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Event Notification Report for May 16, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/15/2007 - 05/16/2007

** EVENT NUMBERS **


43308 43353 43356 43363 43364

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Hospital Event Number: 43308
Rep Org: COMMUNITY HOSPITAL INDIANAPOLIS
Licensee: COMMUNITY HOSPITAL INDIANAPOLIS
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-06009-01
Agreement: N
Docket:
NRC Notified By: ANDREA BROWNE
HQ OPS Officer: GERRY WAIG
Notification Date: 04/18/2007
Notification Time: 14:20 [ET]
Event Date: 04/18/2007
Event Time: 13:30 [EDT]
Last Update Date: 05/15/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
THOMAS KOZAK (R3)
KEITH McCONNELL (FSME)

Event Text

MEDICAL EVENT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED

The following information is taken from a facsimile sent by Community Hospital Indianapolis:

A patient undergoing Yttrium-90 theraSphere treatment of the liver received an under dose. The original estimated intended dose was 301 Gray (Gy). The authorized user confirmed the setup during performance of the pre-administrative checklist. The under dose occurred due a mis-positioned stopcock that resulted in part of the intended source material being directed to a waste vial rather than the patient catheter. When the mis-directed (source) liquid was noted in the waste vial tubing, the authorized user re-checked the delivery system and corrected the stopcock orientation. Based on a delivered source activity of 3.28 GigaBecquerel (GBq), the estimated dose received by the patient is 130 Gy.

The patient has been notified of the under dose.

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 AT 1200 EDT ON 05/15/07 FROM ANDREA BROWNE TO OPS CENTER VIA COMMERCIAL MAIL * * *

The following information was received as an update to this report via letter dated April 30, 2007 addressed to the Operations Center:

"After an investigation by the region III office, Community Hospitals, Indianapolis, Materials License Number 13-06009-01 is expanding the written follow-up to the verbal report of a medical event made 4/18/07, given Notification Number 43308 and the written report filed 4/18/07.

"Per 35.3045

"(i) Licensee's Name: Community Hospitals of Indiana, Inc. (#13-06009-01)

"(ii) Name of Prescribing physician: [DELETED] (Authorized User)

"(iii) Brief Description of Event: Partial dose routed to waste vial because of incorrect stopcock orientation. The prescribed treatment site was the right liver lobe; the prescribed treatment site dose was 120 Gy. Because of the partial routing of the dose to the waste vial the dose delivered to the right liver lobe was 54.4 Gy.

"(iv) Why event occurred: Authorized user confirmed setup was correct when queried during the pre-administration checklist. However, stopcock was turned so that dose was directed to waste vial rather than into the patient delivery catheter. The interventional radiologist noted liquid in the waste vial tubing and directed the authorized user to stop; The authorized user re-checked the delivery system and corrected the stopcock orientation. The remainder of the dose was delivered to the patient.

"(v) Effect, if any, on the individual who received the administration: It is believed by the radiation oncologist and the interventional radiologist that there will be no effect on the patient. This treatment is one of several planned for this patient. Justification for this conclusion is that the original estimated tumor dose was 301 Gy based on the written directive of 120 Gy to the right lobe of the liver. Based on a delivered activity of 3.28 GBq, considering the tumor hypervascularity and volume, the estimated tumor dose is 130 Gy as a result of the 54.4 Gy delivered to the right liver lobe. This is within the dose range that the FDA has accepted for tumor dose in cases of liver metastases.

"(vi) Actions planned to prevent recurrence: A second individual (the interventional radiologist, radiologic technologist, nurse, or similarly trained individual) will be required to check the delivery setup portion in addition to the individual actually delivering the dose. This second check will be built in to the checklist.

"(vii) Certification that the licensee notified the individual (or the individual's responsible relative or guardian), and if not, why not: The interventional radiologist has notified the patient of the event. The referring physician was also notified of the event.

"This revised report will also be sent to the Operations Center."

Notified R3DO (Bruce Burgess) and FSME (Greg Morell).

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Power Reactor Event Number: 43353
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RYAN RODE
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/09/2007
Notification Time: 19:33 [ET]
Event Date: 05/09/2007
Event Time: 16:23 [CDT]
Last Update Date: 05/15/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
PATTY PELKE (R3)

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

Event Text

UNANALYZED CONDITION DUE TO IDENTIFIED NON COMPLIANT FIRE PROTECTION MANUAL OPERATOR ACTIONS

"During performance of NFPA-805 Transition Project Task SUP-1, 'Manual Action Compliance,' it was determined there were 11 non-compliant manual operator actions that were being performed to achieve and maintain hot safe shutdown in Fire Area A06 (1B32 area). These manual actions were being performed in an Appendix R Section III.G.1/G.2 fire area, however, they do not meet the criteria for allowable manual actions specified in RIS 2006-10, 'Regulatory Expectations with Appendix R Paragraph III.G.2 Operator Manual Actions.'

"The discovery of these non-compliant manual actions is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii). Appropriate compensatory measures have been established for Fire Area A06 via initiation of hourly fire rounds. An extent of condition review has been initiated that will encompass the remainder of the safe shutdown areas in both Point Beach Nuclear Plant (PBNP) units. The results of the extent of condition will be documented in the site's corrective action program with compensatory measures being established as appropriate. The 60-day licensee event report, submitted to the Commission in accordance with 10 CFR 50.73(a)(2)ii), will provide the results of the manual action compliance review and follow-up corrective actions.

"The PBNP Resident Inspector has been notified of this event."

* * * UPDATE 1735 EDT ON 05/15/07 FROM ERIC SCHULTZ TO S. SANDIN * * *

"This is an update to EN 43353 submitted at 19:33 EDT on 05/09/07:

"During performance of NFPA-805 Transition Project Task SUP-1, 'Manual Action Compliance,' it was determined that non-compliant manual operator actions are credited to achieve and maintain hot safe shutdown for a fire. The following actions were identified during the extent of condition reviews conducted subsequent to EN 43353 report.

# Non-Compliant Actions

1 - Fire Area A03, 1P-2C CVCS Charging Pump Cubicle
1 - Fire Area A04, 1P-2B CVCS Charging Pump Cubicle
1 - Fire Area A05, 1P-2A CVCS Charging Pump Cubicle
6 - Fire Area A07, Chemical Drain, Laundry Tank and Reactor Coolant Pump Seal Filter Room
5 - Fire Area A08, HVAC Equipment Room & Pipeway No. 1 Valve Gallery Area

"These manual actions are credited for safe shutdown in an Appendix R Section III.G.1/G.2 fire area, however, they do not meet the criteria for allowable manual actions specified in RIS 2006-10, 'Regulatory Expectations with Appendix R Paragraph III.G.2 Operator Manual Actions.'

"The discovery of these non-compliant manual actions is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii). Appropriate compensatory measures have been established for Fire Areas A03, A04, A05, A07 and A08 via initiation of hourly fire rounds. An extent of condition review is continuing that will encompass the remainder of the safe shutdown areas in both Point Beach Nuclear Plant (PBNP) units.

"The PBNP Resident Inspector has been notified of this event." Notified R3DO (Mark Ring).

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General Information or Other Event Number: 43356
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: ST ANTHONY HOSPITAL
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-01428-03
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/11/2007
Notification Time: 10:55 [ET]
Event Date: 04/27/2007
Event Time: [CDT]
Last Update Date: 05/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
SCOTT FLANDERS (FSME)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT MEDICAL EVENT - PATIENT UNDERDOSE

A patient was to receive 150 mCi of I-131 for thyroid cancer on April 27, 2007. The dose was two capsules in a single vial (tube). The intended dose activity was reported to be correct. The patient was presented with the vial containing the dosage. The patient took the dosage. The vial and lead container were placed in storage. On May 9, 2007 a nuclear medical technician discovered a capsule in the vial. The patient had received one-half of the intended dose. The technician reported the discovery to the RSO who reported the incident to the Oklahoma Radiation Management Section supervisor (May 9, 2007 at 5:26 p.m.) by e-mail. Radiation Management Section investigators interviewed St. Anthony Hospital nuclear medicine technicians on May 10, 2007. The patient will be notified. The RSO will submit a written report within 15 days of the initial report. The unused capsule will decay-in-storage.

State of Oklahoma Medical Event reportable under 10CFR35.3045(a)(1)(i)
Event Cause Failure to verify that the entire dose was administered

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 BY E-MAIL AT 07:01 ON 5/14/2007 FROM C. FLANNERY TO M. ABRAMOVITZ * * *

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

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Power Reactor Event Number: 43363
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT KIDDER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/15/2007
Notification Time: 01:53 [ET]
Event Date: 05/15/2007
Event Time: 00:58 [EDT]
Last Update Date: 05/15/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARK RING (R3)
ELMO COLLINS (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 30 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DURING TESTING

"An automatic reactor scram occurred due to lowering reactor water level. Digital feedwater tuning activities were in progress at the time of the scram. All systems functioned as designed. The reactor water level has been restored to normal level band. The plant is stable in Hot Shutdown. There were no ECCS injections."

At the time of the scram, the feedwater pump was in manual control for feedwater tuning. When water level started going down quickly, the operator was not able to restore sufficient feedwater flow before the level 3 (water level low) actuation. All control rods fully inserted on the scram. No valves repositioned and no safety or relief valves lifted after the scram. Reactor water level is being maintained with the motor feed pump and decay heat is being removed to the main condenser. The plant is in the normal shutdown electrical lineup. Reactor pressure is 509 psi and stable.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43364
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: GARRETT SANDERS
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/15/2007
Notification Time: 14:46 [ET]
Event Date: 05/15/2007
Event Time: 11:16 [EDT]
Last Update Date: 05/15/2007
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):
MIKE ERNSTES (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 82 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON TURBINE TRIP DUE TO DIFFERENTIAL GENERATOR PROTECTION

"At 11:16 am Eastern Daylight Time, a reactor trip occurred at the H. B. Robinson Steam Electric Plant, Unit No. 2. The unit was at approximately 82% reactor power and power level was being increased after restart from a refueling outage that had ended on May 13, 2007. The reactor protection system actuation was identified as a turbine trip signal that caused the reactor trip. The turbine trip signal appears to have been caused by the generator differential protection circuitry. The reactor is currently stable in MODE 3. All control rods indicated fully inserted following the reactor trip. The Auxiliary Feedwater (AFW) System actuated as expected in response to plant conditions, except the 'A' motor-driven AFW pump did not start. The plant operators manually started the 'A' motor-driven AFW pump. The cause of the 'A' AFW pump failure and the cause of the reactor trip are being investigated. The primary system and steam generator power operated relief valves and safety valves did not actuate during this event.

"The normal post-trip electrical lineup is providing power to the plant and the electrical system is stable at this time. Decay heat is currently being removed by use of the normal feedwater system and the condenser steam dumps. The 'B' Main Feedwater Pump also tripped during this event. The 'A' Main Feedwater Pump continued to operate and is being used to supply main feedwater to the steam generators."

The licensee informed the NRC Resident Inspector.

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