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Event Notification Report for September 27, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/26/2006 - 09/27/2006

** EVENT NUMBERS **


42802 42850 42853 42855 42864 42865

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Power Reactor Event Number: 42802
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: KEN TIEFENTHAL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/25/2006
Notification Time: 10:36 [ET]
Event Date: 08/25/2006
Event Time: 10:30 [EDT]
Last Update Date: 09/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD CONTE (R1)

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

EMERGENCY RESPONSE DATA SYSTEM AND SAFETY PARAMETER DISPLAY SYSTEM WILL BE UNAVAILABLE

"The BVPS Unit 2 Plant Computer System (PCS) will be taken out of service for approximately 5 weeks (8/25/06 to 9/26/06) to implement a planned modification. The current PCS is being replaced and a computer outage is required to allow for the installation of a new PCS. During this time period the Emergency Response Data System (ERDS) and Safety Parameter Display System (SPDS) will not be available at BVPS Unit 2. ERDS and SPDS parameters will be monitored by control board indications and a temporary computer system (with limited analog inputs). Compensatory actions have been developed, which include a revised emergency implementing procedure specifically addressing temporarily unavailable indications and having an extra Operations Communicator respond to the Control Room during any potential Unit 2 emergency to facilitate data transfer while ERDS/SPDS is out of service. Work on replacing the PCS and returning ERDS/SPDS will be ongoing continuously until complete.

"This is an 8-hour reportable event per 10 CFR50.72(b)(3)(xiii) Major Loss of Assessment Capability. The operation of BVPS Unit 1 and Unit 2 plant systems will not be affected due to this planned action. BVPS Unit 1 ERDS and SPDS will not be affected by these modifications.

"The NRC resident inspector has been notified."

* * * UPDATE ON 09/26/06 AT 1706 EDT FROM KEN TIEFENTHAL TO GERRY WAIG * * *

"Work on replacing the PCS and returning ERD/SPDS remains continuously ongoing. However, minor hindrances have caused the scheduled completion of this function to now be October 1, 2006. Previously described compensatory actions remain in effect."

The licensee has notified the NRC resident inspector.

Notified R1DO (Chris Hott).

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Hospital Event Number: 42850
Rep Org: PENNSYLVANIA HOSPITAL
Licensee: PENNSYLVANIA HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 37-06864-06
Agreement: N
Docket:
NRC Notified By: LEONARD SHABASON
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/20/2006
Notification Time: 12:56 [ET]
Event Date: 05/19/2006
Event Time: [EDT]
Last Update Date: 09/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES TRAPP (R1)
CINDY FLANNERY (NMSS)

Event Text

MEDICAL EVENT INVOLVING UNDERDOSE DUE TO POSSIBLE PATIENT INTERVENTION

On May 19, 2006 an elderly patient was framed and imaged for the treatment of a single large metastatic lesion. The measurements indicated that there would be a "collision" between the anterior left post and the gamma knife helmet. The neurosurgeon who was responsible for the patient decided that it would be in the best interest of the patient to remove the anterior left pin and post rather than having to re-frame and re-image the patient. After the left post was removed the other pins were checked to confirm that the frame was still firmly attached to the patient. In the middle of the first of nine shots, the patient became very agitated and her body was observed to shift. The patient's head is not observable with either of the closed circuit TV cameras when the patient is in treatment position. The treatment was halted after the first shot to examine the patient and found that she was not held in place by the pins. The patient's neurosurgeon immediately spoke with the patient's daughter to explain what had happened and they decided to reschedule the treatment for the following week. On May 26, 2006, the patient was treated to a dose of 18 Gy to a volume of about 6.5 cc. If the patient was in one position during the shot delivered on May 19, the delivered dose is estimated to be 6 Gy to a volume of about 0.6 cc. There is no way of knowing the exact position of the patient's head during this 3.86 minute treatment. At the end of the shot, it was observed that her head was at the correct level but that her head may have dropped down. This would have resulted in a dose delivered anterior to the lesion. Since dose homogeneity is not important for gamma knife treatment and the volume in question is a small fraction of the volume prescribed treatment volume and the position was uncertain, the dose from May 19 was not considered for the treatment of May 26. The area of the patient's brain that could have received unintended incorrect dose did not include an area that would be detrimentally affected by the dose given.


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.

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General Information or Other Event Number: 42853
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: TERRATECH CONSULTANTS
Region: 1
City: MIAMI State: FL
County:
License #: 3210-1
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/21/2006
Notification Time: 14:05 [ET]
Event Date: 09/21/2006
Event Time: 12:00 [EDT]
Last Update Date: 09/21/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
CINDY FLANNERY (NMSS)
ILTAB VIA EMAIL ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER MOISTURE DENSITY GAUGE

Troxler Gauge model 3440, Serial number 24024, was stolen from the locked box in the back of the work truck at 1200 EDT on 09/21/06. The work truck was located at 1090 NW North River Drive, Miami during the theft. The lock on the storage box was cut with bolt cutters and the box remains in the vehicle. Miami-Dade Police have been notified and a police report is pending. The gauge contained a Cs-137 8 millicurie source, serial number 75-6012, and an Am-241 40 millicurie source, serial number 47-20055.

Florida Incident Number: FL06-119

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 42855
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH NUCLEAR PHARMACY
Region: 4
City: SLIDELLE State: LA
County:
License #: LA-10336-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JASON KOZAL
Notification Date: 09/22/2006
Notification Time: 14:44 [ET]
Event Date: 09/22/2006
Event Time: [CDT]
Last Update Date: 09/22/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
JOSEPH HOLONICH (NMSS)

Event Text

AGREEMENT STATE REPORT

"A Cardinal Health vehicle from the Slidell, LA location was carrying 1214 mCi of Tc-99 and 40 mCi of Xe-133 to a Mississippi facility when it was involved in an accident on Highway 43 in Mississippi. Cardinal Health notified the appropriate authorities in Mississippi. Emergency Response in Mississippi took control of the vehicle."

Louisiana event report ID number: LA060017

See Mississippi Agreement State Report: Event Number 42858.

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Power Reactor Event Number: 42864
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF ERDMANN
HQ OPS Officer: BILL GOTT
Notification Date: 09/26/2006
Notification Time: 17:18 [ET]
Event Date: 09/26/2006
Event Time: 15:13 [EDT]
Last Update Date: 09/26/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHRIS HOTT (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 94 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO REACTOR COOLANT PUMP SEAL LEAKAGE.

Salem Unit 2 was manually tripped from 94.1 percent reactor power due to Reactor Coolant Pump "21" number 1 seal leakoff exceeding 6 gpm in accordance with abnormal operating procedure. Reactor Coolant Pump "21" was subsequently stopped upon reactor trip verification in accordance with the Abnormal Operating Procedures. Forced reactor coolant system circulation is via the remaining 3 reactor coolant pumps. All safety systems functioned as designed. Auxiliary feedwater pumps started as expected, offsite power is available, Emergency Diesel Generators are available but not required at this time. Decay heat removal is via steam dumps to the main condenser. Salem Unit 2 is currently stable in Mode 3 (Hot Standby). There is no equipment out of service that contributed to this event. There were no personnel injuries or radiological occurrences associated with this event. The licensee is investigating to determine the cause of the abnormal reactor coolant pump seal leakoff flow rate.

The licensee notified local government officials. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 42865
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK G. GORLEY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 09/27/2006
Notification Time: 04:26 [ET]
Event Date: 09/27/2006
Event Time: 02:47 [EDT]
Last Update Date: 09/27/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (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

Event Text

TECHNICAL SUPPORT CENTER HVAC REMOVED FROM SERVICE FOR MAINTENANCE

"On 9/27/2006, the HVAC for the Hatch Nuclear Plant's Technical Support Center (TSC) was removed from service for planned preventive maintenance and inspections and testing activities. These work activities are planned to be performed and completed within a 12 hour work shift. During the time these activities are being performed, the TSC air handling unit, TSC condensing unit, TSC filter train and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered non-functional during the performance of this work activity.

"If an emergency condition requiring activation of the TSC occurs during the time these work activities are being performed, then contingency plans call for utilization of the TSC as long as radiological conditions allow. The site Technical Support Center activation procedure provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the TSC so that TSC functions can be continued.

"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the evolution."

The licensee will notify the NRC Resident Inspector.

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