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Event Notification Report for November 30, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/29/2005 - 11/30/2005

** EVENT NUMBERS **


42173 42174 42175 42176

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Power Reactor Event Number: 42173
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ETHAN TREPTOW
HQ OPS Officer: PETE SNYDER
Notification Date: 11/29/2005
Notification Time: 01:24 [ET]
Event Date: 11/28/2005
Event Time: 22:20 [CST]
Last Update Date: 11/29/2005
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
Person (Organization):
PATRICK LOUDEN (R3)

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

Event Text

AUTOMATIC REACTOR TRIP FOLLOWING MAIN FEED PUMP TRIP

"At 22:19 CST, Main Feedwater Pump B tripped on over current. A secondary plant runback from 100% power was automatically initiated. During the secondary plant runback, the reactor automatically tripped on Steam Generator B low-low level at 22:20 CST.

"All three Auxiliary Feedwater pumps automatically started due to low-low Steam Generator level. The plant has been stabilized at Hot Shutdown (RCS temperature approximately 547 degrees F, RCS pressure approximately 2235 psig). Investigation into the cause of the trip is on-going.

"This event is being reported under 10CFR50.72(b)(2)(iv)(B) for actuation of the reactor protection system (RPS) when the reactor is critical and 10CFR50.72(b)(3)(iv)(A) for valid actuation of the Auxiliary Feedwater System."

All control rods fully inserted on the automatic trip. Steam generator water levels have recovered to indicate in the narrow range. The current decay heat removal path is auxiliary feedwater to the steam generators steaming through the power operated relief valves. There are no known primary to secondary leaks. All safety related buses are powered from offsite power. Emergency diesel generators are available and in standby.

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 42174
Rep Org: HOSP ONCOLOGICO ANDRES GRILLASCA
Licensee: HOSP ONCOLOGICO ANDRES GRILLASCA
Region: 1
City: PONCE State: PR
County:
License #: 52-11832-02
Agreement: N
Docket:
NRC Notified By: MIGUEL RIOS
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/29/2005
Notification Time: 15:40 [ET]
Event Date: 11/29/2005
Event Time: [EST]
Last Update Date: 11/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
TODD JACKSON (R1)
GREG MORELL (NMSS)

Event Text

MEDICAL EVENT INVOLVING ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE

On 11/22/05 a female patient undergoing treatment for cervical cancer received the third fraction of a five (5) fraction treatment plan using a HDR Brachytherapy source. Each fraction was scheduled to deliver 600 cGy to the intended treatment site for a total delivered dose of 3000 cGy. During the third treatment, the delivered dose was 200 cGy, instead of 600 cGy, due to a miscalculation in the distance factor. The treating physician does not believe there will be any adverse effects upon the patient.

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Hospital Event Number: 42175
Rep Org: STEELE MEMORIAL MEDICAL CENTER
Licensee: NON LICENSED FACILITY
Region: 4
City: SALMON State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: LINDA ASTALOS
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/29/2005
Notification Time: 18:27 [ET]
Event Date: 11/29/2005
Event Time: 15:20 [MST]
Last Update Date: 11/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
REBECCA NEASE (R4)
ROBERT PIERSON (NMSS)
LEN WERT (R4)

Event Text

POTENTIAL OVEREXPOSURE DUE TO SURGICAL REMOVAL OF PROSTATE WITH SEED IMPLANTS

During surgery to remove a patient's prostate gland, the surgeon announced that there were radioactive seed implants present. The surgeon warned surgical staff in the operating room after the surgery commenced to don lead apron shielding and the prostate gland was covered with a lead apron. The prostate was placed in a plastic container submerged in 5 inches of water in a 5 gallon container with the lead apron over the container based on a consultant's recommendation. The container is in an area with limited access and labeled as a radiation hazard. The hospital does not have a nuclear medicine department or any devices to measure radioactivity. The seed implants were supposedly implanted 90 days ago at a hospital in California with approximately a 30 day half life. The hospital will be ordering a lead shipping container for proper disposal later.

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Fuel Cycle Facility Event Number: 42176
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: TONY HUDSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/29/2005
Notification Time: 23:36 [ET]
Event Date: 11/29/2005
Event Time: 08:45 [CST]
Last Update Date: 11/29/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ROBERT HAAG (R2)
ROBERT PIERSON (NMSS)

Event Text

FAULTY SWITCH RENDERED CRITICALITY ACCIDENT ALARM SYSTEM INOPERABLE

"At 0845 CST, on 11/29/2005 the C-337 process building Criticality Accident Alarm System (CAAS) was being tested when a building horn control switch in C-300 Central Control Facility which supplies voltage to actuate the building CAAS evacuation horns was found to not be properly made up. This switch caused the building CAAS horns not to sound when a cluster was actuated. The test which revealed this problem, was the initial
'as found' test, which means the failure most likely occurred prior to today's testing. The C-337 CAAS system is a TSR system which is required to be operable in the current operating mode unless LCO actions are in place. The C-337 CAAS system was last tested on 11/05/2005 and indications are that the switch problem has existed since that time.

"During testing the CAAS alarm was received in C-300, but the evacuation horns did not automatically sound. Per procedure if a criticality alarm had occurred the C-300 operator would have actuated the horn switch manually which would have sounded the evacuation horns. To ensure that not only the C-337 switch was properly repaired, but also to verify all other building horn control switches were in the proper state, a plant wide LCO was implemented and switch outputs were checked to verify the proper voltage output."

The NRC Senior Resident has been notified of this event.

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