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Event Notification Report for January 15, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/12/2007 - 01/15/2007

** EVENT NUMBERS **


42975 43082 43084 43096 43097 43098

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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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) & NMSS (Janet Schlueter).

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Hospital Event Number: 43082
Rep Org: HACKLEY HOSPITAL
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANA
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/08/2007
Notification Time: 15:26 [ET]
Event Date: 01/08/2007
Event Time: 10:30 [EST]
Last Update Date: 01/08/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
THOMAS KOZAK (R3)
GREG MORELL (NMSS)

Event Text

MEDICAL EVENT UNDER DOSE TO INTENDED ORGAN DUE TO IMPROPER SEED IMPLANT

During a seed implant procedure for treating prostate cancer with I-125 (41 seeds with 0.32 millicuries each), the patient moved after inserting 2 of the 14 treatment needles. The procedure was delayed for five minutes to allow the patient to be more completely under general anesthesia. The lineup was checked using ultrasound and once the urologist, the radiation oncologist, and the medical physicist were comfortable with the situation, the seed implant was resumed. Once the procedure was completed, the hospital personnel took a film shot to verify the needle placement. It was discovered that the 12 of 14 remaining needles that were inserted were not in the intended location.

The patient has been notified of the error. The hospital is in the process of determining the prostate underdose and the overdose to the unintended areas (rectal and urethra). The hospital is still evaluating any patient intervention that needs to be identified and if there is any unintended permanent functional damage to other organs.

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: 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: 43096
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: DAVID KARST
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/12/2007
Notification Time: 12:39 [ET]
Event Date: 01/12/2007
Event Time: 10:39 [CST]
Last Update Date: 01/12/2007
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):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 93 Power Operation 0 Hot Shutdown

Event Text

TURBINE TRIP/REACTOR TRIP

"At 1039 Kewaunee Power Station experienced a loss of auto stop oil pressure on the main turbine while performing the monthly Turbine Trip Mechanism Test resulting in a reactor trip. No safeguards equipment was out of service at time of trip. Following the trip one of the moisture separators associated with the main turbine had its associated steam inlet valve fail open, which resulted in RCS temperature decreasing to 536 degrees F. This valve was manually isolated and RCS temperature returned to normal 547 degrees F. Normal heat sink via the condenser was available during the event. Investigation is continuing into the cause of the turbine trip.

"This event is being reported under 10CFR50.72(b)(2)(iv)(B) for actuation of the Reactor Protection System and 10CFR50.72(b)(3)(iv)(A) for actuation of the Auxiliary Feedwater System."

All rods fully inserted and no primary or secondary PORV's lifted. There was no injection from any safety systems, other than AFW. Decay heat is being dumped to the condenser via steam dumps. The reactor coolant pressure and temperature are stable.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43097
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: EDWARD McMUTCHEN, Jr
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/12/2007
Notification Time: 15:33 [ET]
Event Date: 11/19/2006
Event Time: 20:28 [CST]
Last Update Date: 01/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BLAIR SPITZBERG (R4)

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

Event Text

INVALID ACTUATION OF PRIMARY CONTAINMENT ISOLATION SYSTEM

"This telephone report is being made in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event or condition caused by an invalid signal that resulted in an automatic actuation on November 19, 2006 at 2028 CST of the following Primary Containment Isolation System (PCIS) groups:

* Group 2, Primary Containment isolations (partial) including Shutdown Cooling (SDC) valve isolation with no loss of SDC function.
* Group 6, Secondary Containment isolation, and initiation of Standby Gas Treatment System and Control Room Emergency Filtration System (complete).

"The systems above functioned as designed. Reactor Protection System (RPS) bus 'B' had lost power from its Motor Generator (MG) and was found de-energized which caused the actuations. Power was restored to the RPS bus 'B' from auxiliary power, and plant systems were recovered.

"In addition to the actuations reported above, the following actuations also occurred and functioned as designed.
* RPS half-scram on B channel (no rods moved);
* Half-group isolations of the following PCIS Groups;
* Group 1, Main Steam Isolation Valves (valves were already shut),
* Group 3, Reactor Water Clean-up (one valve shut),
* Group 7, Recirculation Loop Sample Lines (valves were already shut),

"The cause of the invalid signal was 'B' RPS MG set high voltage condition produced by a faulty voltage adjust potentiometer in the voltage regulator. This caused a protective relay to trip the RPS MG exciter field which caused the subsequent low voltage and loss of the 'B' RPS bus."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43098
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: EDDIE RIFFLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/12/2007
Notification Time: 17:19 [ET]
Event Date: 01/12/2007
Event Time: 16:31 [EST]
Last Update Date: 01/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MALCOLM WIDMANN (R2)

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

Event Text

UNANALYZED CONDITION OF DECAY HEAT SYSTEM

"Crystal River Unit 3 has determined that an existing condition in the Decay Heat (DH) System is reportable under 10 CFR.50.72 (b)(3)(ii)(B), an Unanalyzed Condition. Two valves in question are in series in the Decay Heat (DH) System drop leg from the Reactor Coolant System (RCS). These valves are High-Low pressure interface valves, where three phase hot shorts from another power cable must be considered under Appendix R. A review of cable routing concluded that the two valve's power cables do not meet required Appendix R separation or protection criteria. As such, there is a low probability that both valves could open due to hot shorts under normal operating RCS pressure and temperature conditions, resulting in a rupture of the downstream piping in the Reactor Building or Auxiliary Building. This event could result in a Loss of Coolant Accident (LOCA) in the Auxiliary Building, which is an unanalyzed condition."

The licensee will notify the NRC Resident Inspector.

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Thursday, March 29, 2012