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Event Notification Report for September 24, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/23/2008 - 09/24/2008

** EVENT NUMBERS **


44500 44501 44505 44513 44515 44516

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 44500
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSAL HEALTH SVC. OF RANCHO SPRINGS, INC.
Region: 4
City: WILDOMAR State: CA
County:
License #: 2811-33
Agreement: Y
Docket:
NRC Notified By: DELIA AQUINO
HQ OPS Officer: DAN LIVERMORE
Notification Date: 09/17/2008
Notification Time: 17:39 [ET]
Event Date: 09/11/2008
Event Time: [PDT]
Last Update Date: 09/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
KEVIN HSUEH (FSME)

Event Text

GREATER THAN PRESCRIBED DOSE ADMINSTERED TO PATIENT

"On Wednesday, September 17, 2008, [a Certified Nuclear Medical Technologist] at Universal Health Services of Rancho Springs, Inc., contacted RHB about a diagnostic misadministration, which had occurred on September 11, 2008. The patient was prescribed a 7 milliCurie dose of Tc-99m Hebrofenin for a Hepatobiliary study (HIDA). At approximately 2:10 P.M. on September 11, 2008, the patient was given a dose of 22 milliCuries of Tc-99m Sestamibi, used for cardiac studies. The dose given was 50% greater than the intended dose. No additional Tc-99m was given since the image required was obtained with the dose that was actually given. The technician had grabbed the wrong syringe from the dose cart. The reason given for the misadministration was a heavy workload. The corrective actions to be taken to prevent a recurrence were to implement new procedures for radiopharmaceutical labeling and handling and to reinstruct personnel. Since the dose administered to the patient was 50% greater than the prescribed dose, the reportability of this event is 24 hours. This event will be investigated by RHB South."

California Report #5010-091708

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.


* * * RETRACTION AT 1044 ON 9/18/2008 FROM DELIA AQUINO TO MARK ABRAMOVITZ * * *

The following report was received via e-mail:

The state of California is retracting this event. "After additional review, we determined that it was not actually a reportable event."

The dose the individual received did not meet the threshold necessary to be reportable under 10CFR35.3045 - Medical Event.

Notified the R4DO (Pick) and FSME (Einberg).

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General Information or Other Event Number: 44501
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: SECOND STREET IRON & METAL
Region: 1
City: EVERETT State: MA
County:
License #:
Agreement: Y
Docket: 09-8006
NRC Notified By: J. THOMAS COULOMBIE
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/18/2008
Notification Time: 15:45 [ET]
Event Date: 08/21/2008
Event Time: 13:15 [EDT]
Last Update Date: 09/18/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1)
CHRIS EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - REPORTABLE QUANITY OF RA-226 FOUND IN SCRAP YARD

"A shipment of ferrous scrap metal from a small scrap metal yard set off the radiation alarms at the entrance to the major regional scrap metal and exporting facility. It was immediately rejected, but the Agency (state of MA) was not notified for almost two hours. An Agency investigator responded and traced the shipment back to a smaller scrap yard across town. The operator of the facility had isolated the rejected shipment and was trying to locate their consultant. Upon surveying the roll-off, the Agency investigator tentatively identified the shipment as containing Radium. The background was recorded as 0.06 millirem/hour and the highest reading was measured as 0.1 millirem/hour.

"This company was advised to acquire the services of a competent health physics consultant to arrange for the separation, storage and legal disposition of the radioactive material; and this was agreed upon without hesitation. Their hired consultant responded to the facility on August 25, 2008; and after collecting a spectrum and necessary measurements for identification purposes, separated one metal device from the roll-off, packaged it in a five gallon drum and had the facility operators secure it on-site depending disposal arrangements. Subsequently, the consultant has confirmed the presence of 12 microcuries of Radium-226. Legal transfer and disposition of this radioactive material is pending."

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General Information or Other Event Number: 44505
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: NEKTAR THERAPEUTICS
Region: 4
City: SAN CARLOS State: CA
County:
License #: 5767-41
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/19/2008
Notification Time: 15:10 [ET]
Event Date: 09/18/2008
Event Time: 17:00 [PDT]
Last Update Date: 09/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE IN GAS CHROMATOGRAPH

"On September 18, 2008, at 5:00pm, the state received a telephone call from the RSO of Nektar Therapeutics that their Aglent Technology gas chromatograph containing generally licensed source is leaking. This notification is based on the swipe test results report from their swipe test laboratory. Source Serial Number U8663, had a confirmed a positive wipe test result of 137,362 DPM which is a result of 0.0619 micro curies/sample.

"The RSO stored the gas chromatograph in a secured locked storage room where the storage is posted with 'Caution Radioactive Material'".

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Power Reactor Event Number: 44513
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RICH KLINEFELTER
HQ OPS Officer: VINCE KLCO
Notification Date: 09/23/2008
Notification Time: 07:34 [ET]
Event Date: 09/23/2008
Event Time: 07:30 [EDT]
Last Update Date: 09/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICHARD CONTE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 94 Power Operation 94 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY OPERATING FACILITY UNAVAILABLE

"PPL Susquehanna is installing a backup diesel to supply power to the Emergency Operating Facility (EOF) during loss of power conditions. A power outage is required to tie-in the transfer switch for the new power supply. The scope of work includes connection of offsite power to a new transformer, connection from the transformer to the transfer switch and connection of power from the transfer switch to the building's distribution panel. This power outage, which is expected to be approximately 3 hours, is required to make final connections and to test the new service.

"During the outage, temporary power will be supplied to the phone lines only. HVAC, lighting and computer terminals will be without power. This condition is a loss of emergency response capability and is reportable to the NRC as an 8 hour ENS notification per 10CFR50.72(b)(3)(xiii)."

The licensee contacted the NRC Resident Inspector.

* * * UPDATE FROM R. KLINEFELTER TO J. KNOKE AT 1303 EDT ON 09/23/08 * * *

This is a follow-up courtesy notification to EN# 44513. As of 12:20, on 09/23/08, power has been restored to the Susquehanna Emergency Operating Facility (EOF).

Licensee has notified the NRC Resident Inspector and the state. Notified R1DO (Conte)

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Fuel Cycle Facility Event Number: 44515
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: JEFF ROTTON
Notification Date: 09/23/2008
Notification Time: 15:22 [ET]
Event Date: 09/23/2008
Event Time: 09:37 [CDT]
Last Update Date: 09/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MIKE ERNSTES (R2)
LARRY CAMPBELL (NMSS)

Event Text

SAFETY EQUIPMENT FAILURE DUE TO LOSS OF POWER

"At 0937 CDST, on 09/23/08 the Plant Shift Superintendent (PSS) was notified that C-315 (tails withdrawal facility) had lost power due to a fault on a 14 KV feeder. As a result of the power loss, the C-315 High Voltage Process Gas Leak Detection (PGLD) System was rendered inoperable. This PGLD System contains detectors that cover the C-315 UF6 condensers, accumulators, and piping heated housing. At the time of this loss of power, these areas were operating above atmospheric pressure. TSR 2.3.4.4 requires that all of detector heads in this system be operable during operations above atmospheric pressure. This PGLD System was declared inoperable. TSR LCO 2.3.4.4.A.1 was entered and a continuous smoke watch was put in place within one hour. This event is reportable as a 24 hour event in accordance with 10CFR 76.120(c)(2)(i). This is an event in which equipment is disabled or fails to function as designed when: a.) the equipment is required by a TSR to prevent releases, prevent exposures to radiation and radioactive materials exceeding specified limits, mitigate the consequences of an accident, or restore this facility to a pre-established safe condition after an accident; b.) the equipment is required by a TSR to be available and operable and either should have been operating or should have operated on demand; and, c.) no redundant equipment is available and operable to perform the required safety function. Once the source of the fault was identified, power was restored to the C-315 facility. The High Voltage PGLD system was tested, and the system was declared operable. Power was restored at 1039 hours and the High Voltage PGLD System was declared operable at 1118 hours.

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

"PGDP Assessment and Tracking Report No. ATR-08-2371; PGDP Event Report No. PAD-2008-29; Responsible Division: Operations."

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Power Reactor Event Number: 44516
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: GENE DORMAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 09/23/2008
Notification Time: 19:25 [ET]
Event Date: 09/23/2008
Event Time: 15:00 [EDT]
Last Update Date: 09/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RICHARD CONTE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

DEGRADED CONDITION DUE TO RECIRC NOZZLE WELD AXIAL CRACK

"On September 23, 2008 at approximately 1500 [EDT] the James A. FitzPatrick Nuclear Power Plant was shutdown and operating in the refueling mode (Mode 5). During an ISI inspection of the dissimilar metal weld on recirc nozzle N2-C an indication was identified. Preliminary analysis of the data indicates a flaw in the nozzle weld that extends into the 'butter', is axially oriented, approximately 0.5 inches in length and 0.4 inches in depth. There is no approved method for predicting crack growth in axially oriented flaws. Therefore, the flaw can not evaluated in accordance with ASME Section XI. This deficiency meets reporting criterion 10 CFR 50.72(b)(3)(ii).

"At this time four of the eight N2 Recirc Nozzles have been inspected with no other flaws or indications identified. The remaining four N2 Nozzles are being inspected during this outage.

"The event has been entered into the corrective action program and a Licensee Event Report (LER) will be filed within 60 Days as required by 10 CFR 50.73(a)(2)(ii).

"The NRC Resident Inspector has been briefed and the state Public Service Commission (PSC) will also be notified."

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Thursday, March 29, 2012