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Event Notification Report for April 2, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/30/2007 - 04/02/2007

** EVENT NUMBERS **


43258 43260 43261 43263 43265 43266 43267 43268 43269

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General Information or Other Event Number: 43258
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CALIFORNIA SURGERY CENTER
Region: 4
City: Bakersfield State: CA
County:
License #: 6833-15
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/27/2007
Notification Time: 17:52 [ET]
Event Date: 03/19/2007
Event Time: [PDT]
Last Update Date: 03/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE - CALIFORNIA - MEDICAL MISADMINISTRATION

The State provided the following information via facsimile:

"On March 16, 2007, the licensee initiated a 'Mammosite' treatment of a patient, with a total prescribed dose of 3400 cGy (3400 rad) to be delivered in 10 fractions of 340 cGy (340 rad) each, over the course of 5 days, using a Nucletron, Model 105.999 HDRA with 4.1 Ci Ir-192 (as of the first day of treatment). The first five fractions were delivered uneventfully. During the last five fractions, the radiation therapy technologist accidentally imported the wrong treatment plan, resulting in an underdose to the treatment area. The dwell position of the source was actually fully outside of the patient, so the tumor received effectively no dose. The licensee is calculating the skin and whole body dose to the patient, but currently estimates it will not have an adverse affect upon the patient. The patient and referring physician have been notified, and re-treatment has been scheduled to begin tomorrow. This event was discovered upon review of the patient's chart when the patient returned for a follow-up exam. The licensee will provide a written report of the event within 15 days."

CA Report #032707

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: 43260
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 1319-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: PETE SNYDER
Notification Date: 03/28/2007
Notification Time: 11:44 [ET]
Event Date: 03/28/2007
Event Time: 10:00 [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - INCORRECT DOSE TO PATIENT DURING I-131 BEXXAR THERAPY

"Mis-administration while performing l-131 therapy. Procedure is called a [Bexxar] Therapy. 74 mCi was prescribed, but the patient received only 5 to 10 mCi. T connector to catheter was not properly fitted tight enough causing connector to come loose from tubing. Some 1-131 spilled on floor. Incident happened on 28-March-2007 at 10:00 am this office notified at 11:10 am. This incident is referred to Radioactive Materials for investigation."

The patient and the prescribing physician are aware of the dosing error. The licensee plans to conduct another procedure 3/30/07.

The state will follow up with the licensee on this incident. This incident is being tracked as Florida incident number FL07-054.

* * * UPDATE FROM FLANNERY (NRC/FSME) VIA E-MAIL TO HUFFMAN AT 1530 EDT ON 3/28/07 * * *

This event has been reviewed and determined to be a reportable medical event.

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: 43261
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: NOVA ENGINEERING
Region: 1
City:  State: GA
County: Fayette
License #: GA-1323-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/28/2007
Notification Time: 16:44 [ET]
Event Date: 03/27/2007
Event Time: [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE - GEORGIA - DAMAGED DENSITY GAUGE

The State provided the following information via email:

"Nova personnel had placed the portable density gauge on the tailgate of the truck and drove off prior to secure the gauge to the truck bed. The Radiation Safety Officer (RSO) of Nova was notified of the incident and responded to the scene. The RSO stated the gauge case had broken apart and the circuit board on the gauge had been damaged. He had surveyed the source rod and source and based on the measurements determined the source rod to be intact and the source not leaking. The fire department and the County had the area secured until it was determined the gauge could be packed up and removed from the road. The RSO stated he would send the gauge to Regis [a gauge repair firm] for either disposal or repair. "

Georgia Report GA-2007-07

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General Information or Other Event Number: 43263
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: KAY COUNTY HOSPITAL LLC
Region: 4
City: PONCA CITY State: OK
County:
License #: OK-14046-02
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/29/2007
Notification Time: 11:37 [ET]
Event Date: 05/03/2006
Event Time: 12:00 [CDT]
Last Update Date: 03/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT FROM OKALAHOMA - HIGHER DOSE THAN PRESCRIBED

This event took place between 05/03/06 and 03/27/07 and involved ten patients during this time period being treated for prostate cancer using Iodine-125. Kay County Hospital LLC (formally known as Via Cristi Hospital) had changed from ordering I-125 doses in Air-Kerma to millicuries. During the time period from 05/03/06 to 03/27/07 they used the incorrect dose count. This caused each of the ten patients to receive a dose 27 percent higher than the written directive. This did not pose any harm to the patients. The error was discovered on 03/28/07 by a newly hired Medical Physicist.

The licensee is in the process of notifying the affected patients. The licensee will also being working with the software vendor to develop better training and procedures for the performance of dose calculations to prevent reoccurrence.

* * * UPDATE ON 3/30/2007 AT 0720 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO ABRAMOVITZ * * *

This event has been reviewed and determined to be a reportable medical event.

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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Hospital Event Number: 43265
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 4
City: LITTLE ROCK State: AR
County:
License #: 03-23583-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: JASON KOZAL
Notification Date: 03/29/2007
Notification Time: 12:48 [ET]
Event Date: 05/31/2006
Event Time: [CDT]
Last Update Date: 03/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
GREG MORELL (FSME)

Event Text

MEDICAL EVENT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED

"The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA.

"The permittee is VA Eastern Colorado Health Care System, Denver, Colorado. The possible medical event occurred on May 31, 2006. The possible medical event was discovered on March 28, 2007.

"The basis for the possible medical event is under 10 CFR 35.3045(a)(1)(i) and involved administration of a dose different from the dose prescribed in the written directive.

"Specifically, the written directive for a patient therapy procedure listed the dose to be 15 millicuries Iodine 131 when in fact 30 millicuries was given to the patient. Since the clinical intent was for the patient to receive 30 millicuries, the possible medical event will not have any adverse impact on the patient.

"The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event.

"The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days."

* * * UPDATE ON 3/30/2007 AT 0720 FROM FLANNERY (NRC/FSME) VIA E-MAIL TO ABRAMOVITZ * * *

This event has been reviewed and determined to be a reportable medical event.

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: 43266
Rep Org: ROSEMOUNT NUCLEAR
Licensee: ROSEMOUNT NUCLEAR
Region: 3
City: CHANHASSEN State: MN
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID ROBERTS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/30/2007
Notification Time: 10:30 [ET]
Event Date: 01/12/2007
Event Time: [CDT]
Last Update Date: 03/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JULIO LARA (R3)
JACK WHITTEN (R4)
VERN HODGE (NRR)
OMID TABATABAI (NRR)

Event Text

PART 21 - ROSEMOUNT PRESSURE TRANSMITTER MAY NOT BE SEISMICALLY QUALIFIED

"During routine operations on the RNII production floor, it was observed that an incorrect torque wrench was being used at mechanical assembly to tighten the Sensor Module Lock Nut. The incorrect tool was calibrated to a value of 12.5 ft-lb, resulting in undertorquing of the lock nut. The incorrect torque wrench was removed from service and replaced with a tool calibrated to the correct torque value of 35 ft-lb. RNII reworked all affected transmitters that had not yet shipped to the correct torque value.

"Assembly with the incorrect tool could result in certain pressure transmitters having a degraded environmental seal between the sensor module and the electronics housing during or after a seismic event."

The five affected models have been delivered to the Byron and Comanche Peak nuclear stations.

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Fuel Cycle Facility Event Number: 43267
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: LON PAULSON
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/30/2007
Notification Time: 14:40 [ET]
Event Date: 03/30/2007
Event Time: 07:40 [EDT]
Last Update Date: 03/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAY HENSON (R2)
JEFFREY CRUZ (IRD)
SANDRA WASTLER (FSME)

Event Text

CRITICALITY WARNING SYSTEM ALARM ACTUATION DUE TO POWER FLUCTUATION

"At approximately 0740 on 3/30/2007, a segment of the inside Criticality Warning System (CWS) covering the Fuel Manufacturing Operation (FMO) failed due to an apparent voltage fluctuation in the power supply to the system. The fluctuation resulted in activation of the CWS evacuation alarm.

"All personnel promptly evacuated the facility and the emergency organization assembled in accordance with normal procedures. A total of 5 out of 6 FMO CWS Data Acquisition Modules (DAMS) were affected by apparent power supply fluctuation. Two additional DAMS, which are independent, continued to provide coverage of the Dry Conversion Process (DCP) process areas.

"The Emergency Director determined that the processes should stay shut down and all personnel not engaged in troubleshooting or recovery actions remain out of the area while investigations and additional testing was conducted. Follow-up tests replaced select hardware, and installed additional power supply monitoring equipment to aid diagnostics. All DAMS have been successfully reset and the inside FMO CWS system returned to normal operation.

"Current plans are to resume normal operations beginning with the 1500 (evening) shift.

"The event is being reported within 24-hours pursuant to 10CFR70.50(b)(2) as a safety equipment failure."

The licensee will also be providing a courtesy notification to the North Carolina Department of Radiological Protection and the New Hanover County Emergency Management organization.

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Fuel Cycle Facility Event Number: 43268
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: KEVIN BEASLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/30/2007
Notification Time: 16:24 [ET]
Event Date: 03/30/2007
Event Time: 10:30 [CDT]
Last Update Date: 03/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAY HENSON (R2)
LARRY CAMPER (FSME)

Event Text

SAFETY EQUIPMENT FAILURE - PROCESS GAS LEAK DETECTION SYSTEM

"At 1030, on 3-30-07 the Plant Shift Superintendent was notified of the failure of the C-333A Process Gas Leak Detection (PGLD) detector head YE-613-21. Detector head YE-613-21 is located in the piping trench between the autoclaves. The trench detector heads are scheduled to be replaced at a six month interval. Operators were performing an "as-found" test on the head prior to scheduled replacement. The detector head did not alarm as required when smoke was applied during the test. The Process Gas Leak Detection system is required to be operable according to TSR 2.2.4.1.

"This event is reportable as a 24 hour event in accordance with 10CFR 76.120(c)(2)(l). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand, and c.) no redundant equipment is available and operable to perform the required safety function."

The YE-613-21 detector head was replaced approximately 6 months ago and was last known to be functional approximately one month ago after some wiring tests were conducted in the area of the detector head. The permittee is conducting failure cause analysis to determine failure mode and possibly identify when failure occurred.

The NRC Senior Resident Inspector has been notified of this event.

PGDP Problem Report No. ATRC-07-0819; PGDP Event Report No. PAD-2007-02

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Power Reactor Event Number: 43269
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MICHAEL POTTER
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/01/2007
Notification Time: 12:55 [ET]
Event Date: 04/01/2007
Event Time: 10:45 [EDT]
Last Update Date: 04/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JAY HENSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 53 Power Operation

Event Text

TECH SPEC REQUIRED SHUTDOWN DUE TO EDG INOPERABILITY

"During post-maintenance operability testing, Diesel Generator 4 exhibited unstable power output while synchronized to the grid. This testing was being performed at the conclusion of a planned Diesel Generator 4 maintenance outage. Preventive maintenance activities included in this scheduled outage included replacement of various relays in the Diesel Generator control logic and replacement of the engine governor.

"Brunswick Nuclear Plant Unit 1 is commencing a unit shutdown as required by Technical Specification 3.8.1 Condition H due to the inoperability of Diesel Generator 4 lasting longer than seven (7) days. TS 3.8.1 Required Action H.1 requires Unit 1 to be in MODE 3 by 1615 on 4/1/2007 and in MODE 4 by 1615 on 4/2/2007. This event is reportable per 10CFR50.72(b)(2)(i).

"Power reduction was commenced at 1045 in accordance with station procedures for unit shutdown. Power level has been reduced from 100% to 53%. Unit 1 shutdown will continue until the unit is in MODE 4 or until the engine is declared operable following appropriate repairs and testing.

"Unit 2 is in MODE 4, Cold Shutdown. The inoperable Diesel Generator 4 is not needed to meet the requirements of Unit 2 Technical Specification 3.8.2.

"The inoperability of Diesel Generator 4 is of minimal safety significance for Unit 1. Unit 1 has two operable off-site circuits and three (3) Diesel Generators are operable. The remaining three (3) operable Diesel Generators and off-site circuits are adequate to supply electrical power to the on-site Class 1 E Distribution System. This maintains the safety function of the AC sources. Unit 1 is being shutdown to place the unit in MODE 4 where the inoperable Diesel Generator 4 is not required. Unit 2 is currently in MODE 4 and does not require Diesel Generator 4 to be operable. As such, this event is of zero safety significance for Unit 2.

"During post-maintenance operability testing, Diesel Generator 4 exhibited unstable power output while synchronized to the grid. Station engineering and a vendor representative continue to evaluate the engine/generator performance. Repair plans will be developed and implemented as appropriate following completion of the engineering evaluation."

The inoperability of Diesel Generator 4 will prevent Unit 2 from changing mode for returning the plant to service.

The licensee notified the NRC Resident Inspector.

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