to the condition reported on March 24, 2005 (reference EN#41524 for additional information)."

Technical Specification minimum switchyard voltage is 348.4 KV. Switchyard voltage at 1607 hrs. was approximately 343.7 KV. Switchyard voltage at the time of NRC notification was 358 KV which is above the Technical Specification minimum.

The licensee has notified the NRC Resident Inspector.

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