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Event Notification Report for February 13, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/12/2007 - 02/13/2007

** EVENT NUMBERS **


43147 43155 43157 43161 43162

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Hospital Event Number: 43147
Rep Org: ST. FRANCIS HOSPITAL, HARTFORD, CT
Licensee: ST. FRANCIS HOSPTIAL, HARTFORD, CT
Region: 1
City: HARTFORD State: CT
County: HARTFORD
License #: 06-00854-03
Agreement: N
Docket:
NRC Notified By: E. WILCOX
HQ OPS Officer: JOHN MacKINNON
Notification Date: 02/06/2007
Notification Time: 13:49 [ET]
Event Date: 02/06/2007
Event Time: 07:00 [EST]
Last Update Date: 02/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WILLIAM COOK (R1)
GREG MORELL (NMSS)

Event Text

MEDICAL EVENT

A patient was being treated for cancer of the cervix. The planned total dose to the cervix was to be 2046.5 cGy, over a 39 hour time period. The licensee was using an LDR Selectron Afterloader. Nine cesium-137 sources, activity of each source 16.7 millicuries, were used in the afterloader. The patient started treatment on 02/05/07 at 1235 EST. Today, 02/06/07, between the hours of 0630 - 0717 EST the patient pulled the applicator out approximately 4 centimeters.

The patient was given the correct dose to the cervix for 16.09 hours for a total dose of 844.5 cGy. The patient was given an incorrect dose to the vaginal area for between 30 - 60 minutes. The total dose to the incorrect area is between 50 - 200 (Max) cGy. This incident was not harmful to the patient. The patient's doctor was notified of this incident. The patient will not be retreated.

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: 43155
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CAPTECH
Region: 1
City: TALLAHASSEE State: FL
County:
License #: 2608-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/08/2007
Notification Time: 11:57 [ET]
Event Date: 02/06/2007
Event Time: 11:00 [EST]
Last Update Date: 02/08/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING PERSONNEL EXTREMITY OVEREXPOSURE

"[Captech representative] reported an overexposure to a Captech employee. [The individual] received 50.68 rem to her left hand as per her dosimetry report. [The individual] is no longer an employee at Captech [and] left at her own volition as per [the Captech representative]. Incident referred to radioactive materials for investigation."

Captech is an independent Nuclear Pharmacy. The individual receiving the overexposure handled various isotopes during the period measured by the dosimetry report.

FL Incident No.: FL07-019

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Power Reactor Event Number: 43157
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/08/2007
Notification Time: 18:40 [ET]
Event Date: 02/08/2007
Event Time: 13:42 [CST]
Last Update Date: 02/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
REBECCA NEASE (R4)

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

RAW WATER PUMPS DECLARED INOPERABLE DUE TO A POTENTIAL FAILURE OF THE PUMP BREAKER LINKAGES

"On February 8, 2007 at 10:22 CST, Raw Water Pump AC-10C was declared inoperable when the pump breaker experienced a plunger linkage failure during a scheduled pump start for a scheduled rotation. Due to a similar failure of Raw Water Pump AC-10B two weeks earlier, a condition report was initiated for engineering to review the potential for a common failure mode. Engineering reviewed the number of cycles of the breakers for AC-10A and AC-10D both have greater than 1600 cycles. The breaker for AC-10B had over 1200 cycles at the time of its failure and AC-10C was over 1700 cycles. Based on the similar numbers of cycles, engineering has determined that continued operation of AC-10A and AC-10D without breaker failure could not he assured. All other safeguards associated breakers have been verified to have less than 1000 cycles and are not considered to be susceptible to breaker failure at this time. After discussion with engineering, Raw Water Pumps AC-10A and AC-10D were declared inoperable on February 8, 2007 at 13:42 CST based on the number of breaker cycles for these two components in relation to the two breakers that failed.

"With three Raw Water Pumps inoperable, Fort Calhoun Station entered Technical Specification 2.0.1 which requires the plant be placed in hot shutdown within six (6) hours. The potential for a common mode failure of the linkage in the 4160 VAC circuit breakers (ABB Combustion Engineering Model No. 5VKBR-250) could have prevented operation of the Raw Water Pumps to fulfill the required design function to remove residual heat during a design basis accident.

"At 15:22 CST, repairs were completed on Raw Water Pump AC-10C breaker and the pump was declared operable. At 15:34 CST, Technical Specification 2.0.1 was exited and Technical Specification 2.4(1)c, 7-day LCO was entered for the inoperability of Raw Water Pumps AC-10A and AC-10D. The repair of the breakers for AC-10A and AC-10D are scheduled for February 9, 2007."

The licensee informed the NRC Resident Inspector.

* * * UPDATE AT 1632 EST ON 2/12/07 FROM ERICK MATZKE TO S. SANDIN * * *

"This communication is meant to supplement the notification of February 8, 2007. The common mode failure of the linkage in the 4160V circuit breaker (ABB Combustion Engineering model number 5VKBR-250) could have prevented the operation of the raw water pumps as required by design. This could have resulted in the inability of the raw water system to remove residual heat during design basis accidents as required."

The licensee informed the NRC Resident Inspector. Notified R4DO (Smith).

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Power Reactor Event Number: 43161
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ELLIS VANN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/12/2007
Notification Time: 14:58 [ET]
Event Date: 02/12/2007
Event Time: 10:52 [CST]
Last Update Date: 02/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK RING (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

BOTH STANDBY FILTER UNITS INOPERABLE

"While performing core alterations and moving irradiated fuel assemblies in the secondary containment, both Standby Filter Units (SFUs) have been declared inoperable per Technical Specification 3.7.4 Condition F. This represents a loss of safety function during the mode of applicability. Core alterations and movement of irradiated fuel assemblies in the secondary containment have been suspended. Movement of irradiated fuel assemblies in the secondary containment, core alterations, and operations with a potential for draining the reactor vessel (OPDRVs) have all been prohibited. As a result of the actions taken, the mode of applicability for Technical Specification 3.7.4 Condition F has been exited.

"The A SFU became inoperable per Technical Specification 3.7.4 Condition A due to being unable to meet surveillance requirement 3.7.4.4: -verify each SFU subsystem can maintain a positive pressure of >= 0.1 inches water gauge relative to the outside atmosphere during the isolation mode of operation. This was discovered at 10:52 on 2/12/07.

"The B SFU was inoperable due to loss of control power from preplanned maintenance per Technical Specification 3.7.4 Condition A. This occurred on 2/9/07 at 00:45.

"DAEC continues to investigate [the cause of the inoperability of the A SFU].

"This event is reportable under 50.72(b)(3)(v) (D), 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: (D) Mitigate the consequences of an accident'. "

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43162
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: FRED MASHBURN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/12/2007
Notification Time: 15:47 [ET]
Event Date: 02/12/2007
Event Time: 11:58 [EST]
Last Update Date: 02/12/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
CAROLYN EVANS (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

FITNESS FOR DUTY - LICENSED EMPLOYEE

A licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been revoked. The employee was working in a non-safety related capacity at the time of the testing. A work review is in progress. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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