United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2007 > July 2

Event Notification Report for July 2, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/29/2007 - 07/02/2007

** EVENT NUMBERS **


43392 43442 43443 43445 43447 43448 43454 43458 43462

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43392
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW RASMUSSEN
HQ OPS Officer: JOE O'HARA
Notification Date: 05/28/2007
Notification Time: 08:48 [ET]
Event Date: 05/28/2007
Event Time: 01:00 [CDT]
Last Update Date: 06/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRIAN BONSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 9 Power Operation 9 Power Operation

Event Text

HPCI PUMP INOPERABLE DUE TO DIFFERENTIAL PRESSURE SETTING NOT WITHIN SPECIFICATION

"On 5/28/07 at 0100 CDT, Browns Ferry Unit 1 was performing 1-SR-3.5.1.7 (Comp) HPCI Comprehensive pump test when it was determined that HPCI pump set differential pressure was not within specifications and therefore would not support a declaration of operability for HPCI.

"The event is reportable under 10CFR 50.72(b)(3)(v)(B) - 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat' and 10CFR 50.72(b)(3)(v)(D) - 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident'.

"This event also requires a 60 day written report in accordance with 10CFR 50.72(b)(3)(v)(B) and 10CFR50.73(a)(2)(v)(D).

"Initial investigation reveals a potential problem with the test equipment."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM M. RASMUSSEN TO W. HUFFMAN AT 1810 EDT ON 6/29/07 * * *

"This report is being retracted. Engineering has re-evaluated the test results and determined that HPCI System pump met its design basis requirements during testing activities. As such, the circumstance discussed in this event report did not result in any condition that could have prevented the fulfillment of the safety function of structures or systems needed to mitigate the consequences of an accident. Therefore, this event is not reportable under 10CFR50.72(b)(3)(v)(B) or 10CFR50.72(b)(3)(v)(D).

The licensee notified the NRC Resident Inspector. R2DO (Ayres) notified.

To top of page
Other Nuclear Material Event Number: 43442
Rep Org: WYETH RESEARCH LABORATORY
Licensee: WYETH RESEARCH LABORATORY
Region: 1
City: COLLEGEVILLE State: PA
County:
License #: 37-00401-03
Agreement: N
Docket:
NRC Notified By: ROBERT WICKLINE
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/25/2007
Notification Time: 13:09 [ET]
Event Date: 06/11/2007
Event Time: [EDT]
Last Update Date: 06/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)
ILTAB (via email) ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

ANALYTICAL INSTRUMENT SHIPPED OFF SITE WITH RADIOACTIVE SOURCES INSTALLED

During a scheduled radioactive source leak test and inventory activity on 18 June 2007, the licensee discovered two Ni-63 sources missing. It was determined that the sources had been shipped off site with the analytical instrument they were installed in on 06/11/07 for an upgrade to a part of the instrument not related to the radioactive sources. The device is a Berger supercritical fluid extraction device and the sealed source device is an Accenture G-2390A, source serial numbers U0891 and U0892. Each source activity level is 14 millicuries. The instrument is scheduled to be returned to the licensee after the upgrade is complete on 06/28/07. The licensee plans to remove the sources from the instrument since their lab has never used that portion of the instrument in the operation of their laboratory.

* * * UPDATE FROM WICKLINE TO HUFFMAN AT 1408 EDT ON 6/29/07 * * *

The licensee provided the following information via email:

The Berger Supercritical Fluid Chromatography instrument with the generally licensed Ni-63 source was returned to Wyeth on 6/29/07. The source was intact. Doses to personnel from the source are not expected because Ni-63 is a weak beta emitter. R1DO (Powell) and FSME EO (Flannery) notified.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

To top of page
General Information or Other Event Number: 43443
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: UNKNOWN
Region: 1
City: TROY State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/25/2007
Notification Time: 16:45 [ET]
Event Date: 06/19/2007
Event Time: [EDT]
Last Update Date: 06/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
JACK DAVIS (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING HIGHER THAN PRESCRIBED DOSE DELIVERED

The following notification was received from the State of NY Bureau of Environmental Radiation Protection via fax:

"AS Agency -New York State Department of Health

"Event Report - ID # NYS DOH 07-002

"Licensee Name and License Number - Withheld as per NYS Law

"Event Date - June 19, 2007

"Event Type - Medical Event

"Event Description:

"A medical event involving yttriurn-90 Zevalin (Ibritumomab Tiuxetan) for treatment of non-Hodgkin's lymphoma was reported to NYS DOH by telephone on June 22, 2007. The authorized physician user (AU) approved a dosage of 29 mCi for treatment on June 19, 2007, however a dose of 36.7 mCi was administered.

"This Zevalin patient (A) was scheduled to receive treatment at the hospital on June 19, 2007. The radiopharmacy prepared the dose but observed that the assay from the supplier was approximately 10 mCi higher than their assay. They reviewed their data including their most recent calibration of the dose calibrator with a NIST traceable syringe standard. They decided to use their NIST traceable calibration factor and associated assay. The dose was dispensed and the patient was treated.

"Another Zevalin patient (B) was scheduled for treatment on June 20, 2007. In preparing patient B's dose the radiopharmacy observed the same condition as with patient A's assay. At this point they realized they had a problem and patient B's dose was not dispensed. An investigation began.

"The radiopharmacy identified the error. They used an AEA Technology QSA Inc. model SIM.SY2 (Sealed Source Registry No. MA-1059-S-360-S) to calibrate their Capintec CRC-15R dose calibrator as well as the hospital's dose calibrator. This source is specifically designed to calibrate Capintec CRC-15R units for yttrium 90 assays. The calibration source label has an assay of 20mCi (740 MBq) of strontium 90/ytrrium 90 and a calibration date of Nov. 14, 2004. However, the source certificate lists the yttrium 90 'Equivalent Activity' as 30.68 mCi (1135 MBq), which is the value that should have been used for the calibration. Apparently the certificate was not available (misplaced?) on June 8 &10 for the calibration. The radiopharmacy used the decay-corrected value from the label rather than a decay-corrected value of the certificate's 'Equivalent Activity'. Since the same calibration error was performed on the hospital's dose calibrator, the hospital's assay matched up with that of the radiopharmacy and with the intended dosage.

"The patient's daughter and the referring physician were notified on the day after discovery. The treating physician is assessing situation and the possible effects to the patient.

"Intended dose - 29 mCi
"Delivered dose - 37.6 mCi
"Date of treatment - 6/20/07
"Date of error discovered - 6/20/07
"Isotope/drug - yttrium-90/Zevalin
"Reported/notification dates:
"Patient/patient rep. - 6/20/07
"Referring MD - 6/20/07
"NYS DOH - 6/22/07
"Cause: Dose calibrator calibration error
"Effect - patient's condition and effects are being assessed
"Investigation - RCA required
"Initial Written report due 6/29/07"

* * * UPDATE AT 1107 EDT ON 6/26/07 FROM FSME (FLANNERY) TO JASON KOZAL VIA EMAIL * * *

"This event (EN43443) 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.

To top of page
General Information or Other Event Number: 43445
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: PROVIDENCE MEDFORD MEDICAL CENTER
Region: 4
City: MEDFORD State: OR
County:
License #: ORE-91035
Agreement: Y
Docket:
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JEFF ROTTON
Notification Date: 06/26/2007
Notification Time: 19:12 [ET]
Event Date: 06/25/2007
Event Time: [PDT]
Last Update Date: 06/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
EDWIN HACKETT (FSME)

Event Text

OREGON AGREEMENT STATE REPORT - UNDERDOSE DUE TO EQUIPMENT MALFUNCTION

"On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated.

"Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment.

"Dosimetry reconstruction of the delivered dose indicates that 17.8% of the prescribed dose was delivered. Physician will reconstruct new treatment plan. Treatment Details: The patient was receiving HDR treatment #2 to a Miami vaginal cylinder with tandem. This apparatus is connected to the HDR After loader (with radioactive wire) with 7 separate connecting tubes, one for each treatment channel. During connection, bloody fluid was noted on one of the connectors, cleaned, and the tube connected. The treatment was initiated, but after that tube was treated, the device's computer indicated the wire positioning was not reproducible (error code 18 - Wire drift detected) and the treatment was paused. The QA positioning test was run and within acceptable limits. The treatment was continued, but the device again indicated positioning errors. The treatment was discontinued without being fully completed.

"Protective caps covering the tubes were removed in surgery instead of waiting until the patient arrived in the department, a typical procedure that had not caused an incident in the past. In the future, it is prudent to leave them connected until the patient is ready to be connected to the treatment device. Two lessons learned from this experience: For HDR cases using a tandem, the tandem channel should be treated first, since the prescribed dose is more influenced by tandem dose than by ovoids or vaginal cylinder. The protective caps on the applicator should be left on as long as possible to reduce or preclude any fluid in the closed system.

"Device: Varian VariSource High Dose Rate After loader, S/N#: 600379, SS&D #: CA-0661-D-103-S,
Source: Alpha - Omega Model #: VS 2000, SS&D #: CA-1080-S-102-S, S/N #: 02-01-0588-001-041907-10089-97, Activity: 10.089 Ci on 4/19/07"


* * * UPDATE AT 0844 EDT ON 6/26/07 FROM FSME (FLANNERY) TO JASON KOZAL VIA EMAIL * * *

"This event (EN43443) 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.

To top of page
General Information or Other Event Number: 43447
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: STARMET NMI
Region: 1
City: CONCORD State: MA
County:
License #: SM-0179, SU-1
Agreement: Y
Docket:
NRC Notified By: BOB GALLAGHAR
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/27/2007
Notification Time: 09:05 [ET]
Event Date: 06/26/2007
Event Time: 20:00 [EDT]
Last Update Date: 06/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - SMALL FIRE AT LICENSEE'S FACILITY

"On Wednesday, June 26, 2007, at approximately 8:00 PM EST a fire was reported at the Starmet NMI facility in Concord, Massachusetts [2229 Main Street]. Starmet NMI possesses two materials licenses with Massachusetts, License No. SM-0179 and License No. SU-1453. The fire occurred in the foundry area within the facility, formerly used for the manufacture of depleted uranium munitions. The fire appeared to be contained to a small area within the building, in the vicinity of a 55-gal drum, a 5-gal bucket and a small pile of metal shavings.

"Radiological surveys performed once the fire was extinguished resulted in no elevated readings from any of these containers or the material. The investigation is ongoing and more information will be provided as it is obtained."

To top of page
General Information or Other Event Number: 43448
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: ECS - CAROLINAS, LLP
Region: 1
City: WILMINGTON State: NC
County:
License #: 584
Agreement: Y
Docket:
NRC Notified By: MARK WINDHAM
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/27/2007
Notification Time: 09:29 [ET]
Event Date: 06/26/2007
Event Time: 13:05 [EDT]
Last Update Date: 06/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE RREPORT - DAMAGED MOISTURE DENSITY GAUGE

The State provided the following information via facsimile:

"The SC Department of Health and Environmental Control (DHEC) was notified on Tuesday, June 26, 2007, at 1315 hrs, that a Humboldt Model EZ 5001, s/n 4965, containing 10 mCi of Cs-137 and 40 mCi of Am-241:Be, had been damaged at 1305 hrs on June 26 2007. The RSO stated that the gauge had been damaged by a bulldozer. [The SC DEHC] Duty Officer responded to the scene and arrived at 1510 hrs. The area around the gauge had been properly roped off and the source rod was locked in its shielded position. The gauge handle and rod had been snapped off at the top of the gauge and the top of the gauge was cracked open at the rod end. The gauge was secured in the transport container and the inspector advised the RSO to return the gauge to the permanent storage location, secure it from further use, and to contact the gauge manufacturer for further instruction regarding disposal.

"The RSO was advised by [the SC DEHC] to submit a written report detailing this event to the Department within 30 days. The event is open and pending the licensee's investigation and report to the Department, updates will be made through the national NMED system.

"Location: Calvary Baptist Church, 3810 Grandview Drive, Spartanburg, SC"

To top of page
Power Reactor Event Number: 43454
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF TODD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/27/2007
Notification Time: 18:44 [ET]
Event Date: 06/27/2007
Event Time: 15:55 [EDT]
Last Update Date: 06/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER HABITABILITY ISSUE

"At 15:55 ET on 6/27/07 - notified by the Vogtle Emergency Preparedness that the limit switch full closed indication on the Technical Support Center (TSC) HVAC Outside Air Damper not being functional [which] impacted habitability of the TSC. This is due to the full closed limit switch providing a signal to inflate the sealing boot on the associated damper. This is reportable under 10CFR 50.72(b)(3)(xiii). (8 hour notification)

"At 6:53 ET on 6/27/07 - TSC HVAC was placed in service in the filtration mode with the damper limit switch manually adjusted to provide full closed indication. The TSC HVAC is fully functional and supporting TSC habitability at this time.

"TSC HVAC will remain in service in the filtration mode until the repair plan for the damper is implemented."

The licensee notified the Region 2 Duty Officer (Ayres).

* * * UPDATE AT 1037 0N 6/29/07 FROM C. WILLIAMS TO P. SNYDER * * *

"A plan has been created to repair the limit switch on the TSC HVAC Outside Air Damper. This will require securing the TSC HVAC for a period of time, thus rendering the TSC non functional. A plan has been written to cover required actions to be taken in the event of a plant event, in accordance with 10CFR50.54(q). Estimated outage time is four hours, it may be shorter depending on actions required to adjust limit switch to return full functionality to the TSC HVAC. You will receive a follow-up call when full TSC functionality has been restored."

The licensee notified the NRC Resident Inspector. Notified R2DO (Ayers).

* * * UPDATE AT 1249 EDT 0N 6/29/07 FROM C. WILLIAMS TO W. HUFFMAN * * *

"The TSC HVAC outside air damper limit switch has been repaired and the TSC has been returned to functional status. The TSC HVAC was non-functional from 11:24 to 12:17 EDT." The licensee notified the NRC Resident Inspector. R2DO (Ayres) notified.

To top of page
Power Reactor Event Number: 43458
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAVE HELD
HQ OPS Officer: PETE SNYDER
Notification Date: 06/29/2007
Notification Time: 00:20 [ET]
Event Date: 06/29/2007
Event Time: 00:14 [EDT]
Last Update Date: 06/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1)

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

Event Text

RADIATION MONITORING INFORMATION TO ERDS AND SPDS WILL BE UNAVAILABLE DURING PLANNED UPGRADE TO THE SYSTEM.


"The computer servers which supply radiation monitoring information to the ERDS (Emergency Response Data System) and SPDS (Safety Parameter Display System) systems will be taken out of service to implement a planned upgrade. The servers are being replaced with upgraded models and are expected to be out of service for approximately 4 to 8 hours. The ability of radiation monitors to alarm in the control room will be unavailable while the servers are being replaced. The in plant radiation monitoring skids will be unaffected, as will any automatic actions generated by the monitors. The safety related radiation monitor displays in the control room will also remain available. As a compensatory measure while both servers are unavailable, a dedicated radiation protection technician will monitor the in plant radiation monitor skids to update the control room if anomalous indications are observed. In addition, operations will record the safety related radiation monitor readings every 2 hours.

"This is an 8 hour reportable event per 10CFR50.72(b)(3)(xiii), Major Loss of Assessment Capability. The operations of BVPS Unit 2 plant systems is not affected by this planned action. BVPS Unit 1 is not affected by this planned action.

"The NRC Resident Inspector has been notified."

* * * UPDATE AT 1736 EDT ON 6/29/07 FROM G. STOROLIS TO W. HUFFMAN * * *

The Radiation Monitor System Servers have been upgraded and returned to service and the Radiation Monitoring Information to the Emergency Response Data System (ERDS) and Safety Parameter Display System (SPDS) is now available and returned to service.

The licensee will notify the NRC Resident Inspector. R1DO (Powell) notified.

To top of page
Power Reactor Event Number: 43462
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/29/2007
Notification Time: 20:45 [ET]
Event Date: 06/29/2007
Event Time: 17:52 [EDT]
Last Update Date: 06/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BILL TRAVERS (R2)
JARED WERMIEL (NRR)
THOMAS BLOUNT (IRD)
MEL LEACH (DPR)
GENE GUTHRIE (R2)
CHUCK CASTO (R2)
VIC MCCREE (R2)
JIM REECE (RI)
DAVID AYRES (R2)

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

Event Text

REACTOR TRIP AND SPURIOUS SAFETY INJECTION

"At 1752 hours EDT Unit 2 received a 'B' train safety injection (SI). This spurious SI on 'B' train caused a trip of the main feedwater pumps and a turbine trip. The Unit 2 reactor tripped due to the turbine trip. The single train SI resulted in ECCS flow to the RCS. Both trains of SI were manually initiated per station procedures. The 'B' train of SI could not be reset and this resulted in RCS inventory increasing and lifting of the pressurizer PORV's. The pressurizer relief tank rupture disc ruptured and released water to the containment sump. SI flow to the core has been secured. Normal charging has been returned to service. This event is reportable per 10CFR50.72(b)(2)(iv)(A) for ECCS flow to the RCS. 10CFR50.72(b)(2)(iv)(B) for RCS Actuation (Rx/Turbine Trip). 10 CFR50.72(b)(3)(iv)(A) for AFW pump start, containment phase 'A' isolation, ECCS pumps actuation, and EDG starts. The AFW pump auto started during the event and operated as expected. Cause of the 'B' train SI is unknown at this time."

All rods fully inserted. All systems functioned as required with the exception of the 'B' train SI which spuriously actuated and then could not be reset. All equipment started as expected from the SI actuation. AFW is still supplying cooling water to the steam generators at this time and decay heat is being discharged via steam dumps to the condenser. The licensee does not yet know how much water was discharged to the containment sump. The reactor is currently stable at no-load temperature and pressure with the level in the pressurizer a little high but tracking down to normal.

The licensee notified the NRC Resident Inspector.

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