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Event Notification Report for March 29, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/28/2007 - 03/29/2007

** EVENT NUMBERS **


43138 43256 43257 43259 43262

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43138
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BOB MURELL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/01/2007
Notification Time: 13:20 [ET]
Event Date: 02/01/2007
Event Time: 08:40 [CST]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
DAVID HILLS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 94 Power Operation 94 Power Operation

Event Text

CONTROLLED SUBSTANCE FOUND IN PROTECTED AREA

Pursuant of 10CFR26.73(b), the following 24 hour notification of a significant fitness for duty event as described in 10CFR26.73(a)(i):

"On 2/01/07 at approximately 0840 CST, off-site testing of a substance proved positive for a controlled substance. The substance was found by a member of plant staff on the plant grounds within the protected area. The plant staff member took possession of the substance and immediately contacted Security staff personnel for assistance. There were no personnel noted in the immediate area of the substance [at the time of discovery]. After confirming the substance, it was turned over to Linn County Sheriff's Department."

The licensee notified the NRC Resident Inspector. Contact the Headquarters Operations Officer for additional details.

* * *UPDATE FROM SCHWERTFEGER TO HUFFMAN AT 1948 EST ON 2/1/06 * * *

The licensee has brought drug dog teams onto the site to assist in locating any other controlled substances that may be present. Contact the Headquarters Operations Officer for additional information. R3DO (Hills) and ILTAB (Hahn) informed.

* * * UPDATE AT 1418 EDT ON 3/28/07 FROM JOHN SCHWERTFEGER TO S. SANDIN * * *

The licensee is retracting this report based on the following:

"Confirmatory analysis performed by State of Iowa Crime Lab has concluded that the substance in question was not a controlled substance and is
therefore not reportable under 10CFR26.73(b) as a significant fitness for duty event as described in 10CFR26.73(a)(i)."

The licensee will inform the NRC Resident Inspector. Notified R3DO(Lara).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 43256
Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: 37-1186-01
Agreement: N
Docket:
NRC Notified By: ANTHONY MONTAGNESE
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/23/2007
Notification Time: 19:30 [ET]
Event Date: 03/23/2007
Event Time: 13:00 [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MEL GRAY (R1)
E. WILLIAM BRACH (FSME)

Event Text

POTENTIAL OVEREXPOSURE INVOLVING BRACHYTHERAPY SOURCE

At 1300 hours on 3/23/07, a male patient received I-125 seed implants for treatment of prostate cancer. The RSO received a call at approximately 1730 hours from the Radiation Oncologist Physicist who had identified that the wrong units were input into the dose planning computer. This resulted in a potential overexposure. A CAT scan is scheduled for Monday, 3/26/07, to verify source placement and more accurately calculate the overexposure. At this time, the preliminary information provided indicates a prescribed dose of 145 Gray with an estimated dose delivery of 155 Gray. The licensee does not believe that there will be any adverse effects to the patient. Following the more accurate calculation the licensee will review whether this notification meets the reporting criteria.

The licensee has notified the prescribing physician of the error.

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 ON 3/28/07 AT 1417 FROM MONTAGENESE TO SNYDER * * *

This event is retracted by the licensee. Since the time of the original notification the licensee has established, by dosimetry readings, that the exposure was below the reporting criteria.

Notified R1DO (Dimitriadis) and FSME EO (Morell).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 43257
Rep Org: BEST MEDICAL INTERNATIONAL, INC
Licensee: BEST MEDICAL INTERNATIONAL, INC
Region: 1
City: SPRINGFIELD State: VA
County:
License #: 45-19757-01
Agreement: N
Docket:
NRC Notified By: BILLY BASS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/26/2007
Notification Time: 13:26 [ET]
Event Date: 03/26/2007
Event Time: 11:00 [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
ANTHONY DIMITRIADIS (R1)
GREG MORELL (FSME)

Event Text

PERSONNEL OVEREXPOSURE ASSEMBLING PALLADIUM SEEDS

On 3/26/07, the licensee's RSO received dosimetry reading (from Landauer) on employees working at his facility indicating that a worker had a deep dose exposure of 9683 mrem and an extremity dose of 9200 mrem. This exposure occurred sometime over the previous two months - the measured dose period was from 1/01/07 to 3/01/07. The individual with the potential overexposure works in the fabrication of Palladium - 103 seeds, a soft gamma emitter, used for brachytherapy treatment. The cause of the overexposure is currently unknown. The dosimetry of coworkers does not indicate overexposures. A survey of the work area shows no contamination and no previously unidentified possible sources of exposure. The worker is a female, approximately 30 years old, and does not exhibit any medical symptoms. No information on pregnancy status was available. Interviews with the individual are in progress.


* * * RETRACTION ON 03/28/07 AT 1130 EDT VIA E-MAIL FROM KRISHNAN SUTHANTHIRAN TO MACKINNON * * *

"We retract the statement. The initial statement was based on information from a dosimeter company without further investigation. Upon further investigation we believe this reading to be in error. Individuals normally receive between 25-30mR per month. Given the fact the isotope they work with is exclusively Pd-103 and the work is inside shielded boxes it's unlikely for them to get such exposure. Our belief at this time is that this reading is in error. We believe the individual's exposure was not higher than they received in previous months. Further, given this is Pd-103, a state (not NRC) regulated isotope, we have and will continue to report findings to the state."

NRC R1DO (Anthony Dimitriadis) & FSME (Greg Morell) notified.

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Power Reactor Event Number: 43259
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JASON HANCOCK
HQ OPS Officer: JASON KOZAL
Notification Date: 03/28/2007
Notification Time: 01:51 [ET]
Event Date: 03/27/2007
Event Time: 20:50 [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)

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

Event Text

LOW STEAM GENERATOR WATER LEVEL INITIATED AUXILIARY FEEDWATER SIGNAL AND A REACTOR TRIP SIGNAL

"This 8-hour notification is being made to report that an Auxiliary Feedwater (AFW) system actuation signal was generated and a Reactor Protective Signal (RPS) generated with the reactor subcritical.

"On March 27, 2007 at approximately 2050, Salem Unit 1 was in Mode 3 following a planned manual reactor trip to begin a scheduled refueling outage. Operators had established initial Reactor Coolant System cooldown using the steam dumps for heat removal and the 11, 12, and 13 AFW pumps for steam generator make-up. All three pumps had been previously placed in-service in accordance with plant procedures. As plant cooldown proceeded, narrow range levels in 11, 12, and 13 Steam Generators reached the low steam generator setpoint trip, resulting in a valid ESF actuation (i.e., start signal to the AFW pumps); however all AFW pumps were already in-service.

"The actuation signal also generated a reactor trip signal to be initiated by the reactor protection system; however, the plant was already in a shutdown condition with the reactor trip breakers open.

"The lowest level during this transient occurred in 13 Steam Generator and was 11.3% narrow range level. Steam generator water level was restored to a normal value and the RCS cooldown recommenced. There were no equipment failures that contributed to this event.

"The NRC Resident has been informed."

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Power Reactor Event Number: 43262
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: WAYNE BENTLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/28/2007
Notification Time: 17:39 [ET]
Event Date: 03/28/2007
Event Time: 13:41 [CDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

HPCI INOPERABLE DUE TO SURVEILLANCE TEST FAILURE

"During the running of the HPCI operability, STP 3.5.1-05, the discharge relief, PSV 2302, lifted and failed to reseat. The relief valve discharges to the Torus Area floor and was captured in the floor drain sump system. The STP was aborted and the HPCI system was declared inoperable.


The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012