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Event Notification Report for February 27, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/26/2008 - 02/27/2008

** EVENT NUMBERS **


43999 44000 44001 44003 44009

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Hospital Event Number: 43999
Rep Org: VIRGINIA COMMONWEALTH UNIVERSITY
Licensee: VCU MEDICAL CENTER
Region: 1
City: RICHMOND State: VA
County:
License #: 45-00048-17
Agreement: N
Docket:
NRC Notified By: DEAN BROGA
HQ OPS Officer: JOE O'HARA
Notification Date: 02/21/2008
Notification Time: 13:22 [ET]
Event Date: 02/20/2008
Event Time: 12:40 [EST]
Last Update Date: 02/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1)
GREG MORELL (FSME)

Event Text

POTENTIAL MEDICAL EVENT - UNDERDOSE OF Y-90 MICROSPHERES

The licensee reported that a patient being treated for liver cancer received approximately half of the prescribed dose of Y-90 microspheres. The licensee calculates the patient received 16 Grays instead of the prescribed 38 Grays.

The treatment is performed in three flushes. The patient receives 50% of the medication in the first flush and the remaining 50% in the second flush. The third flush is performed to ensure all the prescribed medication has been applied to the patient. In this case, the patient received the first flush but the second flush wouldn't go through the line. The licensee is investigating a problem with the three-way valve used in the treatment or potentially a crimp in the line which caused a blockage.

Both the patient and prescribing physician are aware of this problem, and the other half of the patient's therapy is planned for a future time period.


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: 44000
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MARRIOTT RESIDENCE INN
Region: 4
City: SACREMENTO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: JOE O'HARA
Notification Date: 02/21/2008
Notification Time: 13:50 [ET]
Event Date: 02/12/2008
Event Time: [PST]
Last Update Date: 02/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - BROKEN TRITIUM SIGNS

The State provided the following information via email:

"On February 12, 2008, the maintenance engineer from the Residence Inn in Corona, CA contacted RHB headquarters and left a message regarding two broken tritium exit signs. The message was not referred to the South RM ICE office until February 21, 2008. On February 21, 2008, [the State] dispatched an inspector to assess the situation, and ensure the signs are isolated and contained, until disposal can be arranged. The general licensee will also be requested to obtain a health physics consultant to assess potential exposures."

CA NMED # 022108

* * * UPDATE FROM DONELLE KRAJEWSKI TO JOE O'HARA VIA E-MAIL AT 1704 ON 02/21/08 * * *

"There were 2 tritium exit signs whose plexi-glass fronts were cracked. The H-3 tubes do appear to be ruptured since the letters are not completely and evenly lighted when you view the signs in a darkened room.

"Each exit sign contained 0.426 TBq (11.5 Curies) H-3. Manufacturer - Shield Source Inc, Petersbourgh, Canada, Model 101, Distributed by - Safety Light Corp, Bloomsburg, PA 17815. The serial numbers are #U9453 and T7844.

"Wipes were taken from the face of the signs and in the surrounding area, but it will be a couple of weeks before we get the results. The signs were individually packaged in plastic and were placed in a 5 gallon pail which will remain in a secure area until disposal by an authorized waste broker."

Notified R4DO (Howell, L.) and FSME (Suber).

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General Information or Other Event Number: 44001
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: OMAHA PUBLIC POWER DISTRICT
Region: 4
City: NEBRASKA CITY State: NE
County:
License #: GL0543
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/21/2008
Notification Time: 16:21 [ET]
Event Date: 01/29/2008
Event Time: [CST]
Last Update Date: 02/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LINDA HOWELL (R4)
GREG MORELL (FSME)
ILTAB Email ()

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM SIGN

The State provided the following information via email:

"The general licensee reported a possible missing tritium sign on January 29, 2008. The sign (NRD, Inc, Model #3 T-4001, Serial # 91355) had been purchased in September of 1993. The licensee did a search for the missing sign. The search included questioning the electrical working crew leader and crew, electrical maintenance supervisor and a communication to the entire plant requesting information on the status of the sign. They also checked the area where bulbs and electrical material await recycling. The licensee believes the sign had been disposed of in the common trash."

Report NE080001

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

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General Information or Other Event Number: 44003
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: BOEING
Region: 4
City: SEATTLE State: WA
County:
License #: WN-I005-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JOE O'HARA
Notification Date: 02/22/2008
Notification Time: 15:32 [ET]
Event Date: 02/07/2008
Event Time: [PST]
Last Update Date: 02/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
GREG SUBER (FSME)
CANADA ()

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

Event Text

AGREEMENT STATE REPORT - LOST ELECTRON CAPTURE CELL CONTAINING NICKEL - 63 SOURCE

"This is notification of an event in Washington State as reported to or investigated by the WA Department of Health, Office of Radiation Protection.

"The Boeing Company reported February 7th they are unable to find one gas chromatograph electron capture cell that contains 555 MBq (15 millicuries) of nickel-63. The Licensee became aware of the missing source on January 7, 2008, during a routine survey and inventory of their radioactive waste area. Based on their investigation, the licensee thinks the source was disposed of as radioactive waste in a shipment sent to the Low Level Radioactive Waste site in December 2007. The licensee attributes this to staff not following the established procedures for the transfer and disposal of the source. The person assigned waste area duties in December has subsequently left employment with Boeing. Confirming this directly is unlikely to happen. The Boeing RSO has reviewed the procedures and believes that when they are followed they are adequate to prevent loss of a source. However, the RSO will now require two people to be involved in the radioactive waste packaging process with both signing shipment documents before they are complete. The Boeing RSO reviewed the new procedure with the radiation safety staff. We are told, the discussion emphasized the importance of following the procedures. The RSO will have the waste manifest changed to show addition of the source.

"Event Report #WA-08-011."

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.

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Power Reactor Event Number: 44009
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID FUNK
HQ OPS Officer: JOE O'HARA
Notification Date: 02/26/2008
Notification Time: 14:38 [ET]
Event Date: 02/26/2008
Event Time: 13:09 [EST]
Last Update Date: 02/26/2008
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):
ROBERT HAAG (R2)
MARY JANE ROSS-LEE (NRR)

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

Event Text

UNITS 3 AND 4 TRIPPED DUE TO GRID FLUCTUATIONS

"At 1309 both U-3 and U-4 tripped from 100% power due to a momentary power fluctuation caused by grid instabilities. All systems responded normally with the exception of the 4C non-vital 4KV bus which deenergized. All vital 4KV busses on both units are supplied from offsite power and both units are stable with Auxiliary Feed Water supplying feed to all steam generators. Current information from system indicates the grid is stable. 4C non-vital 4KV bus restoration is complete."

No relief valves or safeties lifted. Decay heat path is AFW to S/G's with normal heat sink to the condenser and canal. All safety related equipment is operable and in standby. No ECCS actuation.

FPL has not given a cause of the grid disturbance. The licensee is investigating the cause of the non-vital bus deenergizing.

The Florida State Warning Point has been notified.

The licensee notified the NRC Resident Inspector.

* * *UPDATE PROVIDED BY MARK JONES TO JEFF ROTTON AT 1732 EST ON 02/26/08 * * *

The licensee provided the following update to report a valid specified System actuation per 10CFR50.72(b)(3)(iv)(A) that occurred at 1614 EST on 02/26/08.

"At 1614, an inadvertent initiation of the Auxiliary Feedwater (AFW) System occurred on Unit 4.

"During the Unit 4 reactor trip, the 4C 4KV bus de-energized due to grid transient. This caused the 4B Steam Generator Feed Pump (SGFP) breaker to trip with control switch in 'mid after start' position. Later, with the control switch for the 4B SGFP still in 'mid after start' position, operators performed a procedure to swap feed source for the steam generators from SGFP to Standby SGFP. As part of this procedure, the 4A SGFP was secured. When the control switch for the 4A SGFP was taken to stop, the logic for start of the Auxiliary Feedwater System was met due to loss of last running SGFP.

"The AFW system responded as expected for an auto initiation. Initiation of the AFW system was noted by the operators, and actions were taken to control feed flow rate and Reactor Coolant System temperature, pressure and inventory. The AFW system has been restored to standby status."

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

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Thursday, March 29, 2012