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Event Notification Report for March 14, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/13/2007 - 03/14/2007

** EVENT NUMBERS **


42748 43078 43083 43201 43231 43232 43233 43234

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General Information or Other Event Number: 42748
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: MCKAY-DEE HOSPITAL CENTER
Region: 4
City: OGDEN State: UT
County:
License #: UT 2900147
Agreement: Y
Docket:
NRC Notified By: PHILLIP GRIFFIN
HQ OPS Officer: MIKE RIPLEY
Notification Date: 08/01/2006
Notification Time: 14:55 [ET]
Event Date: 06/19/2006
Event Time: [MDT]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFFREY CLARK (R4)
GREG MORELL (NMSS)

Event Text

UTAH AGREEMENT STATE REPORT - MEDICAL EVENT

The State provided the following information via facsimile:

"On July 11, 2006, the licensee indicated to a Division inspector that a 'misadministration' had occurred.

"The licensee sent a letter dated July 17, 2006, to the Division indicating that a 'medical event' had occurred. The letter did not contain sufficient information to determine if the incident was an actual medical event. Multiple attempts were made to contact the RSO who reported the incident to verify that it was a medical event. The RSO was on vacation during most of July 2006.

"The RSO contacted the Division by telephone on August 1, 2006, and confirmed that a medical event had occurred.

"Event Description: On June 19, 2006, two patients were scheduled at the same time for radioactive treatment of hyperthyroidism. One patient was scheduled for 15 mCi of I-131, and the other patient was scheduled for 29 mCi of 1-131. The patient who was scheduled for 15 mCi of 1-131 ingested 29.0 mCi of 1-131. The error was identified by the licensee prior to the administration of I-131 to the other patient. The other patient's dose was corrected, and the patients' physicians were informed of the incident."

Utah Event Report ID: UT-06-0002

* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *

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General Information or Other Event Number: 43078
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ST. JAMES HOSPITAL AND HEALTH CENTER
Region: 3
City: OLYMPIA FIELDS State: IL
County:
License #: IL-01289-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: PETE SNYDER
Notification Date: 01/05/2007
Notification Time: 13:12 [ET]
Event Date: 01/04/2007
Event Time: 12:00 [CST]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN MADERA (R3)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPPORT - MEDICAL DOSE TO WRONG LOCATION

"On January 4, St. James' Hospital and Health Center's medical physicist called to report that medical event had occurred involving a patient at their Cancer Center Institute. [The medical physicist] advised that a series of high dose rate (HDR) afterloading fractions using 10 Ci of Ir-192 that had been conducted on 11/29, 12/6, 12/13 and 12/20 had inadvertently caused the irradiation, not of the cancerous target intended but instead, a portion of the patient's inner thighs. The delivered radiation dose to the skin was 2,000 Rad and the dose to the intended treatment area was zero.

"[The medical physicist] indicated that the error had been identified as part of a 'chart audit' that was conducted prior to performing the next similar routine treatment of a subsequent patient. Computerized dosimetry planning records showed that although the prescribed treatment was to occur with an automated source travel distance of 120 cm, the actual data point used during the treatment phase was a travel distance of only 100 cm. The patient was asked to come to the hospital on the afternoon of January 4 for a consultation. During that visit the responsible authorized radiation oncologist confirmed reddening of the skin on both inners thighs of approximately 3 square centimeters. [The oncologist] indicated that the skin damage is a 'superficial ulceration with no necrosis of the tissue' and he expected healing to be completed in 2-4 weeks. [The oncologist] has made arrangements to meet with the patient weekly to monitor her progress during that time. HDR afterloader treatments have been rescheduled to occur next week."

The state also said that it appears that correct dose was administered to the wrong location because of a human error not an equipment malfunction.

Other pertinent data related to this event: Type of procedure: BRACHYTHERAPY, Intended Dose: 2000 RAD, Form of Radioactive Material: SEALED SOURCE, Radionuclide: IR-192, Activity: 10 Ci.

Equipment Information: Manufacturer: ALPH-OMEGA SERVICES VARIAN, Model Number: VS2000, Serial Number: 02011368001112006101.

The Illinois Emergency Management Agency will be following up on this incident. This report is IL report number 070001.

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.

* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *

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Power Reactor Event Number: 43083
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: WILLIAM BAKER
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/08/2007
Notification Time: 15:47 [ET]
Event Date: 11/10/2006
Event Time: 00:10 [CST]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
CHARLIE PAYNE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

EDG ACTUATION DUE TO ACCIDENTAL SWITCH MISPOSITIONING

"This 60-day telephone notification is being made under reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of any of the equipment specified in paragraph 50.73(a)(2)(iv)(B). In this case, the equipment actuated was the four Unit 1 and 2 emergency diesel generators (EDG) A, B, C, and D. These EDGs are common equipment for Browns Ferry Units 1 and 2.

"On November 10, 2006, personnel were performing surveillance requirement (SR) test 0-SR-3.8.1.6, Common Accident Signal Logic. At this time Browns Ferry Unit 1 was shutdown and defueled, and Unit 2 was operating at 100% thermal power. During conduct of this testing, at 0010 hours CST, all four of the common U1/2 EDGs were inadvertently started. This occurred when test personnel (non-licensed) inadvertently placed a keylock switch in the wrong position during the equipment restoration portion of the testing. The SR test step being performed was correct, but it was incorrectly implemented.

"All affected equipment operated per the plant design in response to the switch manipulation, with each of the four EDGs properly starting and running in response to the invalid start signal. No loss of normal plant electrical power occurred, and none of the EDGs connected to its associated 4-Kv shutdown board. The EDGs were shutdown in accordance with plant operating procedures approximately 13 minutes after their start.

" Since no actual plant condition existed which required the EDGs to start, and since the starts occurred inadvertently as a result of a human error during a test performance, this event is classified as invalid.

"There were no safety consequences or impacts on the health and safety of the public. The event was entered into TVA's corrective action program for evaluation and resolution. [Reference BFN corrective action document PER 114498].

"The NRC Senior Resident Inspector has been notified."

* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC INTERNAL WEBSITE* * *

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 03/13/2007
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

* * * UPDATE AT 0915 EDT ON 3/13/07 FROM RICHARD PENROD TO S. SANDIN * * *

The State of Louisiana is retracting this report following a review which concluded that their reporting criteria was not met. Notified R4DO (Shannon) and FSME (Morell).

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Power Reactor Event Number: 43231
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JEAN BROILLET
HQ OPS Officer: JASON KOZAL
Notification Date: 03/13/2007
Notification Time: 15:14 [ET]
Event Date: 03/13/2007
Event Time: 07:30 [EDT]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHRIS HOTT (R1)

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

Event Text

LOW MAIN CONDENSER VACUUM ISOLATION SIGNAL RECEIVED DURING PLANT SHUTDOWN

"It was discovered that a valid Low Main Condenser Vacuum group 1A Nuclear Steam Supply Shutoff System (NS4) isolation for the Main Steam Isolation Valves (MSIV's) had been received while breaking main condenser vacuum while in Mode 4 for planned refueling outage 2R09. The isolation actuation was received as main condenser vacuum lowered below the isolation setpoint during the planned evolution of breaking of main condenser [vacuum]. All valves for this isolation signal had previously been closed by approved plant procedures while in Mode 3. The valid isolation signal was caused by not having the isolation signal bypassed as allowed by approved plant procedures."

The licensee will notify the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 43232
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: TONY HUDSON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/13/2007
Notification Time: 15:44 [ET]
Event Date: 09/22/2006
Event Time: 22:00 [CDT]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
JAMES MOORMAN (R2)
GREG MORELL (FSME)

Event Text

REPORTED UNDER NRC BULLETIN 91-01 24 HOUR NOTIFICATION

"On September 22, 2006, during a heavy rain storm, the water level in the C-310 position #4 scale pit reached 3 5/8 inches (3.625 inches). The scale pit liquid sensor alarm system did not function as credited, in violation of NCSA 310-004. The water was found by operators by visual inspection. NCSA 310-004 credits the liquid sensor alarm to provide notification of water in the pit in excess of 2.5 inches.

At the time of the event, the water level was measured to be less than 3 5/8 inches (3.625 inches) deep. However, subsequent measurements accounting for slope in the scale pit floor show that the water could actually have been as deep as 4 3/8 inches (4.375 inches).


The two process conditions relied upon for double contingency are mass and geometry.

"The first leg of double contingency is based on preventing a release of fissile material containing greater than a safe mass of uranium from getting into the scale pits. This is controlled through reliance on the integrity of the UF6 cylinder, liquid UF6 piping, pigtail, and liquid UF6 handling equipment. Since a UF6 release containing greater than a safe mass has not occurred, the mass parameter has been maintained Therefore, this leg of double contingency is maintained.

"The second leg of double contingency relies on the scale pit liquid sensor alarm system to provide notification of water in the pit in excess of 2.5 inches. Requiring the liquid sensor to alarm at 2.5 inches allows ample time to react and prevent the accumulation of more than 3.68 inches water. Although the alarm system did not function, operators performed a surveillance of the scale pits and identified water in the #4 scale pit in excess of 2.5 inches. NCSE 032 shows that the 'subcritical' slab height of UO2F2 solution in the C-310 scale pit is 4.1 inches at (deleted) wt% U235. The NCSE determined that an unsafe geometry slab height (is., greater than 4.1 inches) cannot form if the initial water height is less than 3.6 inches. The as-found water height corrected for the scale pit slope was determined to be as deep as 4 3/8 inches (4.375 inches). Therefore, the parameter limit specified in NCSE 032 was exceeded and double contingency was not maintained.

"The NRC Senior Resident Inspector has been notified of this event. PGDP Problem Report No. ATRC-06-3103; PGDP Event Report No. PAD-2007-01: NRC Worksheet No.


SAFETY SIGNIFICANCE OF EVENTS:

Although the scale pit liquid sensor alarm system failed to alarm when water in the pit exceeded 2.5 inches, an insufficient amount of water was available to achieve a criticality. The assay of the product withdrawal system at the time of the event was less than (deleted) wt%. Additional KENO and bucking calculations were included in design analysis calculation to illustrate the margin of conservatism. Those calculations show that the scale pit would have remained below the PGDP USL even for UO2F2 slab heights up to 7.75 inches at (deleted) wt%. In addition, a UF6 release containing greater than a safe mass did not occur.

POTENTIAL CRITICALITY PATHWAYS INVOLVED:

In order for criticality to be possible, a large UF6 release containing greater than a critical mass of uranium would have to form in the scale pit, and the pit would have to contain a sufficient amount of water.

CONTROLLED PARAMETERS:

The two process conditions relied upon for double contingency are mass and geometry.


ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL:

Product withdrawal assay at the time of the event was less than (deleted) wt% U235. However, no UF6 release occurred.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

All C-310 scale pit sensor alarming systems have been repaired and verified to work properly and put back in service.


The NRC Resident Inspector was notified of this report.

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Power Reactor Event Number: 43233
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: H.EAVES
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/13/2007
Notification Time: 16:47 [ET]
Event Date: 03/13/2007
Event Time: 15:27 [EDT]
Last Update Date: 03/13/2007
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):
JAMES MOORMAN (R2)

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

Event Text

MANUAL REACTOR TRIP DUE TO "A" MAIN FEEDWATER PUMP


"At 1527 EST on 3/13/07 a manual reactor trip was actuated on Unit 2 due to 'A' MFPT (main feedwater pump turbine) malfunction. All systems responded as expected following the manual trip. The plant is currently stable in Mode 3 (Hot Standby) at 547 (degrees) F. No primary system or steam generator safety valves opened due to this trip. AFW (auxiliary feedwater pumps) system started and operated as designed."

All emergency core cooling systems, emergency diesel generators are fully operable if needed and the electrical grid is stable.


The NRC Resident Inspector was notified of this event by the licensee.

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Fuel Cycle Facility Event Number: 43234
Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
                   FABRICATION & SCRAP
                   COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: JASON KOZAL
Notification Date: 03/13/2007
Notification Time: 20:15 [ET]
Event Date: 03/13/2007
Event Time: 14:30 [PDT]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
JAMES MOORMAN (R2)
JOSEPH GIITTER (FSME)

Event Text

POTENTIAL HAZARD AFFECTING CRITICALITY CONTROLS DISCOVERED

"BACKGROUND:

"AREVA NP Richland routinely uses propane powered forklifts to move SNM in and between process buildings and warehouses. These forklifts have been routinely left inside these warehouses when not being used. During re-evaluations of facility hazards, AREVA safety staff questioned the acceptability of such practices in the context of 10CFR 70.61.

"EVENT DESCRIPTION:

"On March 13, 2007 at approximately 14:30 PDST, a member of the AREVA safety staff briefed site management on the conclusion of the safety staff that the practice of leaving propane powered forklifts unattended inside SNM storage warehouses for extended periods of time did not meet the performance requirements of 10 CFR 70.61 in that under certain postulated circumstances, a propane deflagration could occur and initiate a large fire. During some postulated fire-fighting scenarios, it was determined that accidental nuclear criticality was not 'highly unlikely'.

"SAFETY SIGNIFICANCE OF EVENT:

"The safety significance of this condition is low because an accidental nuclear criticality is still considered unlikely. The municipal fire department works closely with the AREVA emergency response organization when they respond to plant abnormal events and emergencies. The NCS organization is an integral part of the ERO and participates in the decision making during such events if NCS concerns exist.

"There have been no propane fires on site during the time of the deficient analysis.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR):

"Criticality could potentially occur during firefighting if the SNM in storage looses geometry control coincident with moderation.

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):

"The process parameters controlled in the various storage warehouses include geometry, mass, moderation and neutron absorbers depending upon the storage configuration.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:

"Plant-wide fire controls are established to ensure that large fires that would require the intervention by the municipal fire department are highly unlikely. This assures that the potential NCS concerns relative to fire-fighting with water are compliant with regulatory requirements. However, in certain areas of the plant the scenario of a propane deflagration and the potential subsequent large fire and response by the municipal fire department could not be shown to be highly unlikely during this unlikely condition.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:

"After discovery of the deficiency, a prohibition of allowing propane powered vehicles to remain unattended for significant amounts of time in warehouses is being established. Additionally, a restriction against using water for fire-fighting in the areas of concern, without approval of a Criticality Safety Engineer is being established. These administrative actions will ensure that accidental nuclear criticality due to a propane-induced fire scenario remains highly unlikely."

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