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Event Notification Report for June 7, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/06/2007 - 06/07/2007

** EVENT NUMBERS **


43398 43399 43401 43404 43408 43409 43410

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General Information or Other Event Number: 43398
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA ST. LUKE'S MEDICAL CENTER
Region: 3
City: MILWAUKEE State: WI
County:
License #: 079-1281-01
Agreement: Y
Docket:
NRC Notified By: SEAN MATYAS
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/01/2007
Notification Time: 10:15 [ET]
Event Date: 05/31/2007
Event Time: [CDT]
Last Update Date: 06/07/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
CYNTHIA FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT OF A MEDICAL EVENT INVOLVING AN UNDERDOSE

The following information was received via email from the State of Wisconsin:

"Event Report ID No.: WI070011

"License No.: 079-1281-01
"Licensee: Aurora St. Luke's Medical Center

"Event Location: Aurora St. Luke's Medical Center, Milwaukee, WI

"Event Type: Medical Event
"Notifications: RSO called DHFS 5/31/2007

"Event description: On the morning of 5/31/2007 a Y-90 TheraSphere procedure was attempted. 1.05 GBq (28.3 mCi) was prescribed by the authorized user's written directive to deliver 123 Gy to the patient tumor. The activity in the dose vial was in agreement with this written directive. The TheraSphere Delivery Device (TDD) was appropriately set up by the radiopharmacist and the RSO, following the check list provided by the TheraSphere manufacturer, MDS Nordion. The interventional radiologist prepared the patient under fluoroscopy and positioned the catheter to fit his desired treatment site. This was completed at 9:30 a.m. At 9:40 the TDD was attached to the catheter. The TheraSphere injection was then started by the authorized user. The RSO was monitoring the radiation exposure in the room and did not see the normally-expected rise in exposure rate as the TheraSpheres enter the catheter and then the patient. After a few moments (after the injection of about half the balloon-inflator/syringe) the injection was stopped to evaluate what had happened. The authorized user and RSO then noticed that the blue stopcock was in the wrong position, directing the TheraSpheres into the waste vial and not into the patient.

"A radiation survey revealed that most of the radioactivity was now in the waste vial, very little (if any) in the patient, and some possibly remaining in the dose vial. It was decided to complete the normal four flushes of the dose vial into the patient, and to estimate the administered dose based on the activity in the waste vial.

"After the procedure the activity in the waste vial was measured in the dose calibrator in nuclear medicine. 25.9 mCi Y-90 was measured at 10:40 a.m. This constitutes approximately 94% of the activity that was originally in the dose vial (accounting for decay).

"The RSO estimates the dose delivered to the target volume in the patient liver is 6% of the intended dose, or 7 Gy.

"At 11:00 a.m. the RSO measured the exposure rate at the surface of the patient to be 0.00 Mr/hr with a GM survey meter and 0.0 Mr/hr with an ionization survey meter. Therefore, very little of the activity was injected into the patient. The waste vial is now being held for decay-in-storage. All personnel in the procedure, the TDD, and the room were surveyed and found to be free of contamination.

"The patient will be scheduled for re-treatment in the next few weeks.

"The licensee is evaluating the checklist provided by the manufacturer. DHFS will review the licensee's 15-day report and evaluate the licensee's proposed corrective actions.

"Media attention: None"

* * * UPDATE AT 1128 EDT ON 6/1/07 FROM FSME (FLANNERY) TO J. ROTTON * * *

This event (EN43398) 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: 43399
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SEATTLE IRON AND METALS
Region: 4
City: SEATTLE State: WA
County:
License #: WN-R1180
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JASON KOZAL
Notification Date: 06/01/2007
Notification Time: 13:25 [ET]
Event Date: 05/17/2007
Event Time: [PDT]
Last Update Date: 06/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - NITON DEVICE SHUTTER MALFUNCTION

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

"The licensee's radiation contact individual notified Washington Department of Health (DOH) on 18 May 2007 that their Niton XLp 818 device's [used for metal composition identification] shutter mechanism malfunctioned. It contains a 30-millicurie americium-241 sealed source.

"On the morning of May 17, 2007 when the licensee attempted to start their analyzer, it failed to start properly. They called the manufacturer who was unable rectify the problem over the phone. They performed a shutter test using a Ludlum Model 19 survey meter; the reading was approximately 90 microR per hour which was greater than expected. As instructed by the manufacturer's service representative, the analyzer was packaged, properly labeled and shipped back to the manufacturer's location in Rhode Island via Federal Express. The manufacturer will repair the malfunction and perform shutter and device leak tests.

"DOH verified with the manufacturer's technical contact that the proper packaging included lead shielding adequate to completely shield the source and shutter, even if the shutter was stuck full open.

"No DOH on-site investigation. No known media attention.

"Notification Reporting Criteria:

"Per WAC 246-233-020 General License - Certain measuring, gauging or controlling devices.

"Isotope and Activity involved: one 30-millicurie americium-241 sealed source.

"Overexposures? Unknown but most likely not. The unit was functioning properly on 16 May 2007, but first thing in the morning on 17 May 2007 the unit would not start up properly. It was then the malfunction was discovered. No workers were exposed. The RCI (radiation contact individual) and one supervisor were the only people to handle this instrument after it had failed.

"Lost, Stolen or Damaged? (mfg., model, serial number): No loss or stolen. No obvious damage. It did not appear that it was dropped or anything happened to it between shut down on 16 May 2007 and start up on 17 May 2007.

"Leak test? Shutter tests have been performed and documented every six months. Most recent leak test was 13 December 2005 (no contamination, < 0.000002 microcuries)."

WA report number : WA-07-048

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General Information or Other Event Number: 43401
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: PEPG ENGINEERING, LLC
Region: 4
City: EAGLE MOUNTAIN State: UT
County:
License #: UT 1800447
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: PETE SNYDER
Notification Date: 06/01/2007
Notification Time: 14:59 [ET]
Event Date: 05/31/2007
Event Time: 10:00 [MST]
Last Update Date: 06/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
WILLIAM RULAND (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

This event took place in the Southmoor Subdivision, Phase 2, Eagle Mountain, UT.

"This event involved Troxler, model 3440, serial number 28420, containing 8 [millicuries] of Cs-137 and 40 mCi of Am-241:Be. The technician was testing sidewalk compaction ahead of the cement crew and was trying to keep ahead of the concrete truck. To do so, the technician would put the gauge in the back of his truck and drive about 200 feet along to the next test site. The gauge was not put in the transportation box nor was it secured. The technician drove off the asphalted road onto a 'roughed in' dirt road. When the truck hit the bump, the Troxler gauge slid or bounced out of the truck and hit the asphalt. The technician realized very quickly that the gauge was no longer in the truck and could see it approximately 200 feet behind the vehicle. Initially, the source rod remained in the safe shielded position, but the technician tried to lift the gauge by the handle and the source rod totally detached from the remaining portion of the gauge.

"The Am-241:Be source was not damaged and remained in place."

UT Event Report ID No.: UT-07-006

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Power Reactor Event Number: 43404
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WILLIAM BODIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/04/2007
Notification Time: 17:28 [ET]
Event Date: 06/04/2007
Event Time: 16:00 [CDT]
Last Update Date: 06/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MONTE PHILLIPS (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 5 non-compliant manual operator actions that were being performed to achieve and maintain hot safe shutdown in Fire Area 29, Admin Building Electrical & Piping Room 1. 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). The alternate compensatory measure for Fire Area 29 is to perform the manual action. An extent of condition review has been initiated that will encompass the remainder of the safe shutdown areas in both Prairie Island Nuclear Generating Plant (PINGP) 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 licensee will notify the NRC Resident Inspector.

* * * UPDATE FROM W. BODIN TO P. SNYDER AT 1643 ON 6/5/07 * * *

"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 43404 report.

Numbers of Non-compliant Actions and Fire Areas Affected:
"2 actions for Fire Area 2, Ventilation Fan Room, Unit 1;
"2 actions for Fire Area 10, Train A Event Monitoring Equipment Room;
"6 actions for Fire Area 20, Unit 1 4.16 KV Safeguards Switchgear (Bus 16);
"2 actions for Fire Area 22, 480V Safeguards Switchgear (Bus 121);
"1 action for Fire Area 23, Unit 2, 4.16 KV Normal Switchgear (Bus 23, 24);
"2 actions for Fire Area 30, Administration Building Electrical & Piping Room #2;
"1 action for Fire Area 33, Battery Room 11;
"1 action for Fire Area 34, Battery Room 12;
"6 actions for Fire Area 37, Unit 1 480V Normal Switchgear Room;
"4 actions for Fire Area 41A, Screenhouse (DDCWP Rooms);
"6 actions for Fire Area 41B, Screenhouse Basement;
"10 actions for Fire Area 58 and 73, [Auxiliary] Building Ground Floor Unit 1 & 2;
"2 actions for Fire Area 59, [Auxiliary] Building Mezzanine Level Unit 1;
"1 action for Fire Area 80, 480V Safeguard Switchgear Room (Bus 112); and
"4 actions for Fire Area 81, 4.16 KV Safeguard Switchgear Room (Bus 15).

"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 or these non-compliant manual actions is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii). The manual actions have been determined to be feasible and will be treated as alternate compensatory measures for Fire Areas 2, 10, 20, 22, 23, 30, 33, 34, 37, 41A, 41B, 58, 59, 73, 80, and 81. An extent of condition review is continuing that will encompass the remainder of the safe shutdown areas in both Prairie Island Nuclear Generating Plant (PINGP) Units."

The licensee notified the NRC Resident Inspector. Notified R3DO (M. Phillips).

* * * UPDATE AT 16:28 ON 6/6/2007 FROM W. BODIN TO M. ABRAMOVITZ * * *

"During performance of NFPA-805 Transition Project Task SUP-1, 'Manual Action Compliance,' it was determined that noncompliant 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 43404 report.
# Non-Compliant Actions
1 action for Fire Area 4, Fuel Handling Area
12 actions for Fire Area 31, 'A' Train Hot SD panel, AFW & Air Compressors
11 actions for Fire Area 32, 'B' Train Hot SD panel, AFW & Air Compressors
2 actions far Fire Area 38, Unit 2 480V Normal Switchgear Room
1 action for Fire Area 39, Radwaste Building
2 actions for Fire Area 46, Cooling Tower Equipment House
4 actions for Fire Area 69, Turbine Building Ground & Mezzanine Floors Unit 1
3 actions for Fire Area 70, Turbine Building Ground & Mezzanine Floors Unit 2
2 actions for Fire Area 71, Containment Unit 2
2 actions for Fire Area 72, Containment Annulus Unit 2
5 actions for Fire Area 74, Aux Building Mezzanine Level Unit 2

"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). The manual actions have been determined to be feasible and will be treated as alternate compensatory measures for Fire Areas 4, 31, 32, 38, 39, 46, 69, 70, 71, 72, and 74. This concludes the extent of condition review of the safe shutdown areas in both Prairie Island Nuclear Generating Plant (PINGP) units."

The licensee notified the NRC Resident Inspector. Notified the R3DO (Phillips).

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Power Reactor Event Number: 43408
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: EDDIE NEVILLE
HQ OPS Officer: JOE O'HARA
Notification Date: 06/06/2007
Notification Time: 09:32 [ET]
Event Date: 06/06/2007
Event Time: 07:45 [EDT]
Last Update Date: 06/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
PAUL FREDRICKSON (R2)

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

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN INITIATED ON UNIT 3

"At 0746, on 6/6/2007, a Unit 3 shutdown was initiated in accordance with station procedures. Unit 3 entered Technical Specification (TS) 3.0.3 at 0745 on 6/6/2007.

"TS 3.0.3 was entered when the Analog Rod Position Indicator (ARPI) for control rod F-4 was declared inoperable. Control rod F-4 is located in control bank C. The ARPI for control rod M6, which is also in control bank C, has been previously declared inoperable. With two ARPIs in control bank C inoperable, TS Limiting Condition for Operation 3.1.3.2, Action a, cannot be met thus necessitating entry into TS 3.0.3. ARPI repairs will be performed as required."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM E. NEVILLE TO P. SNYDER AT 1400 ON 6/6/07 * * *

Turkey Point Unit 3 entered Mode 3 at 1152 on 6/6/07 after manually tripping from approximately 25% power. At 1152 Turkey Point exited TS 3.0.3 since the condition for which it was entered no longer applied. The site borated to compensate for the control rods for which position indication was lost.

All control rods fully inserted on the trip. The plant is currently steaming to atmospheric relief valves. No primary to secondary tube leaks exist.

The licensee will notify the NRC Resident Inspector. Notified R2DO (Fredrickson).

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Power Reactor Event Number: 43409
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DENNIS MAY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/06/2007
Notification Time: 14:32 [ET]
Event Date: 06/06/2007
Event Time: 13:17 [EDT]
Last Update Date: 06/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD BARKLEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 4 Startup 4 Startup

Event Text

PUBLIC NOTIFICATION SYSTEM INOPERABLE

"Notified at 1220 by Emergency Plan personnel that a tone test initiated by the National Weather Service from Albany, NY, failed to activate tone alert radios via the Ames Hill NOAA transmitter. Notified at 1317 that the WTSA Studio to transmitter link also failed to activate the tone alert radios. The tone alert radio system was working when a severe thunderstorm was issued at 1205 on 6-5-07."

The licensee has sent a technician to repair the transmitter.

The licensee notified the NRC Resident Inspector and will notify the states of Vermont, Massachusetts, and New Hampshire.

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Power Reactor Event Number: 43410
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CALVIN WARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/06/2007
Notification Time: 18:10 [ET]
Event Date: 06/06/2007
Event Time: 13:10 [EDT]
Last Update Date: 06/06/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
PAUL FREDRICKSON (R2)

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

Event Text

CONTAINMENT ISOLATION VALVES FOUND MISALIGNED

"On 6/06/07 at 13:10 EDT while performing a surveillance to verify the position of administratively locked valves for Containment and Shield Building Integrity, two manual Containment Isolation valves were found Locked Open, versus the required Locked Closed position. The valves were restored to the Locked Closed position at 13:30 EDT of the same day.

"The subject valves, V18794 and V18796, provide Service Air (a non-safety class system) to the Containment during Mode 5 and 6 conditions through Containment Penetration #8. The subject valves are required to be returned to Locked Closed prior to entering Mode 4 in accordance with the Plant Technical Specifications 3.6.1.1 for Containment Integrity and plant procedures. The valves are to be verified in the Locked Closed position once every 31 days per Administrative Procedure 1-0010123 Appendix E, which was last performed on 5/09/07. Unit 1 exited Mode 5 and entered Mode 4 on 5/20/07 following a refueling outage and is currently in Mode 1 at 100% power. It is assumed the valves have been incorrectly positioned since entering Mode 4.

"The Service Air System is intact and pressurized at approximately 110 psig. There is no open path from Containment to the outside atmosphere.

"This event is being reported pursuant to 10CFR50.72(b)(3)(ii)(A), based on principal safety barriers being seriously degraded."

The licensee notified the NRC Resident Inspector.

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