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Event Notification Report for July 9, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/08/2009 - 07/09/2009

** EVENT NUMBERS **


45182 45184 45187 45189 45190 45191

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General Information or Other Event Number: 45182
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CHESTER COUNTY HOSPITAL
Region: 1
City: WEST CHESTER State: PA
County: CHESTER
License #: PA-0071
Agreement: Y
Docket:
NRC Notified By: DAVE ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/02/2009
Notification Time: 23:28 [ET]
Event Date: 05/13/2009
Event Time: [EDT]
Last Update Date: 07/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - FETAL EXPOSURE FROM RADIOIODINE THERAPY

The following report was received via facsimile:

"Patient was administered 54.1 mCi of I-131 on 3/30/2009. Patient had a false negative pregnancy test on 3/30/2009. Patient found out on May 13, 2009 that she was 9.5 weeks pregnant. Therefore, the therapy dose was given 5 days post-conception. Dose Eq to embryo/fetus = 11.9cGy. Dose Eq to fetal thyroid = 0.97cGy

"PA DEP Bureau of Radiation Protection was notified in writing, dated May 22, 2009, [from] the Radiation Safety Officer.

"The State has an inspection scheduled sometime in the future and will continue to keep NRC informed of the status of our investigation."

PA event: PA090024

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Hospital Event Number: 45184
Rep Org: GAMMA KNIFE CENTER OF THE PACIFIC
Licensee: GAMMA KNIFE CENTER OF THE PACIFIC
Region: 4
City: HONOLULU State: HI
County:
License #: 53-1196602
Agreement: N
Docket:
NRC Notified By: RONALD FRICK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/03/2009
Notification Time: 18:42 [ET]
Event Date: 07/02/2009
Event Time: 14:00 [HST]
Last Update Date: 07/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
GREG PICK (R4DO)
DUNCAN WHITE (FSME)

Event Text

MEDICAL EVENT - GAMMA KNIFE MISADMINISTRATION

A gamma knife treatment was prescribed for a patient being treated for multiple brain metastatic sites using an 8 mm collimator. The prescribed dose was 24 gray. The treatment was prescribed for 7 discrete sites in the brain. After the second discrete site had been treated it was found that an 18 mm collimator was being used to administer the treatment instead of the prescribed 8mm collimator.

After discovery, the collimator was changed to the 8 mm collimator. Treatment to the remaining 5 discrete sites was administered with the 8 mm collimator.

Both the patient and the patient's physician were notified of the use of the wrong collimator. The licensee states that there should be no clinical effects to the patient as a result of this misadministration.

The previous patient had been treated using the 18 mm collimator as the prescribed collimator.

Investigation into this event is continuing and a written report will follow.

In an effort to prevent recurrence, the licensee will send a notice to all authorized users, neurosurgeons and medical physicists that they should each independently check collimator size before each treatment is started.

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.

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General Information or Other Event Number: 45187
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: PERKINELMER
Region: 1
City: BOSTON State: MA
County:
License #: 00-3200
Agreement: Y
Docket:
NRC Notified By: BRUCE PACKARD
HQ OPS Officer: JOE O'HARA
Notification Date: 07/06/2009
Notification Time: 16:55 [ET]
Event Date: 07/01/2009
Event Time: [EDT]
Last Update Date: 07/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
DUNCAN WHITE (FSME)
ILTAB VIA EMAIL ()

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

Event Text

LOST SHIPMENT OF YTTRIUM Y-90

The following was provided from the Commonwealth of Massachusetts via fax:

"Shipment [was] made [by common carrier] from North Billerica to Stanford Medical Center, Palo Alto, CA on 6/23/09. The quantity was 10 milliCuries of Y-90. The package was reported missing as of July 1, 2009."

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

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General Information or Other Event Number: 45189
Rep Org: NEXTERA ENERGY DUANE ARNOLD
Licensee: FLOWSERVE US, INC
Region: 3
City: CEDAR RAPIDS State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB MURRELL
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/08/2009
Notification Time: 13:10 [ET]
Event Date: 05/10/2009
Event Time: [CDT]
Last Update Date: 07/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVE PASSEHL (R3DO)
PART 21 GROUP EMAIL ()
FRED BROWN EMAIL (NRR)

Event Text

PART 21 - SAFETY RELATED CONTROL VALVE SPRING ACTUATOR SIZED INCORRECTLY

"NextEra Energy Duane Arnold (NextEra Energy) makes the following notification under 10 CFR 21.21(d)(3)(i) of a failure to comply found during surveillance testing. The specific issue is insufficient clearance between the spring and the inside of the cylinder of the actuator for a Miller series A63B2N air cylinder actuator for a control valve (CV-1956A, Control Building Chiller Discharge to Emergency Service Water Isolation). The resulting improper clearance caused an increase in running load, which caused the valve to become stuck in the closed position. The valve failure was discovered on May 10, 2009. The control valve actuator was supplied by Flowserve US, Inc, as a basic component in April, 2008 for use at the Duane Arnold Energy Center. Flowserve has indicated that the actuator was procured as a commercial grade item and dedicated for safety related installation under their QA program. The valve and actuator were installed on April 17, 2009.

"The lack of spring to actuator clearance resulted in a loss of capability of CV-1956A to perform its intended safety function of providing a safety related seismic discharge path for cooling water from the safety related Control Building Chiller, 1V-CH-1A. The Chiller was declared inoperable as a result of this failure to comply and, on July 1, 2009 was determined to have resulted in a substantial safety hazard.

"The actuator for CV-1956A was rebuilt with a replacement spring having proper dimensional clearance and higher opening force capability. The actuator has been installed by a plant modification and the control building chiller has been returned to an operable status.

"The air operated valve assembly supplier, Flowserve US Inc, was contacted on July 1, 2009 to discuss NextEra Energy's findings.

"NextEra Energy has verified that no other safety related actuators with the incorrect valve actuator cylinder to spring clearances have been installed at the Duane Arnold Energy Center."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 45190
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOEL LEVINER
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/08/2009
Notification Time: 16:05 [ET]
Event Date: 07/08/2009
Event Time: 10:13 [EDT]
Last Update Date: 07/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
REBECCA NEASE (R2DO)

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

VALID EMERGENCY DIESEL GENERATOR ACTUATION

"On July 8, 2009, at 1013 hours, during planned maintenance activities, electrical power was lost to the 4160V emergency bus E-2. The power loss to emergency bus E-2 affected both Unit 1 and 2. Emergency diesel generator #2 automatically started and re-energized the E-2 bus.

"The loss of power to E2 resulted in Unit 1 Primary Containment Isolation System (PCIS) Group 2 (i.e., Drywell Equipment and Floor Drain, Residual Heat Removal (RHR) Discharge to Radwaste, and RHR Process Sample), Group 3 (i.e., Reactor Water Cleanup), Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems), and Group 10 (i.e., air isolation to the drywell) isolations. The actuations of PCIVs were completed and the affected equipment responded as designed. Per design, no Unit 2 safety system group isolations or actuations occurred.

"Other Unit 1 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start of Standby Gas Treatment (SGT) System trains A and B and the Control Room Emergency Ventilation System (CREV). Systems functioned as designed.

"Safety systems functioned as designed following the de-energization of bus E-2. The safety significance of this event is minimal. Plant systems responded as designed. The cause of the event is under investigation.

"Reporting requirements met by this notification: 10 CFR 50.72(b)(3)(iv)(A). The NRC Resident Inspector has been notified."

Licensee was conducting maintenance on the switchgear at the time of the loss of power.

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Power Reactor Event Number: 45191
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE CHRISTOPHER
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/08/2009
Notification Time: 23:25 [ET]
Event Date: 07/08/2009
Event Time: 22:45 [EDT]
Last Update Date: 07/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
REBECCA NEASE (R2DO)
BRIAN HOLIAN (NRR)
ANTHONY McMURTRAY (IRD)

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

OFFSITE NOTIFICATION - OSHA CONTACTED DUE TO ON-SITE FATALITY

"A non-contaminated individual was transported by ambulance from the Catawba Nuclear Station parking lot to a local hospital due to a personal illness. The individual was pronounced dead at the hospital. Catawba Nuclear Station is notifying [Occupation Safety Health Administration] OSHA of an on-site fatality."

Licensee has notified the NRC Resident Inspector.

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