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Event Notification Report for January 11, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/10/2008 - 01/11/2008

** EVENT NUMBERS **


43868 43881 43882 43888 43889 43891 43892 43893

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 43868
Rep Org: R. M. WESTER CONSULTANTS
Licensee: JACOBI GEOTECHNICAL ENGINEERING
Region: 3
City: O'FALLON State: MO
County:
License #: 24-32231-01
Agreement: N
Docket:
NRC Notified By: KEVIN MCCAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/27/2007
Notification Time: 12:27 [ET]
Event Date: 12/26/2007
Event Time: 10:00 [CST]
Last Update Date: 01/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
STEVE ORTH (R3)
SANDRA WASTLER (FSME)

Event Text

DAMAGED MOISTURE DENSITY GAUGE

Radiation Health Physics consultants, R.M. Wester, notified the NRC of an event in the State of Missouri that resulted in damage to a Humboldt Soil Density Gauge (Model EZ 5001, S/N 693) containing 40 mCi Am-241/Be and 10 mCi Cs-137. The gauge is licensed to Jacobi Geotechnical Engineering. The consultant stated that the event took place at a construction site in Pezley, MO. The gauge was run over by a backhoe. There was some damage to the plastic housing of the gauge. The source rod was undamaged. The source rod was wipe tested with negative results. In addition, soil samples at the incident location also tested negative.

R.M. Wester has taken possession of the gauge and will ship it to Humboldt for repairs. The licensee notified the NRC Resident Inspector.

* * * RETRACTION BY JAMES PYATT TO KARL DIEDERICH ON 1/10/08 AT 1630 * * *

"Wester responded to the site at the time of the accident, and found no indication of leakage. The gauge was shipped to the manufacturer, Humboldt. Humboldt reports there is no leakage, and there is no indication of loss of safety function."

R3DO (Hills) and FSME (Bubar) informed.

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Hospital Event Number: 43881
Rep Org: CHARLOTTE HUNGERFORD HOSPITAL
Licensee: CHARLOTTE HUNGERFORD HOSPITAL
Region: 1
City: TORRINGTON State: CT
County:
License #: 06-08349-04
Agreement: N
Docket:
NRC Notified By: ELIZABETH DEMICCO
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/04/2008
Notification Time: 14:35 [ET]
Event Date: 01/03/2008
Event Time: 10:30 [EST]
Last Update Date: 01/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
RICHARD CONTE (R1)
GREG MORELL (FSME)

Event Text

ADMINISTRATION OF A DOSE TO THE WRONG INDIVIDUAL

The 1st technologist went to standardized waiting room to call for a patient by their first name only. An older gentleman answered and was taken to the radiology lab where the 2nd technologist administered an IV with 7 millicuries of Cholotec (Tc-99). The patient was instructed about the test and when the patient was taken to the Radiologist, it was noticed that they had administered the dose to the wrong patient. The unintended patient had the same first name as the scheduled intended patient. After the error was discovered, the unintended patient was made aware of the mistake. The intended patient was found later and administered the prescribed dose. The RSO was notified and the physician determined that their will be no unintended permanent functional damage to an organ or a physiological system. The licensee plans to perform better screening of patients (using first and last names, SSN, and DOB, by both technologists) to prevent recurrence.

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: 43882
Rep Org: HACKLEY HOSPITAL
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANNA
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/04/2008
Notification Time: 15:20 [ET]
Event Date: 12/13/2007
Event Time: [EST]
Last Update Date: 01/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATRICK LOUDEN (R3)
GREG MORELL (FSME)

Event Text

PATIENT RECEIVED LESS THAT PRESCRIBED DOSE

"On 12/13/07, a patient was scheduled for a thyroid ablation with 100 mCi of NaI-131. The dose arrived with 3 capsules totaling 95.5 mCi. The nuc med tech was unaware that the package contained 3 capsules due to lack of visualization. The nuc med tech administered 1 capsule with the activity of 21.39 mCi of NaI-131. The package was sent back to the pharmacy with the remaining 2 capsules of approximately 70 mCi of NaI-131.

"The mistake was recognized the next morning. The radiologist was made aware of the situation and the patient notified immediately. The patient returned the morning of 12/14/07 and was administered the remaining 2 capsules totaling 69.7 mCi of NaI-131.

"Overall, the patient received a total of 91.09 mCi of Nal-131 over the course of 17 hours."

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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Power Reactor Event Number: 43888
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: PAUL REIMERS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 01/10/2008
Notification Time: 05:37 [ET]
Event Date: 01/10/2008
Event Time: 05:02 [EST]
Last Update Date: 01/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
DAVID AYRES (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO TWO ROD POSITION INDICATORS (RPIs) OUT IN ONE ROD BANK

"At 0408 EST [the licensee] entered into TS 3.0.3 due to an observed RPI B-10 erratic indication. This RPI is in the same bank as currently inoperable F-2 RPI. TS 3.1.3.2 has actions for a maximum of one RPI per bank inoperable. Since there are two [RPIs inoperable] in one bank, and entry into TS 3.0.3 is required.

"Power reduction was initiated at 0502.

"Repairs are currently in progress and [the licensee] anticipates correction prior to completion of the power reduction."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM NIELSEN TO HUFFMAN AT 0755 EDT ON 01/10/08 * * *

The licensee reports that repairs have been completed to RPI B-10 and it has been returned to service. Technical Specification 3.0.3 was exited at 0625. Reactor power has been returned to 100%.

The NRC Resident Inspector will be notified. The R2DO (Ayres) has been informed.

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Power Reactor Event Number: 43889
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GARY MEEKINS
HQ OPS Officer: KARL DIEDERICH
Notification Date: 01/10/2008
Notification Time: 12:22 [ET]
Event Date: 10/13/2007
Event Time: 10:13 [EST]
Last Update Date: 01/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)

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

60 DAY LER REPORT - 1C EDG INVALID START

"This 60-day telephone notification is being made in accordance with the reporting requirements of 10CFR50.73(a)(2)(iv)(A) and 10CFR50.73(a)(1) for an invalid actuation (start) of the 1C Emergency Diesel Generator (EDG).

"On November 13, 2007, at 1013 hours, while performing the replacement of an indicating bulb on the 1C EDG local start/stop CMC switch (a turn to stop/start switch) the switch was pushed inward making up the start contact and causing an inadvertent start of the 1C EDG. The EDG started but did not load since this was not a valid demand for operation of the 1C EDG. The 1C EDG was shutdown in accordance with operating procedures and returned to its normal standby status. The local start/stop switch was replaced and the removed switch was examined. The removed switch was determined to be missing a cardboard collar on the shaft of the switch that prevents inward movement. Lack of the cardboard collar did not inhibit the turn to start/stop function of the switch."

The licensee will notify the NRC Resident Inspector, State of New Jersey, State of Delaware, and local government agencies.

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Power Reactor Event Number: 43891
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MICHAEL D. HUNTER
HQ OPS Officer: KARL DIEDERICH
Notification Date: 01/10/2008
Notification Time: 15:08 [ET]
Event Date: 01/10/2008
Event Time: 12:21 [CST]
Last Update Date: 01/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MALCOLM WIDMANN (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
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

OFFSITE NOTIFICATION - SPILL OF WATER CONTAINING TRITIUM

"This is a voluntary notification for a spill of water containing tritium as specified in section 2.2.a.iii, of Nuclear Energy Institute document NEI 07- 07 entitled 'Industry Groundwater Protection Initiative.' On January 5, 2008 at 13:55, Browns Ferry Nuclear (BFN) Plant operations personnel received a high water level alarm on a sump located within the plant, at the Condensate Piping Tunnel. The high water level was corrected within 3 hours of the alarm. Investigation into this condition determined that the water came from an overflow of the Unit 3 Condensate Storage Tank into the tunnel as a result of failed tank level instrumentation. The water was immediately transferred to the plant radioactive waste system for processing. Laboratory analysis results received on January 9, 2008 indicated this water contained 2.2 E-03 uCi/ml tritium. Based on the tunnel construction, there is a potential for a small amount of this water to permeate into the ground. Subsequent to the spill, a sample obtained from the ground water sampling well adjacent to the tunnel showed no detectable level of tritium. BFN routinely monitors the ground water for radioactivity in accordance with the NEI Groundwater Protection Initiative. Tritium levels at BFN have never reached or exceeded the Environmental Protection Agency drinking water limit. This spill was contained within the plant structure and will not increase the dose to the public. As such, this event poses no threat to public health or safety.

"The licensee notified the NRC Resident Inspector.

"This event is reportable as a 4-hour Non-Emergency Notification report in accordance with 10CFR50.72(b)(2)(xi) Any event or situation, related to the heath and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made."

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Power Reactor Event Number: 43892
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JAMES M. KURAS
HQ OPS Officer: KARL DIEDERICH
Notification Date: 01/10/2008
Notification Time: 20:34 [ET]
Event Date: 01/10/2008
Event Time: 18:12 [CST]
Last Update Date: 01/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RUSSELL BYWATER (R4)

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

VOIDING DISCOVERED IN HIGH HEAD AND INTERMEDIATE HEAD SI COMMON SUCTION

"Both centrifugal charging pumps and both safety injection pumps [were] declared inoperable due to 5% to 7% voiding identified in a portion of common suction piping. [The] pumps were inoperable for 27 minutes. [The] line was vented to remove [the] void and [the] pumps restored to operable. (These pumps are the High Head and Intermediate Head Emergency Core Cooling Pumps.)"

The source of the voiding is not understood and is under investigation. All systems functioned as required.

R4DO (Bywater) notified.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 43893
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM A. GOLDEN
HQ OPS Officer: PETE SNYDER
Notification Date: 01/10/2008
Notification Time: 20:41 [ET]
Event Date: 01/10/2008
Event Time: 16:00 [CST]
Last Update Date: 01/10/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MALCOLM WIDMANN (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
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

INADVERTENT ACTUATION OF OFFSITE EMERGENCY SIREN

"At 1600 on 1/10/2008 the Control Room was notified by [Offsite Duty System engineer] (ODS) that at 1515, one offsite emergency siren (siren # 54) inadvertently actuated for approximately 3 minutes in Tanner. This required ODS to notify the Alabama Emergency Management Agency. The siren is located within the 10 mile EPZ for BFNP. Due to inclement weather a Tornado Watch was in effect at the time. The siren is currently operable.

"The licensee notified the NRC Resident Inspector.

"This event is reportable as a 4 hour Non-Emergency Notification report in accordance with 10 CFR 50.72(b)(2)(xi); 'Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made."
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Thursday, March 29, 2012