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Event Notification Report for January 12, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/11/2007 - 01/12/2007

** EVENT NUMBERS **


42975 43084 43092 43093 43094 43095

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 42975
Rep Org: WILLIAM BEAUMONT HOSPITAL
Licensee: WILLIAM BEAUMONT HOSPITAL
Region: 3
City: Royal Oak State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: CHERYL SCHULTZ
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/08/2006
Notification Time: 17:39 [ET]
Event Date: 11/07/2006
Event Time: 13:45 [EST]
Last Update Date: 01/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMNES CAMERON (R3)
KEITH McCONNELL (NMSS)

Event Text

MEDICAL EVENT - LESS THAN PRESCRIBED DOSE OF YTTRIUM - 90

The Radiation Safety Office for the licensee reported an event where a patient received less than the prescribed dose during a treatment for liver cancer using Yttrium - 90 microspheres. Specifically, the patient was prescribed 9.8 millicuries to the liver using Yttrium - 90 SirTex Sirspheres using a intrahepatic catheter. The patient only received 6.5 millicuries due to problems in the administration of the dose.

After administering about half of the treatment dose, the physician started to encounter injection resistance which is not uncommon with this treatment due to vasculature loading. The physician stopped the treatment and was trying to view the microsphere placement in the liver using fluoroscopy when he noted some unusual "clumping" of the microspheres between the delivery vial and a 3-way stop cock that connects to the catheter. Because of the clumping and the resistance, the physician elected to discontinue the administration of the remainder of the dose.

The licensee has contacted SirTex and plans to send the delivery device with the clumped microspheres to SirTex when the Yttrium - 90 has decayed away (in a couple weeks) for further evaluation of the product.

The licensee has also contacted the Region 3 NRC inspector (Piskura) about this event.

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.

*** UPDATE FROM SCHULTZ TO KNOKE AT 14:29 ON 01/11/07 ***

The RSO called to indicate this event was reviewed by Region 3 and was determined to not meet the criteria for a reportable event, therefore the event is being retracted. Notified R3DO (Kozak)

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General Information or Other Event Number: 43084
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: H&G INSPECTION COMPANY
Region: 4
City: HOUSTON State: TX
County:
License #: L02181
Agreement: Y
Docket:
NRC Notified By: LATISCHA HANSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/09/2007
Notification Time: 18:17 [ET]
Event Date: 01/09/2007
Event Time: [CST]
Last Update Date: 01/09/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4)
JOSEPH GIITTER (NMSS)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE DISCOVERED AFTER BADGE PROCESSING

"The agency [Texas Department of State Health Services (DSHS)] returned a telephone call at 5 p.m. [on 01/09/07] to the licensee, in regards to a voicemail the licensee's RSO left on another program's telephone. The personnel answering the telephone at the facility stated the RSO had just left for the day & gave [the state] partial information that the facility had received the personnel monitoring report for 11/10/06-12/06/06 that showed a radiographer's dose to be 697,408 (mR) -Deep dose. The employee stated that the monitoring processing company was going to repeat the tests again to confirm the dose. The licensee was waiting to hear from DSHS/Radiation Control (RC) on 1/09/07, to decide what to do. They were not sure if they should do blood work, etc.

"DSHS/RC advised the employee to 1) Have the RSO call DSHS/RC Incident Investigation (IIP) personnel first thing in the morning on 1/10/07; 2) Have the RSO perform an inquiry with the radiographer to assess the events during the monitoring period in question; 3) Have the RSO look at personnel monitoring records for co-workers on the same job(s) as the radiographer under review to compare their dosage during this time period; 4) Have RSO check utilization logs during this period to assess what specific equipment was used & the job details; 5) DSHS/RC requested a fax copy of the personnel monitoring report [Deleted]. The employee agreed to comply. DSHS/RC will follow-up first thing 1/10/07 with the licensee's RSO to obtain complete information. Additional clarification/corrective information may be submitted by DSHS/RC after interview with licensee's RSO. "

Texas Incident number: I-8383

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Power Reactor Event Number: 43092
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RODNEY NACOSTE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/11/2007
Notification Time: 13:16 [ET]
Event Date: 01/11/2007
Event Time: 08:16 [CST]
Last Update Date: 01/11/2007
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):
MALCOLM WIDMANN (R2)

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

Event Text

REACTOR SCRAM WHEN TURBINE OUTPUT BREAKERS OPENED

"Unit 2 reactor scrammed due to a main turbine trip. PCIS [Primary Containment Isolation Signal] groups 2, 3,and 6 isolated, CREV [Control Room Emergency Ventilation] A, SBGT [Standby Gas Treatment] trains A, B, and C started as expected. All control rods fully inserted, eight main steam relief valves lifted and no ECCS actuations occurred. This event is reportable within four hours according to 10CFR50.72(b)(2)(iv)(B) and eight hours according to 10CFR50.72(b)(3)(iv)(A)."

The turbine trip was the result of the 500kV main output breaker opening causing the generator output breaker to open. All relief valves fully seated during the scram recovery. The reactor water level is being maintained using normal feedwater and decay heat is being removed using the steam dumps. The plant is using the startup transformer for electrical power.

The cause of the 500kV breaker opening is under investigation.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 43093
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MICHAEL HETTWER
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/11/2007
Notification Time: 16:59 [ET]
Event Date: 01/11/2007
Event Time: 10:00 [EST]
Last Update Date: 01/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
RONALD BELLAMY (R1)

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

FITNESS FOR DUTY

A non-licensed contract employee supervisor had a confirmed positive result during the initial fitness-for-duty test. The employee's access to the plant has been denied. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43094
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: CLIFFORD CHAPIN
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/11/2007
Notification Time: 17:40 [ET]
Event Date: 01/11/2007
Event Time: 07:10 [EST]
Last Update Date: 01/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
RONALD BELLAMY (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

FITNESS FOR DUTY

A licensed employee had a for cause fitness-for-duty test performed and was determined to be unfit for standing duty. The employee's access to the plant has been restricted pending review. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43095
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: ROBERT SCHREIFELS
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/11/2007
Notification Time: 19:09 [ET]
Event Date: 01/11/2007
Event Time: 17:30 [CST]
Last Update Date: 01/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS KOZAK (R3)

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

Event Text

OFFSITE NOTIFICATION TO STATE AGENCIES

"Notification to NRC following notification to the following government agencies:

State of Minnesota Pollution Control Agency
State of Minnesota Dept of Natural Resources Enforcement
State of Minnesota Dept of Natural Resources Area Fisheries Office
State of Minnesota Dept of Natural Resources Local Conservation Office

Notifications made to above government agencies in accordance with Monticello Nuclear Plant water appropriations permit for fish kill in Mississippi river following Rx scram on 1-10-07."

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012