Event Notification Report for January 12, 2006
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/11/2006 - 01/12/2006
General Information or Other
Event Number: 42256
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: CAREALLIANCE HEALTH SERVICES ROPER HOSPITAL
Region: 1
City: CHARLESTON State: SC
County:
License #: 646
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: JOHN KNOKE
Licensee: CAREALLIANCE HEALTH SERVICES ROPER HOSPITAL
Region: 1
City: CHARLESTON State: SC
County:
License #: 646
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/13/2006
Notification Time: 16:24 [ET]
Event Date: 01/12/2006
Event Time: 00:00 [EST]
Last Update Date: 01/13/2006
Notification Time: 16:24 [ET]
Event Date: 01/12/2006
Event Time: 00:00 [EST]
Last Update Date: 01/13/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICHARD CONTE (R1)
C.W. (BILL) REAMER (NMSS)
RICHARD CONTE (R1)
C.W. (BILL) REAMER (NMSS)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The State provided the following information via facsimile:
"The South Carolina Department of Health and Environmental Control was notified (telephone) on January 13, 2006, by the licensee, that a medical misadministration had occurred. A patient being treated with a Iridium 192 HDR after loading brachytherapy system received a fractionated dose that differed from the prescribed dose, for a single fraction, by 50 percent or more. The patient was undergoing the first of three treatments to the pelvic region. The prescribed dose for this first treatment was 700 centigray but the patient only received 233 centigray, approximately one third of the intended dose. Further details of the misadministration will be supplied by the licensee in the forthcoming written report. Updates to this event will be made through the NMED system."
SC Report ID No. - SC060001
The State provided the following information via facsimile:
"The South Carolina Department of Health and Environmental Control was notified (telephone) on January 13, 2006, by the licensee, that a medical misadministration had occurred. A patient being treated with a Iridium 192 HDR after loading brachytherapy system received a fractionated dose that differed from the prescribed dose, for a single fraction, by 50 percent or more. The patient was undergoing the first of three treatments to the pelvic region. The prescribed dose for this first treatment was 700 centigray but the patient only received 233 centigray, approximately one third of the intended dose. Further details of the misadministration will be supplied by the licensee in the forthcoming written report. Updates to this event will be made through the NMED system."
SC Report ID No. - SC060001
Power Reactor
Event Number: 42254
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: JOHN KNOKE
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/12/2006
Notification Time: 16:07 [ET]
Event Date: 01/12/2006
Event Time: 09:20 [EST]
Last Update Date: 01/12/2006
Notification Time: 16:07 [ET]
Event Date: 01/12/2006
Event Time: 09:20 [EST]
Last Update Date: 01/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOEL MUNDAY (R2)
JOEL MUNDAY (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
CONTROL ROOM AIR CONDITIONING AND CONTROL ROOM EMERGENCY VENTILATION SYSTEMS INOPERABLE
"At 0400 hours on January 12, 2006, 2A Control Building Standby Instrument Air Compressor was taken out of service for scheduled maintenance. Subsequently, at 0920 hours, the in-service 2B Control Building Standby Instrument Air Compressor failed, resulting in the loss of control air. As a result, the three Control Room Air Conditioning subsystems required by Technical Specification (TS) 3.7.4, "Control Room Air Conditioning (AC) System," and the two Control Room Emergency Ventilation subsystems required by TS 3.7.3, "Control Room Emergency Ventilation (CREV) System," became inoperable. As a result, this condition could have prevented the fulfillment of the safety function for these systems. The Control Room AC and CREV systems became inoperable due to loss of control air to the systems. Because Brunswick has a shared control room, Unit 1 and Unit 2 entered TS 3.7.3 Required Action B.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours) and TS 3.7.4, Required Action E.1, for three Control Room AC subsystems inoperable (i.e., enter LCO 3.0.3 immediately).
"Operability of two Control Room AC subsystems and one CREV subsystem was restored and LCO 3.0.3 was exited, at 1014 hours, when the 2A Control Building Standby Instrument Air Compressor was restored to service. [The licensee stated the actual maintenance was completed on 2A Control Building Standby Instrument Air Compressor at the time it was restored to service.]
"No power reduction took place as a result of the LCO 3.0.3 entry. This report applies to both Units 1 and 2 and is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident.
"The safety significance of this event is considered minimal. The condition existed for approximately 54 minutes. Plant staff took immediate actions to return the equipment to service. For the brief time the Control Room AC and CREV systems were inoperable, performance of plant personnel and equipment in the Control Room was not adversely affected. The maximum Control Room back panel temperature during this event was approximately 73 degrees F.
"Operability of the Control Room AC system and one subsystem of the CREV system were restored at 1014 hours when the 2A Control Building Standby Instrument Air Compressor was restored to service. Troubleshooting activities are under way to determine the cause of the 2B Control Building Standby Instrument Air Compressor failure. Initial indications are that the unloading ability of the 2B Control Building Standby Instrument Air Compressor failed."
The licensee notified the NRC Resident Inspector.
"At 0400 hours on January 12, 2006, 2A Control Building Standby Instrument Air Compressor was taken out of service for scheduled maintenance. Subsequently, at 0920 hours, the in-service 2B Control Building Standby Instrument Air Compressor failed, resulting in the loss of control air. As a result, the three Control Room Air Conditioning subsystems required by Technical Specification (TS) 3.7.4, "Control Room Air Conditioning (AC) System," and the two Control Room Emergency Ventilation subsystems required by TS 3.7.3, "Control Room Emergency Ventilation (CREV) System," became inoperable. As a result, this condition could have prevented the fulfillment of the safety function for these systems. The Control Room AC and CREV systems became inoperable due to loss of control air to the systems. Because Brunswick has a shared control room, Unit 1 and Unit 2 entered TS 3.7.3 Required Action B.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours) and TS 3.7.4, Required Action E.1, for three Control Room AC subsystems inoperable (i.e., enter LCO 3.0.3 immediately).
"Operability of two Control Room AC subsystems and one CREV subsystem was restored and LCO 3.0.3 was exited, at 1014 hours, when the 2A Control Building Standby Instrument Air Compressor was restored to service. [The licensee stated the actual maintenance was completed on 2A Control Building Standby Instrument Air Compressor at the time it was restored to service.]
"No power reduction took place as a result of the LCO 3.0.3 entry. This report applies to both Units 1 and 2 and is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident.
"The safety significance of this event is considered minimal. The condition existed for approximately 54 minutes. Plant staff took immediate actions to return the equipment to service. For the brief time the Control Room AC and CREV systems were inoperable, performance of plant personnel and equipment in the Control Room was not adversely affected. The maximum Control Room back panel temperature during this event was approximately 73 degrees F.
"Operability of the Control Room AC system and one subsystem of the CREV system were restored at 1014 hours when the 2A Control Building Standby Instrument Air Compressor was restored to service. Troubleshooting activities are under way to determine the cause of the 2B Control Building Standby Instrument Air Compressor failure. Initial indications are that the unloading ability of the 2B Control Building Standby Instrument Air Compressor failed."
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 42271
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: COLUMBIA WEST ENGINEERING
Region: 4
City: VANCOUVER State: WA
County:
License #: WN-I0517-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: JEFF ROTTON
Licensee: COLUMBIA WEST ENGINEERING
Region: 4
City: VANCOUVER State: WA
County:
License #: WN-I0517-1
Agreement: Y
Docket:
NRC Notified By: CRAIG LAWRENCE
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/18/2006
Notification Time: 18:05 [ET]
Event Date: 01/12/2006
Event Time: 00:00 [PST]
Last Update Date: 01/20/2006
Notification Time: 18:05 [ET]
Event Date: 01/12/2006
Event Time: 00:00 [PST]
Last Update Date: 01/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)
WILLIAM JONES (R4)
LAWRENCE KOKAJKO (NMSS)
AGREEMENT STATE REPORT REGARDING A DAMAGED TROXLER MOISTURE DENSITY GAUGE
The State provided the following information via email:
"ABSTRACT: The licensee states the gauge was in use near several construction vehicles [at a work site in Clackamas, Oregon]. The gauge was located behind a nearby pickup truck attached flatbed trailer. The gauge user thought the vehicles were not occupied. A driver in the truck started the vehicle and promptly backed it into the gauge before it could be moved by the operator, resulting in damage to the index rod. No other damage was noted. The licensee says the gauge operator was in proper control of the gauge at the time the truck struck the gauge. Regardless, the licensee will provide training to the operators reminding them of the requirements to maintain proper surveillance and control of gauges while away from the licensed storage locations. An explanation of what occurred in this event was also provided to the operators as lessons learned.
"Notification Reporting Criteria: WAC 246-221-250 Notification of Incidents.
"Isotope and Activity involved: 8 mCi of Cesium 137, and 40 mCi of Americium 241/Beryllium.
"Damaged Troxler 3430, serial number 31153.
"Disposition/recovery: The licensee was able to get the source rod back into the shielded position. They had a count rate survey meter and used it to determine that readings were normal. They called the manufacturer's local representative and the RSO for Troxler in North Carolina. The licensee was instructed on how to package the gauge properly. The gauge was taken back to the licensed and secured storage area where additional gauge packaging was used to secure the damaged index rod. They took a wipe test of the gauge. The results came back normal to allow for a normal means of shipping back to Troxler in North Carolina. Shipping is scheduled for January 19, 2004.
"Leak test? Leak test analysis - less than 0.005 microcuries.
"Release of activity? None found.
"Consultant used? Local Troxler representative and Troxler RSO.
Event Report # WA-05-006.
* * * UPDATE ON 01/20/06 * * *
The correct Washington Event report number is WA-06-006.
The State provided the following information via email:
"ABSTRACT: The licensee states the gauge was in use near several construction vehicles [at a work site in Clackamas, Oregon]. The gauge was located behind a nearby pickup truck attached flatbed trailer. The gauge user thought the vehicles were not occupied. A driver in the truck started the vehicle and promptly backed it into the gauge before it could be moved by the operator, resulting in damage to the index rod. No other damage was noted. The licensee says the gauge operator was in proper control of the gauge at the time the truck struck the gauge. Regardless, the licensee will provide training to the operators reminding them of the requirements to maintain proper surveillance and control of gauges while away from the licensed storage locations. An explanation of what occurred in this event was also provided to the operators as lessons learned.
"Notification Reporting Criteria: WAC 246-221-250 Notification of Incidents.
"Isotope and Activity involved: 8 mCi of Cesium 137, and 40 mCi of Americium 241/Beryllium.
"Damaged Troxler 3430, serial number 31153.
"Disposition/recovery: The licensee was able to get the source rod back into the shielded position. They had a count rate survey meter and used it to determine that readings were normal. They called the manufacturer's local representative and the RSO for Troxler in North Carolina. The licensee was instructed on how to package the gauge properly. The gauge was taken back to the licensed and secured storage area where additional gauge packaging was used to secure the damaged index rod. They took a wipe test of the gauge. The results came back normal to allow for a normal means of shipping back to Troxler in North Carolina. Shipping is scheduled for January 19, 2004.
"Leak test? Leak test analysis - less than 0.005 microcuries.
"Release of activity? None found.
"Consultant used? Local Troxler representative and Troxler RSO.
Event Report # WA-05-006.
* * * UPDATE ON 01/20/06 * * *
The correct Washington Event report number is WA-06-006.