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Event Notification Report for February 16, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/15/2007 - 02/16/2007

** EVENT NUMBERS **


43163 43168 43169

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General Information or Other Event Number: 43163
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHRISTUS SANTA ROSA SURGERY CENTER - LLP
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L05805
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/13/2007
Notification Time: 12:50 [ET]
Event Date: 02/12/2007
Event Time: [CST]
Last Update Date: 02/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA SMITH (R4)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING MULTIPLE PATIENTS RECEIVING >20% PRESCRIBED DOSE

The following information was received via email:

"On Tuesday, February 13, 2007, the Agency [Texas Department of Health] was notified of a series of at least five medical events that were discovered when an improper dose rate constant was used in the treatment planning of the therapeutic application of permanent implants. The radioisotope is I-125 and it was used exclusively for the treatment of prostate cancer. The range of misadministrations is 21-36% over that which was prescribed in the written directive. The licensee is investigating the situation that involved some 28 patients treated over the past year but only one patient complication has been reported thus far. The Agency is continuing to investigate the events with the licensee and will provide updated information as it is received."

Texas Incident No.: I-8391

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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Other Nuclear Material Event Number: 43168
Rep Org: MCCALLUM TESTING LABORATORY
Licensee: MCCALLUM TESTING LABORATORY
Region: 1
City: CHESAPEAKE State: VA
County:
License #: 45-15325-01
Agreement: N
Docket:
NRC Notified By: PHIL BERMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 02/15/2007
Notification Time: 14:17 [ET]
Event Date: 02/15/2007
Event Time: 13:50 [EST]
Last Update Date: 02/15/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN WHITE (R1)
MICHELE BURGESS (NMSS)
ILTAB (e-mail) ()

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

Event Text

LOST TROXLER MOISTURE DENSITY GAUGE

A Troxler Moisture Density Gauge (model 3411, serial number 6957) was lost at a traffic intersection in Chesapeake, VA. The location of the intersection is at Route 17 and George Washington Parkway. The licensee called local police. The radiation safety officer (RSO) is responding to the site to see if the gauge can be found or if any damage to instrument exists.

* * * UPDATE AT 1447 ON 2/15/07 FROM P. BERMAN TO P. SNYDER * * *

The licensee reports that the gauge has been found and taken to the local fire department. The RSO is going to the location to examine the gauge for damage.


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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Power Reactor Event Number: 43169
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: ROB MEIXELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/15/2007
Notification Time: 19:00 [ET]
Event Date: 02/15/2007
Event Time: 16:54 [EST]
Last Update Date: 02/15/2007
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):
PAUL FREDRICKSON (R2)

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

Event Text

UNIT 1 AND UNIT 2 REACTOR TRIP

"At 1654 EST on 2-15-07, Oconee Units 1 & 2 tripped from 100% power. The cause of the trips is under investigation. Unit 1 experienced a partial loss of 4160 volt power [Non-Safety Related] which resulted in a loss of Main Feedwater. Emergency Feedwater started on Unit 1. Unit 2 remained on Main Feedwater. Reactor Coolant Pump power was not affected by the trip on either Unit. Post trip equipment response on Unit 2 was normal. On Unit 1, a second HPI pump auto-started due to a non-safety low seal flow signal [one normally running for normal RCS makeup].

"Units 1 & 2 have been stabilized in Mode 3. Restoration of 4160 volt loads on Unit 1 is in progress."

All Control rods fully inserted on both units. No PORVs or Safety valves lifted during the event for either unit. Both units are removing decay heat by steaming to the Main Condenser via the Turbine Bypass valves. Both units are in a normal shutdown electrical lineup. Unit 3 was not affected by this event.


The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012