Event Notification Report for October 22, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/21/2008 - 10/22/2008
EVENT NUMBERS
4459944593445944459044591
General Information or Other
Event Number: 44599
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: N.E GEORGIA MEDICAL CENTER, WD STRIBLING HEART CLINIC
Region: 1
City: GAINESVILLE State: GA
County:
License #: 1479-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: VINCE KLCO
Licensee: N.E GEORGIA MEDICAL CENTER, WD STRIBLING HEART CLINIC
Region: 1
City: GAINESVILLE State: GA
County:
License #: 1479-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: VINCE KLCO
Notification Date: 10/24/2008
Notification Time: 14:46 [ET]
Event Date: 10/22/2008
Event Time: 00:00 [EDT]
Last Update Date: 10/28/2008
Notification Time: 14:46 [ET]
Event Date: 10/22/2008
Event Time: 00:00 [EDT]
Last Update Date: 10/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1)
ANDREW MAUER (FSME)
CHRISTOPHER CAHILL (R1)
ANDREW MAUER (FSME)
AGREEMENT STATE REPORT - EXCESS DOSE TO THE FETUS OF A PREGNANT PATIENT
The licensee notified the State of Georgia on 10/23/2008 regarding a dose of greater than 500 mrem administered to the fetus of a pregnant patient. The apparent unintended dose was identified by the licensee on 10/22/08.
The State of Georgia is attempting to contact the licensee for additional follow-up details and a report related to this event.
* * * UPDATE RECEIVED VIA FAX FROM IRENE BENNETT TO JOE O'HARA AT 1531 ON 10/27/08 * * *
The following information was provided to the State of Georgia by the licensee:
"The patient was administered the radiopharmaceutical on October 13, 2008. Our facility was informed of the patients pregnancy on October 22, 2008. The RSO and our consulting medical physicists were notified. A dose calculation was performed and it was determined that the embryo/fetus received an effective dose equivalent in excess of 500 millirem.
"The patient was scheduled for a Nuclear Cardiology treadmill stress test on October 13, 2008. The patient was asked by the staff if she was pregnant per facility policy. The patient indicated that she was not pregnant. This was documented by our staff. The patient was administered 10 mCi Tc-99m Myoview for resting procedure and 30 mCi Tc-99m Myoview for stress. The patient subsequently determined she was pregnant and notified us as described above.
"The patient withheld information regarding pregnancy and fertility medication when asked prior to the study. The dose to the conceptus is estimated to be approximately 1.12 rad with an uncertainty factor of 50 percent. Determination of dose is limited by patient habitus and metabolic parameters.
"The prescribing physician was notified October 23, 2008 at 9:34 AM and stated that she will notify the primary physician and patient."
Notified R1DO(Cobey) and FSME(Mauer)
The licensee notified the State of Georgia on 10/23/2008 regarding a dose of greater than 500 mrem administered to the fetus of a pregnant patient. The apparent unintended dose was identified by the licensee on 10/22/08.
The State of Georgia is attempting to contact the licensee for additional follow-up details and a report related to this event.
* * * UPDATE RECEIVED VIA FAX FROM IRENE BENNETT TO JOE O'HARA AT 1531 ON 10/27/08 * * *
The following information was provided to the State of Georgia by the licensee:
"The patient was administered the radiopharmaceutical on October 13, 2008. Our facility was informed of the patients pregnancy on October 22, 2008. The RSO and our consulting medical physicists were notified. A dose calculation was performed and it was determined that the embryo/fetus received an effective dose equivalent in excess of 500 millirem.
"The patient was scheduled for a Nuclear Cardiology treadmill stress test on October 13, 2008. The patient was asked by the staff if she was pregnant per facility policy. The patient indicated that she was not pregnant. This was documented by our staff. The patient was administered 10 mCi Tc-99m Myoview for resting procedure and 30 mCi Tc-99m Myoview for stress. The patient subsequently determined she was pregnant and notified us as described above.
"The patient withheld information regarding pregnancy and fertility medication when asked prior to the study. The dose to the conceptus is estimated to be approximately 1.12 rad with an uncertainty factor of 50 percent. Determination of dose is limited by patient habitus and metabolic parameters.
"The prescribing physician was notified October 23, 2008 at 9:34 AM and stated that she will notify the primary physician and patient."
Notified R1DO(Cobey) and FSME(Mauer)
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 44593
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: MERT PROBASCO
HQ OPS Officer: JEFF ROTTON
Region: 1 State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: MERT PROBASCO
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/22/2008
Notification Time: 17:42 [ET]
Event Date: 10/22/2008
Event Time: 12:17 [EDT]
Last Update Date: 12/12/2008
Notification Time: 17:42 [ET]
Event Date: 10/22/2008
Event Time: 12:17 [EDT]
Last Update Date: 12/12/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTOPHER CAHILL (R1)
CHRISTOPHER CAHILL (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 |
RCIC DECLARED INOPERABLE DUE TO AGING CONCERN OF SEVERAL FLOW CONTROLLER COMPONENTS
"On October 22, 2008, at 1217 hours, with the reactor at 100% core thermal power and steady state conditions, Pilgrim Nuclear Power Station (PNPS) conservatively declared the Reactor Core Isolation Cooling System (RCIC) inoperable in response to a concern regarding the reliability of aged capacitors that are installed in the RCIC flow controller.
"As background, the RCIC flow controller was calibrated and successfully tested on October 7th, 2008 as part of normal surveillance activities, however several of the capacitors installed in the controller were noted to be between 21 to 30 years of age. Industry recommended replacement interval for the capacitors is typically between 7 to 10 years of age. PNPS engineering review in conjunction with Entergy fleet consultation concluded today (10/22) that there was no definitive technical bases to provide a reasonable expectation that the RCIC flow controller function can be assured throughout it's mission time due to the capacitor aging concern. Therefore, RCIC was declared inoperable and a 14 day limiting condition for operability action statement was entered in accordance with TS 3.5.D.1. A replacement controller is being prepared for installation, with post maintenance testing projected to be completed by 2100 hours this evening. Ultimately the suspect controller will be the subject of further evaluation and this notification will be updated as appropriate.
"This notification has no impact on the health and safety of the public.
"The NRC Senior Resident Inspector is onsite and has been notified.
"This is an 8 hour notification made in accordance with 50.72(b)(3)(v)(D)."
* * * RETRACTION AT 1435 EST ON 12/12/2008 FROM JOHN WHALEY TO DONALD NORWOOD * * *
"Basis for Retraction: Event Notification 44593 was conservatively made to ensure that the eight-hour non-emergency reporting requirements of 10 CFR 50.72 were satisfied pending the evaluation of RCIC System operability.
"On 10/22/08, RCIC flow controller FIC-1340-1 was declared inoperable due to engineering uncertainty for controller operability. The controller's electrolytic capacitors appeared to be aged beyond the expected useful life, and the resultant degrading power supply voltage indicated that the controller may not operate for the required FSAR mission time of eight hours.
"The controller was replaced on 10/23/08 with a refurbished controller and subsequent post-maintenance RCIC system flow testing demonstrated RCIC system operability.
"The controller that was removed from service was evaluated. Controller bench testing was performed on 11/6 and 11/7, 2008. This testing demonstrated that the controller could provide a full demand output signal for a minimum of 15 continuous hours. During this testing, it was also determined that the power supply output voltage was not degrading.
"Based on this post-service controller testing, and the successful in-service RCIC flow controller calibration and system performance test conducted on 10/07/08, the controller was operable when installed. The RCIC system was capable of performing its intended safety functions and would have started and supplied design basis flow to the reactor vessel under design basis conditions. Thus there would have [been] no impact on nuclear safety. Therefore, this event was not reportable pursuant to 10CFR50.72(b)(3)(v)(D).
"Event Number 44593, made on 10/22/2008, is being retracted."
The licensee notified the NRC Resident Inspector.
Notified R1DO (Bellamy).
"On October 22, 2008, at 1217 hours, with the reactor at 100% core thermal power and steady state conditions, Pilgrim Nuclear Power Station (PNPS) conservatively declared the Reactor Core Isolation Cooling System (RCIC) inoperable in response to a concern regarding the reliability of aged capacitors that are installed in the RCIC flow controller.
"As background, the RCIC flow controller was calibrated and successfully tested on October 7th, 2008 as part of normal surveillance activities, however several of the capacitors installed in the controller were noted to be between 21 to 30 years of age. Industry recommended replacement interval for the capacitors is typically between 7 to 10 years of age. PNPS engineering review in conjunction with Entergy fleet consultation concluded today (10/22) that there was no definitive technical bases to provide a reasonable expectation that the RCIC flow controller function can be assured throughout it's mission time due to the capacitor aging concern. Therefore, RCIC was declared inoperable and a 14 day limiting condition for operability action statement was entered in accordance with TS 3.5.D.1. A replacement controller is being prepared for installation, with post maintenance testing projected to be completed by 2100 hours this evening. Ultimately the suspect controller will be the subject of further evaluation and this notification will be updated as appropriate.
"This notification has no impact on the health and safety of the public.
"The NRC Senior Resident Inspector is onsite and has been notified.
"This is an 8 hour notification made in accordance with 50.72(b)(3)(v)(D)."
* * * RETRACTION AT 1435 EST ON 12/12/2008 FROM JOHN WHALEY TO DONALD NORWOOD * * *
"Basis for Retraction: Event Notification 44593 was conservatively made to ensure that the eight-hour non-emergency reporting requirements of 10 CFR 50.72 were satisfied pending the evaluation of RCIC System operability.
"On 10/22/08, RCIC flow controller FIC-1340-1 was declared inoperable due to engineering uncertainty for controller operability. The controller's electrolytic capacitors appeared to be aged beyond the expected useful life, and the resultant degrading power supply voltage indicated that the controller may not operate for the required FSAR mission time of eight hours.
"The controller was replaced on 10/23/08 with a refurbished controller and subsequent post-maintenance RCIC system flow testing demonstrated RCIC system operability.
"The controller that was removed from service was evaluated. Controller bench testing was performed on 11/6 and 11/7, 2008. This testing demonstrated that the controller could provide a full demand output signal for a minimum of 15 continuous hours. During this testing, it was also determined that the power supply output voltage was not degrading.
"Based on this post-service controller testing, and the successful in-service RCIC flow controller calibration and system performance test conducted on 10/07/08, the controller was operable when installed. The RCIC system was capable of performing its intended safety functions and would have started and supplied design basis flow to the reactor vessel under design basis conditions. Thus there would have [been] no impact on nuclear safety. Therefore, this event was not reportable pursuant to 10CFR50.72(b)(3)(v)(D).
"Event Number 44593, made on 10/22/2008, is being retracted."
The licensee notified the NRC Resident Inspector.
Notified R1DO (Bellamy).
Power Reactor
Event Number: 44594
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KARL HANTHO
HQ OPS Officer: JOHN KNOKE
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KARL HANTHO
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/22/2008
Notification Time: 21:42 [ET]
Event Date: 10/22/2008
Event Time: 18:50 [EDT]
Last Update Date: 10/22/2008
Notification Time: 21:42 [ET]
Event Date: 10/22/2008
Event Time: 18:50 [EDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
CHRISTOPHER CAHILL (R1)
CHRISTOPHER CAHILL (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
WORKER TRANSPORTED TO LOCAL HOSPITAL
"A potentially contaminated individual was transported to the Salem County Memorial Hospital by the on-site Fire Protection personnel. The individual had been working in Unit One containment and collapsed. The individual was surveyed en-route to the hospital and was determined to be-not contaminated. The individual remains at the hospital and is undergoing testing and evaluation. Salem Unit One remains defueled with spent fuel cooling in-service."
The NRC Resident Inspector has been notified.
"A potentially contaminated individual was transported to the Salem County Memorial Hospital by the on-site Fire Protection personnel. The individual had been working in Unit One containment and collapsed. The individual was surveyed en-route to the hospital and was determined to be-not contaminated. The individual remains at the hospital and is undergoing testing and evaluation. Salem Unit One remains defueled with spent fuel cooling in-service."
The NRC Resident Inspector has been notified.
Fuel Cycle Facility
Event Number: 44590
Facility: BWX TECHNOLOGIES, INC.
Region: 2 State: VA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: CHERYL GOFF
HQ OPS Officer: JOHN KNOKE
Region: 2 State: VA
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
NRC Notified By: CHERYL GOFF
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/22/2008
Notification Time: 13:35 [ET]
Event Date: 10/22/2008
Event Time: 12:17 [EDT]
Last Update Date: 10/22/2008
Notification Time: 13:35 [ET]
Event Date: 10/22/2008
Event Time: 12:17 [EDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
10 CFR Section:
PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL
Person (Organization):
ALAN BLAMEY (R2)
EUGENE PETERS (NMSS)
FUELS OUO
ALAN BLAMEY (R2)
EUGENE PETERS (NMSS)
FUELS OUO
CONCURRENT REPORT CONCERNING NRC NEWS RELEASE
"In response to media inquiries concerning the NRC's news release involving a notice of violation and proposed civil penalty, Babcock & Wilcox Company responded for BWXT with the attached information to media representatives from Lynchburg News & Advance and the Associated Press out of West Virginia. As requested the NRC news release is also attached.
"B&W Response to NRC's Notice of Violation: The incident occurred when an operator responded to a spill of hydrofluoric acid using an incorrect neutralizing chemical. As a result, the operator incurred an injury to his eyes.
"As noted in the Nuclear Regulatory Commission's (NRC) Notice of Violation, the actions of the employee, his coworkers and our onsite emergency team after the hydrofluoric acid exposure occurred ensured that the employee was not seriously injured as a result of this incident. This fact is confirmed by the statements of four independent medical opinions; one of these physicians was independently contracted by the NRC.
"The company [BWXT] acknowledges that this incident identified weaknesses in our spill response procedures and chemical labeling practices. Corrective actions have been developed to address these weaknesses. The company will submit a written response to the NRC within 30 days."
The licensee will be notifying the NRC Resident Inspector.
"In response to media inquiries concerning the NRC's news release involving a notice of violation and proposed civil penalty, Babcock & Wilcox Company responded for BWXT with the attached information to media representatives from Lynchburg News & Advance and the Associated Press out of West Virginia. As requested the NRC news release is also attached.
"B&W Response to NRC's Notice of Violation: The incident occurred when an operator responded to a spill of hydrofluoric acid using an incorrect neutralizing chemical. As a result, the operator incurred an injury to his eyes.
"As noted in the Nuclear Regulatory Commission's (NRC) Notice of Violation, the actions of the employee, his coworkers and our onsite emergency team after the hydrofluoric acid exposure occurred ensured that the employee was not seriously injured as a result of this incident. This fact is confirmed by the statements of four independent medical opinions; one of these physicians was independently contracted by the NRC.
"The company [BWXT] acknowledges that this incident identified weaknesses in our spill response procedures and chemical labeling practices. Corrective actions have been developed to address these weaknesses. The company will submit a written response to the NRC within 30 days."
The licensee will be notifying the NRC Resident Inspector.
General Information or Other
Event Number: 44591
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ACUREN INSPECTIONS
Region: 4
City: EATON State: CO
County:
License #: RML-997-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: JOHN KNOKE
Licensee: ACUREN INSPECTIONS
Region: 4
City: EATON State: CO
County:
License #: RML-997-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/22/2008
Notification Time: 14:57 [ET]
Event Date: 10/22/2008
Event Time: 12:40 [MDT]
Last Update Date: 10/22/2008
Notification Time: 14:57 [ET]
Event Date: 10/22/2008
Event Time: 12:40 [MDT]
Last Update Date: 10/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICK DEESE (R4)
MICHELE BURGESS (FSME)
RICK DEESE (R4)
MICHELE BURGESS (FSME)
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION
The state faxed the following report
"We [state] received a phone call today from the RSO of Acuren Inspections (RML- 997-01). On October 21, 2008, a two-man crew was making radiography shots at a field location near the intersection of County Roads 59 and 70, east of Eaton, CO.
"The incident involved an Amersham 660 camera, with an Ir-192 source with an estimated 24 Ci of activity.
"While making a shot, the pipe fell and resulted in a kink in the guide tube that prevented the source from being retracted. The crew cranked the source back into the collimator and called the RSO, who responded. Upon arrival, the RSO placed bags of shot over the collimator and used pliers to straighten the guide tube and safely retract the source into the camera. The RSO received a dose of zero mrem. The radiographer had a total dose for the day of 20 mrem, and the assistant had a total dose for the day of 68 mrem.
"A written report is being prepared by the licensee and will be forthcoming."
Incident Report I08-019
The state faxed the following report
"We [state] received a phone call today from the RSO of Acuren Inspections (RML- 997-01). On October 21, 2008, a two-man crew was making radiography shots at a field location near the intersection of County Roads 59 and 70, east of Eaton, CO.
"The incident involved an Amersham 660 camera, with an Ir-192 source with an estimated 24 Ci of activity.
"While making a shot, the pipe fell and resulted in a kink in the guide tube that prevented the source from being retracted. The crew cranked the source back into the collimator and called the RSO, who responded. Upon arrival, the RSO placed bags of shot over the collimator and used pliers to straighten the guide tube and safely retract the source into the camera. The RSO received a dose of zero mrem. The radiographer had a total dose for the day of 20 mrem, and the assistant had a total dose for the day of 68 mrem.
"A written report is being prepared by the licensee and will be forthcoming."
Incident Report I08-019