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Event Notification Report for May 28, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/27/2009 - 05/28/2009

** EVENT NUMBERS **


45089 45091 45097

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 45089
Rep Org: ST. JOHNS MERCY MEDICAL CENTER
Licensee: ST. JOHNS MERCY MEDICAL CENTER
Region: 3
City: ST. LOUIS State: MO
County: ST. LOUIS
License #: 24-0079403
Agreement: N
Docket:
NRC Notified By: ROBERT TURCO
HQ OPS Officer: VINCE KLCO
Notification Date: 05/22/2009
Notification Time: 09:51 [ET]
Event Date: 05/21/2009
Event Time: 15:30 [CDT]
Last Update Date: 05/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT INVOLVING A DOSE THAT IS DIFFERENT THAN PRESCRIBED

The patient was undergoing brachytherapy treatment of the prostate. After 6 seeds were implanted, the procedure was aborted because of concerns in placing additional needles into the patient. The prescribed dose was 145 Gy. However, only 6 of 88 prescribed seeds were implanted. Each seed total activity is 0.288 mCi of I-125.

Family members were notified of the aborted procedure.

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.

* * * UPDATE FROM ROBERT TURCO TO JOHN KNOKE AT 1643 EDT ON 5/22/09 * * *

This event is being retracted because the physician made a choice to terminate the brachytherapy treatment of the prostate to the patient. The physician then rewrote the procedure to the patient to limit the prescribed number of seeds to 6. Having 6 seeds implanted into the patient the prescribed dose was now met under the new directive.

Notified R3DO (Richard Skokowski) , FSME(Lydia Chang)

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General Information or Other Event Number: 45091
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: DOW CHEMICAL COMPANY
Region: 4
City: FREEPORT State: TX
County:
License #: 00451
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/22/2009
Notification Time: 13:30 [ET]
Event Date: 05/20/2009
Event Time: [CDT]
Last Update Date: 05/22/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4DO)

Event Text

AGREEMENT STATE REPORT - SHUTTER ON GAUGE INOPERATIVE

"On March 21, 2009, at 1050 AM, the Agency [Texas Department of Health] received a report from the licensee that while performing the biannual test on a Ronan Engineering nuclear gauge, model # SA-1, containing an original activity of 100 millicuries (calculated current activity of 75 millicuries) of Cesium (Cs) - 137, the shutter failed to close. The gauge is installed on the side of a vessel approximately 50 feet above ground and is used for level detection. A dose rate measurement taken at the gauge indicated 0.03 millirem per hour, and poses no risk of radiation exposure to their workers. The manufacturer has been contacted to provide corrective maintenance on the shutter."

Texas Incident # I-8635I

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Power Reactor Event Number: 45097
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRUCE BUCH
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/27/2009
Notification Time: 22:12 [ET]
Event Date: 05/27/2009
Event Time: 19:04 [EDT]
Last Update Date: 05/27/2009
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):
GEORGE HOPPER (R2DO)

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

Event Text

REACTOR TRIP FROM POWER RANGE HIGH NEUTRON FLUX RATE

"At approximately 1904 on 05/27/09, Sequoyah Unit 2 received an Automatic Reactor trip on Power Range High Neutron Rate Reactor Trip. The automatic trip occurred during severe weather and lightning onsite. ESF functions initiated as designed including Aux Feed Water auto-start and automatic Feedwater isolation. All control rods fully inserted. The plant is currently being maintained in Mode 3 at approximately 547 degrees F 2235 PSIG. Decay heat is being removed by the Auxiliary Feedwater system and Steam Dump valves.

"The cause of the Power Range Neutron Flux High Rate Reactor Trip is not known at this time and investigation is ongoing.

"Unit 1 remains at 100% power".

No relief or safety valves lifted. The electrical lineup is normal and the 2B Diesel Generator is tagged out for maintenance.

The licensee has contacted the NRC Resident Inspector.

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Thursday, March 29, 2012