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Event Notification Report for April 13, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/12/2005 - 04/13/2005

** EVENT NUMBERS **


41576 41580 41585 41588 41590 41592

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General Information or Other Event Number: 41576
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 25-1323-01
Agreement: Y
Docket:
NRC Notified By: PAUL SCHMIDT
HQ OPS Officer: WESLEY HELD
Notification Date: 04/08/2005
Notification Time: 14:07 [ET]
Event Date: 04/08/2005
Event Time: 08:30 [CST]
Last Update Date: 04/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
TOM ESSIG (NMSS)

Event Text

POTENTIAL MEDICAL EVENT INVOLVING A THERAPEUTIC ADMINISTRATION OF YTTRIUM-90

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

"On Friday, April 8, 2005 at approximately 8:30 a.m., the Wisconsin Radiation Protection Section (RPS) received notification from the University of Wisconsin, Madison, WI (license number 25-1323-01) of a potential medical event involving a therapeutic radiation dose from a Yittrium-90 Zevelin treatment in which the delivered dose may have differed from the prescribed dose by more than 0.5 Sv (50 rem) and by 20% or more of the prescribed dose. [HFS 157.72 (1) (a) 1.]

"On Tuesday, April 5, 2005, a physician at the University of Wisconsin Hospital and Clinics, Madison, WI administered a 48 mCi dose of Y-90 Zevalin to a patient. Based upon patient weight and platelet count, the intended dose should have been 28 mCi. The dose was dispensed as a unit dose by a nuclear pharmacy and administered as received. There is no indication of a written directive. The error was not discovered until Thursday, April 7 during a licensee review of records.

"The licensee is investigating the incident. The ordering physician has been notified

"HFS 157.72 (1) (a) 1. requires a licensee to report an event in which the administration of radioactive material or resulting radiation results in 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem), 0.5 Sv (50 Rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and the total dose delivered differs from the prescribed dose by 20% or more'.

"DHFS, RPS staff plan to investigate. "

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General Information or Other Event Number: 41580
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SADDLEBACK MEMORIAL HOSPITAL
Region: 4
City: LAGUNA HILLS State: CA
County:
License #: 2652-30
Agreement: Y
Docket:
NRC Notified By: MARK PIETZ
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/08/2005
Notification Time: 17:42 [ET]
Event Date: 04/08/2005
Event Time: 12:35 [PST]
Last Update Date: 04/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
MELVYN LEACH (NMSS)

Event Text

AGREEMENT STATE REPORT OF POTENTIAL MEDICAL MISADMINISTRATION

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

"At 12:35 pm [the] manager of the [Saddleback Memorial Hospital] Imaging Department contacted [the CA Radiological Health Branch] to report a therapy misadministration involving HDR and Ir-192. [The hospital manager] knew few details, other than to report that the source was apparently implanted 8 cm short of its desired location. At this time it is not known how much under treatment there was to the tumor site, nor how much exposure there was to healthy tissue. [It has] not been determined if this is a CA SS&D [Sealed Source and Device]. [The hospital manager] is obtaining this information and will be reporting it back, via fax, as soon as possible. [The CA Radiological Health Branch] has requested narrative as to flow of events.

"This form will be updated and forwarded to NRC Ops Center as information comes in."

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Power Reactor Event Number: 41585
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GORDON ROBINSON
HQ OPS Officer: WESLEY HELD
Notification Date: 04/10/2005
Notification Time: 12:08 [ET]
Event Date: 04/10/2005
Event Time: 11:50 [EDT]
Last Update Date: 04/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JAMES NOGGLE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO FAILED 125V DC BATTERY CHARGER

"At 0352 the 2C 125VDC battery charger failed. Fuses internal to the charger were found blown. Technical Specifications require restoration of the charger within 2 hrs or enter Mode 3 within the next 12 hrs and Mode 4 within the next 36 hrs. Investigation has not been able to restore the charger, and therefore the shutdown of the unit has commenced. Loads are currently being carried by the batteries, and personnel are monitoring battery voltage. Initial investigation has not identified any generic issues or any indication of tampering.

"This event is a Technical Specification required shutdown, and is reportable as a four hour ENS Notification under 10 CFR 50.72(b)(2)(i). Additionally, this is a voluntary notification due to an anticipated press release associated with the downpower towards unit shutdown."

There is evidence of degraded insulation on wires inside the affected battery charger. Battery loads are very small with an initial estimate of battery life at 80 hours. All safety systems are operable. There is no impact on Unit 1.

Unit 2 is expected to reach Mode 3 at 1720 on 4/10/05.

The NRC Resident Inspector has been notified. State (FEMA) will be notified.

* * * UPDATE PROVIDED BY LICENSEE (HUFFORD) TO NRC (HELD) AT 2030 ON 4/10/05 * * *

"At 17:28 the plant completed a normal reactor shutdown and entered Mode 3 in accordance with plant procedures to fulfill the requirements of Technical Specification 3.8.4. There were no ECCS initiations and lowest water level was approximately -4 inches."

The licensee reported that the 2C battery charger was back in service but remained in the LCO due to battery requirements. They are also completing engineering evaluations for extent of condition.

The NRC Resident Inspector was notified.

R1DO (Noggle) notified.

* * * UPDATE PROVIDED BY LICENSEE (KLINEFELTER) TO NRC (HELD) AT 1710 ON 4/12/05 * * *

"At 16:28 on April 12th, 2005 Susquehanna Unit 2 entered Mode 2 (Start-up) following the completion of repairs to the failed 125VDC battery charger and inspection to the remaining 3 Unit 2 125VDC battery chargers. A courtesy call was made [to] the Pennsylvania Emergency Management Agency. An informational press release will be made."

The NRC Resident Inspector was notified by the licensee.

R1DO (White) was notified.

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Power Reactor Event Number: 41588
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ANDREW OHRABLO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/11/2005
Notification Time: 19:11 [ET]
Event Date: 04/11/2005
Event Time: 16:04 [CST]
Last Update Date: 04/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
REBECCA NEASE (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

Event Text

LOSS OF PUBLIC PROMPT NOTIFICATION CAPABILITY

"At approximately 1604 CDT on 4/11/05, Cooper Nuclear Station (CNS) was informed by Emergency Preparedness officials of Atchison County that the radio transmission tower that provides signals to activate tone alert radios within the 10-mile Emergency Planning Zone (EPZ) was not functioning. Tone alert radio is relied on by approximately 650 households in the EPZ who are not in audible range of sirens for notification of an emergency at CNS. Based on a total EPZ population currently estimated at 4600 persons (who are alerted principally by sirens and the tone alert radio), this is considered to be a major loss of the Public Prompt Notification system capability, and is reportable under 10CFR50.72(b)(3)(xiii).

"Investigations are ongoing, a repair technician has been dispatched to the tower. During the interim, compensatory measures have been verified to be in place via state and local emergency planning officials for backup route alerting for personnel within the 10-mile EPZ."

NRC Resident Inspector was notified.

* * * UPDATED PROVIDED BY LICENSEE (JOBE) TO NRC (HELD) AT 1632 ON 4/12/05 * * *

"22:53 on 4/11/05- CNS was notified by the NWS [National Weather Service] that the transmitter had been returned to high power service at 19:35. The cause of the high power transmitter loss was a lightning strike to the transmitter. The strike did not result in any equipment damage, however the transmitter had to be manually reset.

"22:55 on 4/11/05- CNS contacted Nemaha and Richardson County Sheriff's Departments and the Atchison County 911 center to notify them that the transmitter/tower had been returned to service.

"Operation of equipment was verified. Transmitter tower and tone alert radios have been returned to service."

NRC Resident Inspector was notified by the licensee.

R4DO (Nease) was notified.

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Power Reactor Event Number: 41590
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 04/12/2005
Notification Time: 08:47 [ET]
Event Date: 02/19/2005
Event Time: 05:50 [EST]
Last Update Date: 04/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
WALTER ROGERS (R2)

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

Event Text

60 DAY INVALID ACTUATION OF SYSTEM REPORT.


"(A): The specific train(s) and system(s) that were actuated.

"This report is being made under 10 CFR 50.73(a)(2)(iv)(A). On February 19, 2005 at 05:50 ET the implementation of a clearance to de-energize the Division 1 24/48 VDC battery chargers were being performed using the system operating procedure. The clearance instructions were misinterpreted and the section of the procedure for de-energizing Division 1 24/48 VDC bus was used. Upon de-energizing the bus, a half scram was received, all 4 Standby Gas Treatment (SBGT) fans auto started and both unit ONE and unit TWO reactor building and refueling floor normal ventilation systems automatically shutdown/isolated.

"(b) Whether each train actuation was complete or partial.

"The 1/2 scram was a partial initiation of the RPS system logic. No control rods inserted as a result of this event, nor were they required to insert. The RPS logic functioned as expected during the 1/2 RPS trip.

"The 4 Standby Gas Treatment (SBGT) fans auto started and both unit ONE and unit TWO reactor building and refueling floor normal ventilation systems automatically shutdown/isolated. THE SBGT initiation and the ventilation system shutdown were both complete actuations.

"(C) Whether or not the system started and functioned successfully.

"The above systems functioned successfully."

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

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Hospital Event Number: 41592
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA NATIONAL HEALTH PHYSICS PROGRAM
Region: 4
City: DALLAS State: TX
County:
License #: 03-23856-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT, PHD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/12/2005
Notification Time: 16:18 [ET]
Event Date: 04/09/2005
Event Time: [CST]
Last Update Date: 04/12/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHN MADERA (R3)
SCOTT FLANDERS (NMSS)
REBECCA NEASE (R4)

Event Text

POSSIBLE MEDICAL EVENT

The VA National Health Physics Program (master materials licensee) reported a possible medical event at one of its permittees involving a Co-60 teletherapy device. The possible event occurred at the VA North Texas Health Care System, Dallas, Texas, on the dates of April 9 and 10, 2005.

"A patient was treated on Saturday and Sunday, April 9 and 10, 2005, for spinal cord compression. The written directive prescribed a dose of 500 cGy in two equal daily fractions. The intent was to give a total dose of about 2900 cGy, with another directive for the remainder of the fractions to be written on April 11, 2005. The treatment time for the fractions on April 9 and 10, 2005, was miscalculated. 330 cGy were administered instead of the prescribed 500 cGy. To avoid too low a dose, an additional fraction of 200 cGy will be given to the patient. This would not have met the definition of a medical event had a single directive, instead of two, been written for the entire treatment series.

"No adverse effect to the patient from the event is expected. The permittee has notified the referring physician and patient."

The licensee will notify the NRC Region III Project Manager (Kevin Null).

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