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Event Notification Report for September 8, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/05/2008 - 09/08/2008

** EVENT NUMBERS **


44460 44461 44465 44467 44468 44470 44471

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General Information or Other Event Number: 44460
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOE O'HARA
Notification Date: 09/03/2008
Notification Time: 12:49 [ET]
Event Date: 08/15/2008
Event Time: [CDT]
Last Update Date: 09/03/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR CRANK MECHANISM FAILURE

"On 9/2/08 at 16:30, the [Texas Department of State Health Services] received a letter from the licensee stating that on 8/15/08, they were unable to move the source head on a U.S. Nuclear Model E-0103 Irradiator. The device contains a Cesium (Cs) - 137 source with an estimated activity of 2251 curies and is used in research irradiation of in vitro samples. The source is fully shielded. Dose rates and contamination surveys conducted on the source head were normal. The unit has been taken out of service awaiting repairs."

TX Incident # I-8547

* * * UPDATE RECEIVED FROM ART TUCKER TO JOE O'HARA VIA E-MAIL AT 1538 ON 9/3/08 * * *

"The RSO called at 1444 and stated that he had some corrected information. He stated that the device contained two 2660 curie Cs 137 sources installed in 1975 and manufactured on 2/15/68 making the current activity 1045 curies each. He stated that the device had been repaired, but was still trying to find out when."

Notified R4DO(Jones)

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44461
Rep Org: QUEENS MEDICAL CENTER
Licensee: QUEENS MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County:
License #: 53-16533-02
Agreement: N
Docket:
NRC Notified By: BRIAN OYTOMARI
HQ OPS Officer: JOE O'HARA
Notification Date: 09/03/2008
Notification Time: 14:01 [ET]
Event Date: 06/02/2008
Event Time: [HST]
Last Update Date: 09/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WILLIAM JONES (R4)
RICHARD TURTIL (FSME)

Event Text

POTENTIAL MISADMINISTRATION GREATER THAN 20% OF PRESCRIBED DOSE

The RSO performed a quarterly audit on 9/2/08 and discovered that a misadministration greater than 20% of prescribed dose and greater than 50 Rem to the lung tissue occurred on 6/2/08. The prescribed dose was 1.0 ml of P-32 chromic phosphate into two separate syringe applications.

The technician prepared the first P-32 dose into syringe "A" and recorded into the written record after calibrated assay as 1.3 ml and performed the same procedure for the second dose which was recorded into the written record as 1.0 ml into syringe "B". The first dose in syringe "A" exceeded the allowable dose. Both syringe applications were given to the patient into separate lung tube injections.

The prescribing physician and authorized user have been notified. It is not known if the patient has been notified.

* * * RETRACTION AT 1545 EDT ON 9/5/08 FROM OYTOMARI TO SANDIN * * *

Based on further review of this event by the licensee, it was determined that the total dose to the lung was less than 50 Rem. As a result, the event does not meet reportability criteria under 10CFR35.3045. The licensee has reviewed its conclusion with NRC Region 4 inspectors (Whitten and Munoz).

R4DO (Jones) and FSME (Turtil) have been notified.

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Power Reactor Event Number: 44465
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: DAVE FOSS
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/05/2008
Notification Time: 08:45 [ET]
Event Date: 07/23/2008
Event Time: 23:25 [EDT]
Last Update Date: 09/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JAMES DWYER (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
3 N Y 100 Power Operation 100 Power Operation

Event Text

INVALID SYSTEM ACTUATION DUE TO LOSS OF ONE OFFSITE POWER CIRCUIT TO SAFETY BUSES

"This 60-day report, as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of specified systems, specifically the Units 2 and 3 Primary Containment Isolation Systems (PCIS). On 7/23/08, at approximately 2325 hours, Units 2 and 3 experienced invalid Primary Containment Isolation System (PCIS) partial isolations. Unit 2 experienced an outboard PCIS Group II isolation, while Unit 3 experienced inboard and outboard PCIS Group II isolations. The isolations involved various process lines including Reactor Water Cleanup (RWCU), Containment Atmospheric Control (CAC) / Containment Atmospheric Dilution (CAD), Drywell Sumps, and Containment Instrument Nitrogen. The Units 2 and 3 PCIS isolations were reset by approximately 2350 hours in accordance with procedures. All required isolation valves operated as designed.

"The invalid PCIS isolations were a result of a fast transfer on associated 4 kV safety-related electrical buses for Units 2 and 3 caused by a loss of one of the two off-site power circuits that supply the 4 kV buses. This fast transfer resulted in a momentary voltage transient on electrical power supplies to the logic for the Units 2 and 3 PCIS. The two station off-site power circuits are fed from three offsite sources. The loss of the offsite power circuit was caused by failure of the 'A' phase of the '#1' transformer, which is associated with one of the three offsite power sources. This transformer is located at the North Substation. The transformer automatically isolated as a result of a fire associated with this transformer and resulted in the loss of two of the three offsite power sources. Subsequent to fire extinguishment, appropriate electrical switching was performed and the offsite power circuit was returned to an operable status by 0650 hours on 7/24/08.

"This issue has been entered into the site Corrective Action Program (CR 799684, 811332) for evaluation and implementation of further corrective actions including determining why two offsite sources were lost as a result of the transformer failure. The NRC resident has been informed of this notification."

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Power Reactor Event Number: 44467
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: WARREN BRANDT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/05/2008
Notification Time: 18:52 [ET]
Event Date: 09/05/2008
Event Time: 17:00 [CDT]
Last Update Date: 09/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
WILLIAM JONES (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

OFFSITE NOTIFICATION TO THE EPA AS REQUIRED DUE TO A REFRIGERANT APPLIANCE REPAIR DELAY

"In accordance with Title 40 Code of Federal Regulations, Part 82, Subpart F, Wolf Creek Nuclear Operating Corporation (WCNOC) reported a refrigerant appliance repair delay to the US Environmental Protection Agency - Region 7. This unit involved is subject to the 15% leak rate threshold and the 30-day repair requirement applicable to a comfort-cooling appliance. WCNOC has requested additional time be permitted to conduct the required repairs on this appliance due to the unavailability of parts. The appliance is located at the Wolf Creek Generating Station, on the roof of the building that houses the maintenance support staff."

The licensee informed the NRC Resident Inspector.

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Hospital Event Number: 44468
Rep Org: US AIR FORCE
Licensee: US AIR FORCE
Region: 1
City: WASHINGTON State: DC
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: Lt. Col. CRAIG ADAMS
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/05/2008
Notification Time: 19:50 [ET]
Event Date: 06/04/2008
Event Time: [EDT]
Last Update Date: 09/05/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
JAMES DWYER (R1)
WILLIAM JONES (R4)
RICHARD TURTIL (FSME)

Event Text

REPORT INVOLVING A PATIENT WITH AN UNDETECTED PREGNANCY WHO RECEIVED THERAPEUTIC I-131 TREATMENT

On 06/02/08, a female patient was tested for pregnancy prior to receiving a therapeutic Iodine-131 (I-131) dose at the Wilford Hall Medical Center located on Lackland AFB near San Antonio, TX. The serum screening result was negative. A dose of 149.2 millicuries I-131 was subsequently administered on 06/04/08 with no complications. On 08/13/08, the patient was informed she was pregnant. Follow-up consultation with the REAC (Radiation Emergency Assistance Center) and calculations determined that the dose to the fetus was approximately 31.5 Rad. However, since the incident occurred early in the zygote phase of development there is no anticipated adverse consequences.

The Air Force Radioisotope Committee was notified of this incident on 08/27/08.

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Power Reactor Event Number: 44470
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: GLEN MORROW
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/07/2008
Notification Time: 14:45 [ET]
Event Date: 09/07/2008
Event Time: 08:05 [CDT]
Last Update Date: 09/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
RICHARD SKOKOWSKI (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 67 Power Operation 67 Power Operation

Event Text

ISOLATION CONDENSER DECLARED INOPERABLE FOLLOWING SURVEILLANCE TESTING

"Unit 2 Isolation Condenser did not meet acceptance criteria per DOS 1300-01 Isolation Condenser 5 year heat removal capability test. This is a single train system and cannot fulfill its safety function. The Isolation Condenser is a single train system. The function of the IC System is to respond to main steam SAFETY ANALYSES line isolation events by providing core cooling to the reactor. The IC System is an Engineered Safety Feature System, and credit is taken in the loss of feedwater transient analysis for IC System operation."

Unit 2 entered a 14-day TS LCO A/S 3.5.3 at 0249 CDT on 09/07/08 after declaring the IC System Inoperable. The Action Statement (A/S) requires restoration of the IC System to Operable status within 14 days or place the unit in hot shutdown within 12 hrs followed by entry into cold shutdown in the following 24 hrs. The licensee is performing maintenance to adjust the cooling flow valve stroke time in order to re-test and exit the LCO A/S.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 44471
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 BOLAND
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/07/2008
Notification Time: 23:12 [ET]
Event Date: 09/07/2008
Event Time: 17:20 [CDT]
Last Update Date: 09/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
REBECCA NEASE (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 Y 100 Power Operation 100 Power Operation

Event Text

PARTIAL LOSS OF OFFSITE COMMUNICATION CAPABILITY CAUSED BY AN UNPLANNED POWER OUTAGE

"On 09/07/2008 at 1720 CDT, Browns Ferry Nuclear Plant experienced a partial loss of offsite communication to include the Emergency Notification System to the NRC, normal phone communication to offsite, the Operations Duty Specialist ring down phone to Chattanooga and the satellite phone to offsite located in the control room. This loss of communications was the result of an unplanned electrical power outage due to loss of temporary diesel generator supplying power to the communications network. The control room indications and assessment capability were not affected. Cell phones and the Health Physics Radio Network were available to be used onsite to communicate offsite. The plant radio system and sound powered phones were unaffected and plant staff communication capability was available.

"Communication capability was restored at 1758 CDT 09/07/2008.

"Operation of Unit 1, Unit 2 and Unit 3 was not affected by the event.

"The NRC Sr. Resident Inspector has been notified.

"This event is reportable under 10CFR50.72(b)(3)(xiii), 'Any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System or offsite notification system.'"

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Thursday, March 29, 2012