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Event Notification Report for February 6, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/03/2006 - 02/06/2006

** EVENT NUMBERS **


39586 42038 42296 42298 42305 42309 42310 42311 42312

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 39586
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: PHILADELPHIA VA MEDICAL CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 37-00062-07
Agreement: N
Docket:
NRC Notified By: PAUL YURKO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/14/2003
Notification Time: 14:32 [ET]
Event Date: 02/03/2003
Event Time: [EST]
Last Update Date: 02/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
GLENN MEYER (R1)
FRED BROWN (NMSS)

Event Text

POSSIBLE MEDICAL EVENT AT PHILADELPHIA VETERANS ADMINISTRATION MEDICAL CENTER

Informed by a representative of the Department of Veteran's Affairs National Health Physics Program (NHPP) that a possible medical event may have occurred at the Philadelphia Veterans Administration Medical Center. The event took place on February 3, 2003 but was not determined until it was discussed on February 13, 2003.

The procedure being performed at the time of the event was a permanent prostate seed implant brachytherapy. The nuclide involved is I-125. A fraction of the seeds intended to be implanted into the prostate were recovered from the bladder. The medical authorized user (the physician prescribing and performing the procedure) rewrote the written directive in the operating room to reflect the number of seeds that were successfully implanted into the prostate. Calculations are presently being made to determine the exposure to the bladder. Preliminary calculations indicate that there are no deterministic effects to the patient as a result of the event. All the seeds are presently accounted for. There was no patient intervention. The NHPP is currently investigating the event.

* * * RETRACTION AT 14:05 EST ON 2/3/2006 FROM GARY WILLIAMS TO ABRAMOVITZ * * *

"Based on our discussions with NRC Region III, the circumstances for event do not meet the definition in 10CFR35.3045 as a medical event."

Contacted the R1DO (Meyer), R3DO (Riemer), and NMSS EO (Morell).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 42038
Rep Org: PHILADELPHIA VA MEDICAL CENTER
Licensee: DEPARTMENT OF VETERANS
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: PAUL YURKO
HQ OPS Officer: PETE SNYDER
Notification Date: 10/05/2005
Notification Time: 13:17 [ET]
Event Date: 10/03/2005
Event Time: [EDT]
Last Update Date: 02/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
JOHN ROGGE (R1)
GREG MORELL (NMSS)
DAVID GRAVES (R4)
BRUCE BURGESS (R3)

Event Text

MEDICAL EVENT - SOME BRACHYTHERAPY SEEDS ADMINISTERED TO WRONG SITE

"l am calling per 10 CFR 35.3045 to notify you of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania. On October 3, 2005 a permanent implant prostate brachytherapy procedure was performed at the medical center. A written directive prescribed 90 Iodine 125 seeds to be implanted in the patient's prostate.

"However, 45 of the seeds were implanted mistakenly in bladder. The seeds were recovered from the bladder prior to completion of the procedure in the operating room.

"The written directive was revised by the authorized user prior to completion of the procedure in the operating room to document the actual number of seeds implanted in the prostate (45).

"Based on dosimetry calculations performed October 4, 2005, a medical event may have occurred since the dose to the prostate and other tissues may differ from that originally prescribed in the written directive by values greater than those given in 10 CFR 35.3045.

"These circumstances appear to be similar to a previously reported event (Event No. 39586), which NRC ultimately decided did not represent a medical event.

"However, the NHPP has decided conservatively to perform an on-site review at the medical center next week to assess the particular circumstances of this event."

At the time of this report the licensee did not know why the event happened but will be investigating to determine the cause and the significance on 10/13/2005. The licensee stated that the patient was notified of the situation.

* * * RETRACTION AT 14:05 EST ON 2/3/2006 FROM GARY WILLIAMS TO ABRAMOVITZ * * *

"Based on our discussions with NRC Region III, the circumstances for event do not meet the definition in 10CFR35.3045 as a medical event."

Contacted the R1DO (Meyer), R3DO (Riemer), and NMSS EO (Morell).

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General Information or Other Event Number: 42296
Rep Org: COLORADO DEPT OF HEALTH
Licensee: KUMAR AND ASSOCIATES
Region: 4
City: WESTMINSTER State: CO
County:
License #: 778-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: BILL GOTT
Notification Date: 01/31/2006
Notification Time: 09:19 [ET]
Event Date: 01/30/2006
Event Time: 15:00 [MST]
Last Update Date: 01/31/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
GREG MORELL (NMSS)
TAS (email) ()

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"The Department received notification at 3:00 pm on 1/30/06, from the RSO at Kumar and Associates, Colorado License # 778-01, that one of their Troxler Model 3430 moisture/density gauges had been stolen from a construction site in Westminster, Colorado. Apparently the technician, who was using the gauge at the construction site, left it unattended for 5 minutes, and discovered it missing when he returned. Local police were notified and responded to the scene. The gauge was found, undamaged, in a field at the construction site a short time later. No public exposures are expected from this incident. The Department is investigating."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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.

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General Information or Other Event Number: 42298
Rep Org: NEW MEXICO RAD CONTROL PROGRAM
Licensee: BAKER HUGHES OILFIELD OPERATIONS
Region: 4
City: EUNICE State: NM
County: LEA
License #: WL-241-33
Agreement: Y
Docket:
NRC Notified By: WALTER MEDINA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/01/2006
Notification Time: 19:45 [ET]
Event Date: 01/31/2006
Event Time: 09:50 [MST]
Last Update Date: 02/01/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MIKE RUNYAN (R4)
GARY JANOSKO (NMSS)

Event Text

AGREEMENT STATE - MATERIAL LOSS OF CONTROL

The State provided the following information via email:

"[The] RSO for Baker Hughes Oilfield Operations, Inc. (NM license number WL 241-33), reported at 9:50 a.m. on January 31, 2006 that Baker Hughes temporarily lost control of a 2 Ci Cs-137 sealed source after completion of a job two to three miles south of Eunice, NM in Lea County. Upon completion of the job, the crew from the Midland, TX facility secured the 18 Ci Am/Be source in its shipping container and departed the job site, leaving the unshielded Cesium source on the ground.

On returning to Midland, the crew discovered the Cesium source was not in the vehicle and they immediately notified Baker Hughes personnel in Hobbs, NM. Hobbs personnel located, recovered, and secured the source approximately 2 hours after the Midland crew left the site. Preliminary information indicated there was no drilling going on at the job site when Hobbs personnel recovered the source and it was not known if any individuals received a dose.

A follow-up telephone call to [the RSO] today indicates non-badged individuals were working in the area of the unshielded source. Initial calculations show the highest dose to any of these individuals to be less than 70 mRem.

The New Mexico Radiation Control Bureau is continuing the investigation of the incident and will provide updated information as it becomes available. A visit to the licensee's Hobbs, NM office is planned."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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.

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event.

Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3"

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Power Reactor Event Number: 42305
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MICHAEL POTTER
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/03/2006
Notification Time: 04:59 [ET]
Event Date: 02/02/2006
Event Time: 23:36 [EST]
Last Update Date: 02/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RUDOLPH BERNHARD (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

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE DUE TO ONE HPCI TURBINE EXHAUST VACUUM BREAKER ISOLATION VALVE FAILURE

"On February 2, 2006 at 23:36 [EST], during testing of the HPCI System per OPT-09.7, HPCI System Valve Operability Test, 1-E41-F079, Turbine Exhaust Vacuum Breaker valve, was given a close signal and failed in the intermediate position. The 1-E41-F079 is one of the two HPCI Turbine Exhaust Line Vacuum Breaker isolation valves. When 1-E41-F079 failed in the intermediate position, the HPCI system was considered inoperable. HPCI is a single-train, safety function system. Approximately two minutes later, the valve was reopened and HPCI was restored to operable status (1-E41-F079 remains inoperable).

"The cause of the 1-E41-F079 failing to stroke is being investigated and will be repaired."

HPCI will be inoperable after 1-E41-F079 is isolated for maintenance.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42309
Facility: VOGTLE
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE A PHILLIPS
HQ OPS Officer: ARLON COSTA
Notification Date: 02/03/2006
Notification Time: 23:05 [ET]
Event Date: 02/03/2006
Event Time: 21:24 [EST]
Last Update Date: 02/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
RUDOLPH BERNHARD (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

IDENTIFIED RCS PRESSURE BOUNDARY LEAKAGE

"At 2124 hrs on 2/3/06, a containment leak inspection team reported pressure boundary leakage (RCS) at a welded connection on a 3/4" bypass line around the RHR loop suction valve 2HV8701B. Presently the unit is in Mode 3. Preparations are being made to commence cooldown to Mode 5 for repair of the leak.

"Unit 2 was taken from 100% RTP to approximately 30% RTP beginning at 1200 hrs on 2/01/06 for repairs of an EHC leak on the main turbine front standard. The EHC leak was repaired and power ascension to 100 % RTP commenced at 2213 hrs on 2/01/06. Approximately 100 % RTP was reached on 2/3/06 at 0600 hrs.

"Between 1900 hrs on 2/01/06 and 1600 hrs on 2/02/06, radiation monitor 2RE2562A went into Intermediate Alarm for short durations on three different occasions. Due to moving the plant, an accurate RCS leak rate could not be performed.

"A containment entry was performed on the night shift 2/2/06 and again on dayshift 2/3/06. Utilizing a robot and camera, leakage was observed inside the bioshield in the area of RCS Loop #1. The source of the leak on both containment entries was inconclusive. At 1412 hrs on 2/3/06, a shutdown of Unit 2 was initiated to allow further investigation/repair of the leak inside containment.

"Unit 2 was placed in Mode 3 at 1807 hrs on 2/3/06."

See also EN# 42194 for a similar incident.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42310
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: CLAY WILLIAMS
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/04/2006
Notification Time: 00:46 [ET]
Event Date: 02/03/2006
Event Time: 18:15 [PST]
Last Update Date: 02/04/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MIKE RUNYAN (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE POWER NOT WITHIN SPECIFICATIONS

"On February 3, 2006, at about 1646 PST the Devers-Palo Verde line relayed. This required an evaluation of grid nomograms for San Onofre. At about 1815 PST, the Grid Control Center (GCC) notified San Onofre that the grid nomograms predicted offsite power would not be within limits if San Onofre Unit 3 were to trip (San Onofre Unit 2 is currently shutdown in a refueling outage and Unit 3 is operating at about 100 percent power). Plant Operators declared offsite power inoperable at about 1815 PST.

"At about 1843 PST, the GCC notified San Onofre that the grid operator added generation to the grid and that offsite power was within nomogram limits. Plant Operators declared offsite power operable at that time. Consistent with the guidance provided in NUREG-1022, Rev. 2, Southern California Edison is reporting this event in accordance with 10CFR50.72(b)(3)(v)(D).

"All four San Onofre diesel generators (two per Unit) remained operable during this event. The San Onofre Senior Resident Inspector has been notified of this event and will be provided with a copy of this report."

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Power Reactor Event Number: 42311
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: KEN LEFFEL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/05/2006
Notification Time: 14:56 [ET]
Event Date: 02/05/2006
Event Time: 10:25 [CST]
Last Update Date: 02/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JULIO LARA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

LOSS OF SPDS FOR GREATER THAN 8 HOURS

"On February 5, 2006 at 0225 hours, the Clinton Power Station shutdown the Plant Process Computer in preparation for transferring Uninterruptible Power Supply (UPS) 1A to its alternate source to make preps for the upcoming DC MCC 1E outage. This caused the loss of the Safety Parameter Display System (SPDS). The computer would not restart following the power supply transfer.

"This event is reportable due to the major loss of emergency assessment capability per 10CFR50.72(b)(3)(xiii) (when the SPDS has been unavailable for 8 hours or greater). The cause of the failure of the computer is not known at this time.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 42312
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVE SCHMIDT
HQ OPS Officer: ARLON COSTA
Notification Date: 02/05/2006
Notification Time: 14:59 [ET]
Event Date: 02/05/2006
Event Time: 13:36 [CST]
Last Update Date: 02/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JULIO LARA (R3)

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

Event Text

REQUIRED T.S. SHUTDOWN DUE TO EMERGENCY DIESEL GENERATOR INOPERABILITY

"Unit 2 Train B emergency diesel generator D6 was removed from service at 2010 CST on 1/29/06 for planned maintenance and Technical Specification (TS) 3.8.1, 'AC Source - Operating,' Condition B, 'One DG inoperable,' was entered. TS Required Action 3.8.1.B.4 requires D6 be restored to operable status with a Completion Time of 7 days. The planned maintenance activities included replacing two sets of two pistons, rings and cylinder liners on Engine 2 of D6 (D6 is a tandem-engine diesel generator). Return-to-service testing was initiated on 2/4/06 and at approximately 0000 CST; the test was halted due to high-indicated crankcase pressure on Engine 1. The test procedure specifies shutting down the diesel generator if crankcase pressure on either engine exceeds 30mm for more than a few minutes (the setpoint for the crankcase pressure trip is 52 mm).

"Investigation of the cause of the high-indicated crankcase pressure on Engine 1 started immediately. Unit 2 Train A emergency diesel generator (D5) was demonstrated operable by completing a surveillance test at 1507 CST on 2/4/06. Evaluation of the scope of work to return D6 to operable status and the schedule for completing the work indicated that repairs could not be completed within the remainder of the 7-day Completion Time. Based on this assessment an orderly shutdown of Unit 2 is being performed.

"Shutdown [to mode 5] of Unit 2 commenced at 1336 CST on 2/5/06. Unit 2 shutdown will continue until D6 is restored to operable status."

The licensee notified the NRC Resident Inspector.

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