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Event Notification Report for March 6, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/05/2007 - 03/06/2007

** EVENT NUMBERS **


43177 43193 43200 43201 43203 43212

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43177
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: MIKE MacLENNAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/20/2007
Notification Time: 19:52 [ET]
Event Date: 02/20/2007
Event Time: 17:20 [CST]
Last Update Date: 03/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRUCE BURGESS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 96 Power Operation 96 Power Operation

Event Text

HPCI DECLARED INOPERABLE DUE TO AN APPARENT EQUIPMENT MALFUNCTION

"On February 20, 2007 at 1720 hours, the High Pressure Coolant Injection (HPCI) system was declared inoperable. During a system walkdown the HPCI Motor Speed Changer (MSC) was discovered energized. The MSC controls HPCI turbine speed during system startup and shutdown, and should not have been energized at the time of the walkdown. Additional troubleshooting determined the MSC was not functioning properly, rendering the HPCI system inoperable. This event is being reported as a condition that could have prevented fulfillment of a safety function in accordance with 10CFR50.72(b)(3)(v)(D) because the HPCI system is a single train system and the loss of HPCI could impact the plant's ability to mitigate the consequences of an accident. In accordance with Technical Specification Action 3.5.1.F, the Reactor Core Isolation Cooling (RCIC) system was confirmed operable. Further troubleshooting and engineering evaluations are continuing."

The licensee informed the NRC Resident Inspector.

* * * RETRACTION AT 1146 ON 3/5/2007 FROM ERIK MARKS TO MARK ABRAMOVITZ * * *

"The purpose of this report is to retract the ENS report made on February 20, 2007 at 1720 hours (ENS #43177) under 10CFR50.72(b)(3)(v)(D), a condition that could have prevented fulfillment of a safety function. The initial report was made when the Unit 2 High Pressure Coolant Injection (HPCI) system was declared inoperable following a system walkdown that discovered the HPCI Motor Speed Changer (MSC) was energized. The MSC controls HPCI turbine speed during system initiation, and should not have been energized at the time of the walkdown since the system was not in operation. During troubleshooting the MSC responded slower than expected. Due to this unexpected behavior, it was not certain if HPCI could have met its design basis requirements. However, a subsequent engineering evaluation has determined that at the time of discovery, the HPCI system injection time would have been sufficient to meet its safety function. Repairs to HPCI were completed and the system was declared operable on February 22, 2007 at 0036 hours."

The licensee notified the NRC Resident Inspector.

Notified the R3DO (Orth).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 43193
Rep Org: HANNIBAL CLINIC
Licensee: HANNIBAL CLINIC
Region: 3
City: HANNIBAL State: MO
County:
License #: 24-32619-01
Agreement: N
Docket:
NRC Notified By: JOEL HASSIEN
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/27/2007
Notification Time: 15:20 [ET]
Event Date: 02/27/2007
Event Time: 08:30 [CST]
Last Update Date: 03/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
ROGER LANKSBURY (R3)
GREG MORELL (FSME)

Event Text

MEDICAL EVENT - TREATMENT TO WRONG PATIENT

Patient "A" was suppose to receive a non-nuclear stress treatment by a technologist. Patient "B" was suppose to receive a nuclear treatment by a technologist. Patient "B" did not show up for the scheduled appointment. The technologist mistakenly gave patient "A" an injection (0.67 ml) of Tc-99m Cardolite (15 millicuries), which was suppose to go to patient "B". The attending physician notified patient "A" of this error, and deemed no corrective action to the patient was necessary. The error was determined to be that the technologist did not follow procedures, which is to verify patient name. As a corrective measure, the technologist was provided additional instruction in this matter.

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 HASSIEN TO KNOKE AT 11:50 ON 03/05/07 ***

The RSO called to retract this event stating that patient "A" did not reach the threshold of effective dose equivalent.

Notified R3DO (Orth) and FSME (G. Morell).

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General Information or Other Event Number: 43200
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CHEMICAL WASTE MANAGEMENT
Region: 4
City: SULPHUR State: LA
County:
License #: LA-4187-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2007
Notification Time: 11:49 [ET]
Event Date: 02/02/2007
Event Time: [CST]
Last Update Date: 02/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - CONTAMINATION FROM LEAKING SEALED SOURCE

The following information was provided by the state via facsimile:

On 02/05/07, the licensee notified the Louisiana Department of Environmental Quality that one of its Electron Caption Detectors (ECD) had a removable activity above 0.005 microcuries as a result off a recent "wipe test". The ECD is a Agilent Technologies, Inc. model number: 19233-69570, serial number YA353 with an estimated activity of 15 millicuries of Ni-63. Leak test results from a test performed on 01/26/07 were 0.024 microcuries. The wipe test results were reported to the licensee on 02/02/07.

On 02/07/07 an onsite inspection was performed by licensee corporate personnel. On 02/07/07 the ECD was returned to the manufacturer's location in Wilmington, DE for disposal.

LA Event Report ID No.: LA070002

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General Information or Other Event Number: 43201
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: CARDINAL HEALTH
Region: 4
City: SHREVEPORT State: LA
County:
License #: LA-10217-L01
Agreement: Y
Docket:
NRC Notified By: RICHARD PENROD
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2007
Notification Time: 12:07 [ET]
Event Date: 02/14/2007
Event Time: [CST]
Last Update Date: 02/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - DISPENSING ERROR FOR THALLIUM -201 DOSE

The following information was provided by the state via facsimile:

"Description of Event: On February 14, 2007, a customer called to report that the Thallium-201 Chloride dose they ordered was only 2.9 mCi instead of the 4.0 mCi requested. Thallium-201 Chloride is an imaging agent used for myocardial perfusion imaging or parathyroid and tumor imaging. Another TI-201 dose was sent to the customer to account for the incorrect activity.

"An investigation revealed that the pharmacist who dispensed the dose had selected the incorrect setting on the dose calibrator when assaying the dose at the pharmacy. The dose calibrator was set on Tc-99m instead of TI-201, resulting in an incorrect assay.

"Root Causes: The root cause of this event was an error by the pharmacist while assaying the dose. By not double-checking that the dose calibrator was on the correct setting, an incorrect assay was recorded.

"Actions Taken to Prevent a Recurrence: In an effort to prevent a recurrence of this event, the pharmacist will be sure to check that the correct isotope settings are in place on the dose calibrator for the dose being assayed. Additionally, checking the volume on the dose label will help reinforce that the pharmacist has checked which dose is being assayed and if the isotope setting is correct."

LA Event Report ID No.: LA070003

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General Information or Other Event Number: 43203
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: GALLET & ASSOCIATES
Region: 1
City: SPARTANBURG State: SC
County:
License #: GA 1316-1
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/01/2007
Notification Time: 11:22 [ET]
Event Date: 03/01/2007
Event Time: 08:00 [EST]
Last Update Date: 03/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1)
GREG MORELL (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN HUMBOLDT MOISTURE DENSITY GAUGE

The following information was provided via facsimile:

"The SC Department of Health and Environmental Control was notified on Thursday, March 1, 2007, at 1015 hrs, that a Humboldt Model EZ 5001, s/n 4751, containing 11 mCi of Cs-137 and 44 mCi of Am-241:Be, had been stolen from the rear of a company truck, located at Extended Stay America, Spartanburg, SC. [The State of SC] contacted [the] RSO, at 1030 hrs and was advised that [the] authorized user, had reported at 0800 hrs that the gauge had been stolen from the vehicle. [The RSO] stated that the tailgate was locked to prevent access to the steel lock box that the gauge storage container was secured in and the lockbox is bolted to the truck bed. The tailgate had been damaged to gain access to the lockbox and a blowtorch had been used to cut the lock of the steel box. [The RSO] stated that local law enforcement had been notified and a police report had been completed. [The RSO] stated that he would e-mail an incident report, police report, and images of the security measures used to secure gauges in company vehicles within the next two business days.

"[The RSO] was advised by the State of SC to submit a written report detailing this event to the Department within 30 days. [The RSO] was advised that if the gauge was recovered, to contact the Department immediately. The event is open and pending the licensee's investigation and report to the Department, updates will be made through the national NMED system."

The licensee is located in Marietta, GA and has a reciprocity license in SC.



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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Other Nuclear Material Event Number: 43212
Rep Org: SCHLUMBERGER - P.T.C.
Licensee: SCHLUMBERGER - P.T.C.
Region: 1
City: PRINCETON JUNCTION State: NJ
County:
License #: 29-08636-02
Agreement: N
Docket:
NRC Notified By: TOM BRACKE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/05/2007
Notification Time: 11:45 [ET]
Event Date: 03/01/2007
Event Time: [EST]
Last Update Date: 03/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
JOHN CARUSO (R1)
GREG MORELL (FSME)
ILTAB VIA E-MAIL ()

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

Event Text

PULSE NEUTRON GENERATOR TRITIUM SOURCE MISSING

The licensee reported that a shipment of a pulse neutron generator (PNG), ID #1146-01, containing a 1.5 curie tritium sealed source (s/n 5066) was determined to be lost by the freight forwarder (Yellow Freight) and reported missing in transit to the licensee's NJ facility on 3/1/07. The PNG originated in Indonesia, arrived at Dallas - Fort Worth Airport, and cleared Customs on 2/9/07. The PNG package was picked up by Yellow Freight and was to be shipped to NJ through Nashville TN. It appears that there are some discrepancies with the Yellow Freight tracking number and that the package never arrived at Nashville. A search for the package is still in progress.

The licensee intends to notify NRC Region 1 inspector (Jackson).

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.

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