Event Notification Report for November 08, 2005

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THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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EXCEEDED MASS LIMIT REQUIREMENTS

Licensee reported an administrative IROF [Item Relied On For Safety] failure for the Environmental Safety Program. During the transfer of NaOH based uranium solution from Tank # XX-0023 to Tank # XX-0011 the licensee failed to identify a mass limit more restrictive for Tank # XX-0011 prior to transfer. The licensee exceeded the mass limit requirements due to the two tanks not being identical. Tank #XX-0011 was quarantined and the accident sequence for the tank transfer re-evaluated. This event did not involve or violate any criticality controls, and no release occurred.

The licensee notified the NRC Resident Inspector.

* * * UPDATE 05/11/08 BY P. SNYDER * * *

THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.

REACTOR TRIP DUE TO REACTOR COOLANT PUMP BUS UNDERVOLTAGE

At 03:58 on 11-08-05, D.C. Cook Unit 2 experienced an automatic, reactor trip due to Reactor Coolant Pump Bus Undervoltage. The cause of the reactor trip its under investigation. This requires a 4-hour report under 10CFR50.72(b)(2)(iv)(B).

"All four reactor coolant pumps have remained running.

"The Unit 2 Turbine Driven Auxiliary Feedwater Rump (TDAFP) started automatically due to low-low levels in at least two steam generators which is expected for a reactor trip from 100% power. The 'B' train Emergency Diesel Generator (2AB EDG) automatically started and loaded "B" train emergency bus T21A. These automatic actuations of the reactor protection system, TDAFP start, and 2A13 EDG start require an 8-hour report under I OCFR50.72(b)(3)(iv)(A).

"'B' train emergency bus T21B was declared inoperable after it failed to be energized automatically on the start of the 2AB EDG. The cause of this failure is under investigation.

"The 'A' train Emergency Diesel Generator (2CD EDG) had been inoperable for scheduled maintenance during the time of the event. It was restored to operable status at 06:06."

All control rods fully inserted. Steam generators are discharging steam to the main condenser using steam dumps.

The licensee notified the NRC Resident Inspector.

MARYLAND AGREEMENT STATE REPORT - MISSING TECHNETIUM-99m


At 0400 EST on 11/08/05 a delivery person left Mallinckrodt, Inc., located in Beltsville, MD to make deliveries. When he arrived at Cardiology Associates of Frederick, Maryland license MD21-039-01, he was missing the 5 doses of Technetium-99m that were supposed to be delivered to them. The delivery person had made 6 delivery stops before arriving at Cardiology Associates of Frederick. Mallinckrodt, Inc., is calling and sending personnel to the first 6 delivery stops to try to find the missing 5 doses of Technetium-99m. The 5 doses were divided into 2 lots. Lot 1 number is 95143 which contained 4 doses of Tc-99m for cardiolite studies. Activity of each one of the doses as of 0400 hours was 61 millicuries, 73 millicuries, 78 millicuries, and 82 millicuries. The second lot number is 95138 it had one dose with an activity of 62 millicuries (as of 0400 hours) of Tc-99m.

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

ALERT DECLARED DUE TO LOSS OF MAIN CONTROL BOARD ANNUNCIATOR PANELS

"An Alert was declared at 13:19 CST for Unit 2 due to a loss of all main control board (MCB) annunciator capability. I&C [instrumentation & controls] personnel were working on a light bulb which tripped a breaker thus losing all MCB annunciator capability. The condition was recognized and an Alert was declared. The deficiency was corrected and the breaker supplying the annunciator system was reclosed, restoring all annunciator capabilities. The total time without annunciator capability was 14 minutes. The Alert was terminated at 13:39 CST. Unit 1 [was not affected by this event and] is currently Mode 1, 100%." Unit 2 is currently defueled.

The licensee notified the NRC Resident Inspector along with State, local, and other government agencies. The licensee will be issuing a press release. Notified NRR Jim Dyer. External notifications also included HHS (Miller).

EMPLOYEE REFUSED TO TAKE A RANDOM DRUG TEST.

On 11/08/05 at 1000 CST a licensed employee was selected for a random drug test. The employee refused to take the drug test. The employee last Friday tendered his resignation and his last day of work was supposed to be 11/11/05. Upon refusing to take the drug test his plant access was denied and he moved up his last day of work to today, 11/08/05. Licensee will write a condition report and review his past work. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector was informed of this report by the licensee.

DESIGN BASIS FOR LONG TERM COOLING NOT CORRECTLY MODELED

"While investigating an issue related to containment coatings and their potential to clog the containment sump strainers, errors were discovered in the calculations that were used as the basis for responding to GL98-04. The errors involved the improper application of a correlation that was used to derive head loss across a screen that was assessed to be partially fouled with debris and the incorrect application of the results to a partially submerged screen that would be susceptible to air intrusion. Further investigation revealed that the flow path for a partially blocked strainer was not correctly modeled for the containment sump strainer and containment sump valve (SI-850A&B). The SI-850 valves have a rising disk and are located inside and at the bottom of the containment sump strainer. These errors in the modeling fidelity potentially impact the analytical basis for demonstrating compliance with the acceptance criteria in 10 CFR 50.46 (b)(5), Long-term Cooling.

"Immediate actions - Operability analyses were performed. These operability analyses demonstrated that adequate NPSH would be available to the ECCS pumps to ensure long-term cooling.

"Long-term action - The containment sump strainer will be modified, as committed to in Point Beach letter NRC 2005-0109, "Nuclear Management Company Response to Generic Letter 2004-02, Potential Impact of Debris Blockage on Emergency Recirculation During Design Basis Accidents at Pressurized Water Reactors, for Point Beach Nuclear Plant," dated September 1, 2005. This modification will result in a larger strainer surface area and a greater clearance in the vicinity of the SI-850 valves. These modifications will be supported by design analysis and testing that will demonstrate the strainers comply with the long-term cooling capability requirement of 10 CFR 50.46 (b)(5)."


The licensee notified the NRC Resident Inspector.

NOTIFICATION OF A MEDICAL EVENT - DOSE TO INCORRECT AREA OF BODY

Community Hospitals of Indiana reported that a high dose rate (HDR) remote afterloader treatment field was incorrectly performed. On November 8, 2005, Community Hospital East in Indianapolis, Indiana performed a HDR treatment on a terminally ill lung cancer patient. Community Hospital East applied the correct dose to the patient. However, a catheter used to carry the source into the patients body was inserted into the patients airway without a cap on the end. As a result of the cap not being in its proper place on the catheter, the source was placed approximately 7 mm higher than originally intended per the physicians written directive. As a result, the field which was irradiated was greater by approximately 7 mm. Immediately following the treatment, the error was noted and the physician was informed. The physician noted that the area which was irradiated was within her area of concern and that everything was "o.k." This treatment was conducted to relieve patient symptoms rather than cure the disease. The patient succumbed to the disease approximately two weeks later. The treatment and its results were documented by the licensee in its Radiation Safety Committee Meeting minutes.

During a routine inspection of its records on 4/4/06, a Region III NRC Inspector noted that this event appeared to be a medical event and should be reported. As a result of that guidance, the licensee is reporting the event.

* * * UPDATE FROM K STEFFEN TO J. KNOKE AT 1610 ON 04/06/06 * * *

The licensee provided the doses for the above event. Due to the catheter cap not being in its proper place the airway area above the lung received an actual dose 500 rads, whereas the prescribed dose was to be 200 rads. The area of treatment in the lung received an actual dose 200 rads, whereas the prescribed dose was to be 500 rads.

Notified R3DO (Anne-Marie Stone) and NMSS (Greg Morell)

AGREEMENT STATE REPORT - BRACHYTHERAPY DOSAGE LESS THAN PRESCRIBED

The following information was obtained from the State of Ohio via email:

"ODH [Ohio Department of Health] received information on 3/3/10 of a unreported medical event that occurred at Mercy St. Vincent Medical Center in Toledo on 11/8/05. ODH performed an on-site investigation on 3/5/10 and confirmed the unreported medical event. On 11/8/05, the licensee performed a prostate seed implant with 67 I-125 seeds prescribed to deliver a dose of 160 Gray to the prostate. Thirteen seeds were removed from the bladder immediately after the procedure leaving 54 seeds in the patient. A post implant dose calculation showed an under dose to the prostate greater than 20% of the prescribed dose. The licensee then performed an external beam treatment with a linear accelerator to treat the tumor.

"ODH is continuing the investigation of this event along with other brachytherapy cases performed by the licensee. ODH is also requesting assistance from the NRC's contract medical expert in evaluating the event."

Ohio Report Number: OH100003

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.