United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2008 > March 13

Event Notification Report for March 13, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/12/2008 - 03/13/2008

** EVENT NUMBERS **


43917 44043 44045 44047 44054 44055 44056 44057

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 43917
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: DEPARTMENT OF VETERANS AFFAIRS
Region: 1
City: BOSTON State: MA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: GARY WILLIAMS
HQ OPS Officer: JASON KOZAL
Notification Date: 01/18/2008
Notification Time: 15:20 [ET]
Event Date: 01/17/2008
Event Time: [EST]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
EUGENE COBEY (R1)
HIRONORI PETERSON (R3)
KEITH McCONNELL (FSME)

Event Text

POTENTIAL OVEREXPOSURE

"The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts.

"The possible medical event occurred on January 17, 2008, and was discovered the same day. The basis for the possible medical event is under 10 CFR 35.3045(a)(2) and involved administration of radiopharmaceutical that might have resulted in more than 50 rem to tissue and involved a wrong route of administration.

"Specifically, a F-18 FDG injection of approximately 3.6 millicuries was infiltrated into a patient's arm.

"The Department of Veterans Affairs and permittee are reviewing the possible medical event circumstances and the dose calculation methods.

"The permittee informed the patient and referring physician."

* * * RETRACTION FROM THOMAS HUSTON TO HOWIE CROUCH ON 3/12/08 @ 1430 HRS. * * *

"The basis for retracting the event is that infiltration is not considered to be a wrong route of administration. This basis was communicated to NHPP [National Health Physics Program] in a phone call received from our NRC Region III Project Manager (Cassandra Frazier) on March 7, 2008 at 4:40 pm."

Notified R1DO (Lorson), R3DO (Ring), and FSME (Burgess).

To top of page
General Information or Other Event Number: 44043
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NOT APPLICABLE
Region: 4
City: COMPTON State: CA
County: LOS ANGELES
License #:
Agreement: Y
Docket:
NRC Notified By: K. KAUFMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/07/2008
Notification Time: 14:03 [ET]
Event Date: 03/06/2008
Event Time: 09:30 [PST]
Last Update Date: 03/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
CINDY FLANNERY (FSME)

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

Event Text

CALIFORNIA AGREEMENT STATE REPORT - LOST LICENSED MATERIAL

Received the following information from the State of California via fax:

"A person contacted the California Radiologic Health Branch (RHB) on 03/06/08 to report that the radiation detector at the Compton Transfer Station had alarmed from a bin that had come from FedEx at 5927 W. Imperial, [Los Angeles] (near LAX); the reading was 22.8 kcpm, with a background of [approximately] 3.4 kcpm. [A RHB Investigator] went that afternoon, and after sorting through the bin contents, found an [approximately] 13 mCi Cs-137 source. The source is [about] 1/4 inch long and 1/8 inch in diameter. The radiation measurement was about 50 mrem/hr at one foot (measured using a Bicron microrem meter and a Keithley 36150). [The RHB Investigator] placed the source in a lead pig and secured it in the trunk of his car.

"On 3/7/08, [RHB Investigators] discussed the incident with the Manager at the Fed Ex Imperial location, [the Manager of] FedEx Dangerous Goods, and other FedEx employees in Dangerous Goods. [An RHB Investigator] advised them that [RHB Investigators] would be there later today (03/07/08) to survey the facility to make sure there aren't any other sources, and that Fed Ex is to interview their employees to try and determine how the source came to be in the bin, and from whom it had come."

California RHB will continue to investigate this incident and has assigned incident report number 5010-030608 to this event.

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: 44045
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: APPLETON MEDICAL CENTER
Region: 3
City: APPLETON State: WI
County:
License #: 087-1014-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/07/2008
Notification Time: 16:32 [ET]
Event Date: 03/06/2008
Event Time: [CST]
Last Update Date: 03/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATTY PELKE (R3)
SCOTT FLANDERS (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE PATIENT UNDERDOSES

"The Department of Health and Family Services (DHFS) was notified on March 6, 2008, of possible underdoses to up to eight patients treated with Samarium-153 since late 2006.

"When the licensee was preparing a recent dose of Samarium-153, the activity measured in the dose calibrator did not read as expected. After review, the licensee determined that the dose calibrator was calibrated to measure Samarium-153 in a vial, but the nuclear medicine technologist had measured the activity of Samarium-153 in a syringe instead. For this particular case, the dosage was remeasured properly prior to administration, but further review of cases identified up to eight additional instances when the nuclear medicine technologists may have measured the activity of Sarnarium-153 in a syringe instead of in a vial. Samarium-153 has a combined beta and gamma decay spectrum, and when the activity is measured in a syringe, the attenuation and volume geometry is estimated to lead to administered activities of approximately 30% less than prescribed in the written directives.

"DHPS will investigate this incident next week."

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
Power Reactor Event Number: 44047
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MARK JONES
HQ OPS Officer: PETE SNYDER
Notification Date: 03/07/2008
Notification Time: 22:49 [ET]
Event Date: 03/07/2008
Event Time: 19:14 [EST]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GEORGE HOPPER (R2)

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

Event Text

INTERMITTENT OPERATION OF EMERGENCY RESPONSE DATA SYSTEM

"At 1914 on 3/07/08, the Unit 4 RCO noted that the ERDADS OPCON displays in control room and computer room stopped updating. This rendered the Unit 4 ERDS link to the Nuclear Regulatory Commission Operations Center (NRCOC) to be inoperable for greater than 30 minutes, as the link can not be initialized if required.

"Attempts to reboot the OPCON displays and the PEDS Computers were initially performed per plant procedure, but did not correct the issue. Troubleshooting is in progress at this time. No estimated return to service is available at this time.

"8-hour notification being performed to NRCOC under event classification 10 CFR 50.72 (b)(3)(xiii)."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM MARK JONES TO PETE SNYDER ON 3/12/08 @ 1431 hrs. * * *

A CPU board had been replaced. At 1420 the ERDS link to the NRC has been restored and is considered operable.

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

To top of page
Power Reactor Event Number: 44054
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: LARRY WHEELER
HQ OPS Officer: JOE O'HARA
Notification Date: 03/12/2008
Notification Time: 10:01 [ET]
Event Date: 03/12/2008
Event Time: 05:00 [EDT]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK LESSER (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

INTERRUPTION TO ENS TELEPHONE SERVICE

"At 05:00 hours on 3/12/2008, it was discovered that the Surry Power Station Emergency Notification System (ENS) phone was nonfunctional. This was discovered when the NRC attempted to contact the Surry Main Control Room, and no response was obtained. The ENS phones in the Main Control Room and the Technical Support Center cannot dial out. Telecommunications has been contacted to investigate the problem.

"This event is reportable in accordance with 10CFR50.72(b)(3)(xiii), any event that results in a major loss of offsite communications capability. (e.g., Emergency Notification System).

"At 08:00 the NRC ENS phone was tested and it was determined to be functional from the Main Control Room to the NRC. The NRC Resident was notified that the ENS phone was returned to service at 09:20."

To top of page
Power Reactor Event Number: 44055
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RODNEY DELAP
HQ OPS Officer: PETE SNYDER
Notification Date: 03/12/2008
Notification Time: 13:07 [ET]
Event Date: 03/12/2008
Event Time: 08:15 [CDT]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK RING (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

ACCIDENTAL EMERGENCY SIREN ACTIVATION

"At approximately 0815 CDT, on March 12, 2008, a Dakota County corrections officer inadvertently activated the Dakota County sirens from the backup unit during the conduct of a silent siren test. The licensee was notified of the siren activation by the activation signal received on the informer unit in the Technical Support Center (TSC) at 0815, as well as a subsequent phone call from the siren contractor. Seven of the 117 sirens in the 10-mile Emergency Planning Zone (EPZ) were activated for approximately 3 minutes. No press release is planned by Xcel Energy. Dakota Communications Center received a call from a local radio station asking why the sirens were activated. No other press release is planned by Dakota County.

"The NRC Senior Resident Inspector was notified."

To top of page
Fuel Cycle Facility Event Number: 44056
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: CALVIN PITTMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 03/12/2008
Notification Time: 13:44 [ET]
Event Date: 03/11/2008
Event Time: 14:57 [CDT]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
MARK LESSER (R2)
DENNIS DAMON (NMSS)

Event Text

TWO CYLINDERS IDENTIFIED WITH WEIGHT CHANGE PRIOR TO WASH

"Between 1979 and 1985, approximately 960 thin-walled cylinders were obtained by Paducah Gaseous Diffusion Plant (PGDP), transferred to Allied Chemical, and filled with near-normal assay material as part of a strategic feed reserve. These cylinders were transferred to Oak Ridge Gaseous Diffusion Plant (ORGDP) for storage. They were shipped back to PGDP beginning in the early 1990s. All but three of these cylinders have been fed. In early 2003, the Nuclear Criticality Safety Evaluation (NCSE) was revised to evaluate the washing of the heeled cylinders.

"At 1457 hours on 3/11/2008, the Plant Shift Superintendent was notified that two non-fissile cylinders were identified in the ORGDP strategic reserve category that had a weight change while stored at ORGDP in violation of the NCSE for the C-400 cylinder wash operation. One leg of double contingency is based on it being unlikely that cylinders in this category would be introduced into the process while stored at ORGDP. The weight change indicated that these cylinders were introduced into the process at ORGDP. The other leg of double contingency is based on two individuals independently verifying that the cylinder had no weight change while it was stored at ORGDP. This control was not violated. The NCSE concern associated with these cylinders entering the process is the potential to introduce fissile material into the cylinder while stored at ORGDP and subsequent washing at the non-fissile C-400 cylinder wash. Even though one leg of double contingency was lost, these cylinders were not washed.

"The cylinder heel of one cylinder is approximately 11 lbs. at 0.711 wt% U-235 in solid form and the other cylinder is approximately 39 lbs. at 0.7 wt% U-235 in solid form.

"The NRC Senior Resident Inspector has been notified of this event.

"PGDP Problem Report No. ATRC-08-0730; PGDP Event Report No. PAD-2008-06."

To top of page
Power Reactor Event Number: 44057
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RODNEY DELAP
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/12/2008
Notification Time: 17:33 [ET]
Event Date: 03/12/2008
Event Time: 14:30 [CDT]
Last Update Date: 03/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

LONG TERM HABITABILITY OF TECHNICAL SUPPORT CENTER UNDER ACCIDENT DOSE ANALYSIS EXCEEDS ACCEPTANCE CRITERIA

"At approximately 1430 CDT on 3/12/08 Prairie Island staff completed a preliminary review of a revised dose analysis for the Prairie Island Technical Support Center (TSC) that called into question the long term habitability of the TSC under bounding accident conditions. The preliminary calculation result exceeds the 30-day 5 rem whole body dose acceptance criteria of NUREG-0696 and is based on bounding case assumptions consistent with Regulatory Guide 1.4 (including fuel melt, highest allowable containment leakage and bounding atmospheric dispersion factors). The primary contributor is an approximately 25 square foot window in the north wall of the TSC. Compensatory measures are being established to provide shielding over the window in the TSC."

The licensee will notify the NRC Resident Inspector.

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