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Event Notification Report for August 1, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/29/2005 - 08/01/2005

** EVENT NUMBERS **


41868 41873 41880 41881 41882

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Power Reactor Event Number: 41868
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ANDREW WISNIEWSKI
HQ OPS Officer: PETE SNYDER
Notification Date: 07/25/2005
Notification Time: 17:35 [ET]
Event Date: 07/25/2005
Event Time: [EDT]
Last Update Date: 07/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GLENN MEYER (R1)
CLIFF ANDERSON (R1)
CORNELIUS HOLDEN (NRR)
PETER WILSON (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR TRIP CAUSED BY FAILURE IN SWITCHYARD

"At 1525 the plant experienced a load reject generator trip due to a catastrophic failure in the 345 Kv switchyard. A reactor scram occurred as a result. The degraded AC power system prevented a fast transfer from occurring. Degraded bus voltage caused the emergency diesel generators (EDGs) to start. A residual bus transfer restored power to the 4 Kv busses. The [main steam isolation valves] (MSIVs) closed on a low-low reactor water level of 82.5 inches. [Reactor Core Isolation Cooling] and [High Pressure Coolant Injection] (HPCI) also started on the low-low reactor vessel water level.

"The [Safety Relief Valves] were cycled twice for pressure control. OT 3100 Reactor Scram procedure was executed. EOP-3 was entered due to elevated torus water temperature and both loops of [Residual Heat Removal] (RHR) are in torus cooling. Water level has restored and is being maintained by feedwater. The MSIVs have been reopened and the scram reset. EDGs were secured."

The plant is currently shutdown and stable with all control rods fully inserted. Decay heat removal is being accomplished with HPCI in pressure control mode. The licensee is transitioning to feeding with normal feedwater and steam exhausting through drains. Both trains of RHR are providing torus cooling. Electric power is being provided by offsite power. The licensee is currently investigating the event in the switchyard.

The licensee notified the NRC Resident Inspector and will issue a press release.

* * * UPDATED ON 07/29/05 BY MACKINNON * * *

Corrected incorrect entry for Scram Code from N (N/A) to A/R (Automatic/with Rod Motion). R1DO (Glenn Meyer) notified.

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General Information or Other Event Number: 41873
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: SCHLUMBERGER
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-2783-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: PETE SNYDER
Notification Date: 07/26/2005
Notification Time: 18:50 [ET]
Event Date: 07/26/2005
Event Time: 16:00 [CDT]
Last Update Date: 07/28/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID GRAVES (R4)
JOSEPH GIITTER (NMSS)

Event Text

AGREEMENT STATE REPORT - POSSIBLE LOST TRITIUM GENERATORS

Schlumberger called the State of Louisiana to report a missing shipment of four tritium generators. Each unit contains 3 to 5 Ci (curies) of tritium. The shipment was picked up by Federal Express on July 15, 2005 in Shreveport, LA. It was to arrive at its destination on July 17, 2005 at Princeton, NJ. Federal Express notified Schlumberger yesterday that as of that date the shipment had not arrived at its Memphis transportation hub.

The units are sealed in the sense that they need software to be used.

The State of Louisiana is following up.

* * * UPDATE TO NRC (HUFFMAN) FROM STATE REP (NOBLE) @ 12:12 EDT ON 7/28/05 * * *

Federal Express has located the shipment of tritium generators and redirected the shipment to the final destination in New Jersey. The State was told that the shipment was misdirected due to a package labeling problem. The State considers this report closed.

R4DO (Graves) and NMSS EO (Essig) notified.

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Hospital Event Number: 41880
Rep Org: SAINT LUKE HOSPITAL
Licensee: SAINT LUKE HOSPITAL
Region: 1
City: BETHLEHEM State: PA
County:
License #: 37-07939-01
Agreement: N
Docket:
NRC Notified By: TIANYOU XUE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/29/2005
Notification Time: 11:52 [ET]
Event Date: 07/26/2005
Event Time: 11:00 [EDT]
Last Update Date: 07/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GLENN MEYER (R1)
SCOTT MOORE (NMSS)

Event Text

MEDICAL EVENT - DOSE LESS THAN PRESCRIBED DURING MEDICAL TREATMENT

A patient being treated for liver cancer was scheduled to be administered two SIR-spheres treatments (SIR-spheres utilizes radioactive micro-spheres that contain yttrium-90). The first treatment was prescribed as 0.46 GBq (GigaBecquerels) of Y-90. Due to difficulty in determining how much of the Y-90 remained in the vial and the injection catheter, the licensee has determined that only 0.25 GBq were administered in the first treatment dose. The patient will be given a second treatment that takes into consideration the actual amount administered on the first treatment.

The licensee notes that the fraction of Y-90 administered differs from the prescribed dose by 46%. The regulatory criteria under 10 CFR
35.3045(a)(1)(iii) states that the reportability criteria is 50% or greater. The licensee has elected to conservatively report this event since it is close to the regulatory criteria.

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Hospital Event Number: 41881
Rep Org: SAINT VINCENT HOSPITAL
Licensee: SAINT VINCENT HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-000133-02
Agreement: N
Docket:
NRC Notified By: EDWARD WROBLEWSKI
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/29/2005
Notification Time: 15:55 [ET]
Event Date: 07/21/2003
Event Time: [CST]
Last Update Date: 07/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MARK RING (R3)
SCOTT MOORE (NMSS)

Event Text

MEDICAL EVENT - DOSE BOTH GREATER THAN AND LESS THAN PRESCRIBED

"An independent review of HDR (High Dose Rate) treatment records occurred on July 28, 2005. During this review, a Medical Event was discovered which meets reporting requirements of 10 CFR 35.3045.

"On July 21, 2003, an 87 year old male received what was to be the first of two High Dose Rate (HDR) treatments for esophageal cancer using a remote afterloading unit. The physician Authorized User prescribed a dose of 500 cGy (centiGray) at 0.5 cm from the surface of the NG (naso-gastric) tube for an active length of 5.5 cm using a 5.551 Curie iridium-192 source. The treatment plan called for 12 indexer step positions at 5.0 mm spacing. The medical physicist entered 12 indexer step positions with 2.5 mm spacing and treatment was delivered. On August 14, 2003, the second fraction occurred without incident.

"A simulated plan was calculated on July 29, 2005, to reproduce the initial treatment plan and actual treatment delivered. The simulations suggest the patient may have received as much as 74% over dosage to a portion of his esophagus and as much as 92% under dosage to a portion of his esophagus.

"The patient returned to the facility on July 14, 2005, for treatment and is currently under our care."

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Fuel Cycle Facility Event Number: 41882
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: M.C. PITMAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/29/2005
Notification Time: 16:55 [ET]
Event Date: 07/28/2005
Event Time: 21:25 [CDT]
Last Update Date: 07/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MALCOLM WIDMANN (R2)
JOSEPH GIITTER (NMSS)

Event Text

FAILURE OF SAFETY EQUIPMENT ON C-310 CYLINDER VALVE CLOSURE SYSTEM

"At 2125, on 7-29-05 the Plant Shift Superintendent was notified that the nitrogen bottle pressure for the C-310 Cylinder Valve Closure System was reading 0 psig. The function of this system is to close the cylinder valve in the case of an actuation of the UF6 Release Detection and Isolation System at the UF6 Withdrawal Station. TSR 2.3.4.1 requires this system to be operable while operating in mode 2. At the time the nitrogen bottle pressure was discovered to be reading 0 psig, withdrawal positions 3 and 4 were operating in mode 2. The UF6 Release Detection and Isolation System was declared inoperable by the PSS and withdrawal positions 3 and 4 were placed in mode 3 as required by TSR LCO 2.3.4.1.

"This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.

"The NRC Senior Resident Inspector has been notified of this event."

The nitrogen bottle normally maintains a pressure of 1500-2000 psig. The system malfunction was found on the daily equipment check by the operator.

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