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Event Notification Report for September 1, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/31/2009 - 09/01/2009

** EVENT NUMBERS **


45291 45292 45293 45294 45295 45296 45301 45303 45311 45313 45314 45315
45316

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General Information or Other Event Number: 45291
Rep Org: LOUISIANA DEQ
Licensee: GE HEALTHCARE
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA-5470-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/25/2009
Notification Time: 10:57 [ET]
Event Date: 07/09/2009
Event Time: [CDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING RADIOPHARMACEUTICALS

The following report was received from the State of Louisiana via facsimile:

"On July 9, 2009, a facility reported a mislabeled unit dose from GE Healthcare nuclear pharmacy. Three 20 mCi unit doses of Tc-99m MDP (bone scans) were ordered by Ochsner [a medical facility]. Two patients were injected. After viewing the images, it was determined that the unit doses were mislabeled. An investigation of GE Healthcare was performed. A preliminary cause was determined to be a mix up of MDP cold vial with DTPA [renal scans] as they closely resemble each other with the same vial configuration and same color label. Contributing factors leading to the incident were Tc-99m/Mo-99 shortage, late arrival of generators, increased number of kits to prepare as a result of the shortage, and pharmacist working alone. Corrective actions involved reviewing procedures and discontinuing manual changes of inventory dispensed on prescription labels."

Louisiana incident number: LA090017

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: 45292
Rep Org: LOUISIANA DEQ
Licensee: CAMERON VALVE AND MEASUREMENTS
Region: 4
City: VILLE PLATTE State: LA
County:
License #: LA-7095-L01
Agreement: Y
Docket:
NRC Notified By: ANN TROXLER
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2009
Notification Time: 10:56 [ET]
Event Date: 07/28/2009
Event Time: [CDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE DISCONNECT OF RADIOGRAPHY CAMERA

The following is a summary of a fax received from the state of Louisiana:

At approximately 10:30 p.m. on the night of July 28, 2009, a radiographer failed to connect the source tube to the camera before he cranked out the source. The cable stop that is attached to the worm cable did not work properly. After dismantling the crankout assembly, the source was hand retrieved and placed back into the camera using the worm cable. A survey was taken to verify that the source was stored safely. The total time of retrieval was approximately 2 minutes.

No personnel were overexposed during this event.

Louisiana Report #: LA090016

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Hospital Event Number: 45293
Rep Org: HEARTS CLINICS NORTHWEST
Licensee: HEARTS CLINICS NORTHWEST
Region: 4
City: COUR D'ALENE State: ID
County:
License #: 46-27704-01
Agreement: N
Docket:
NRC Notified By: WAYNE WHITNEY
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/25/2009
Notification Time: 12:53 [ET]
Event Date: 08/24/2009
Event Time: 16:00 [MDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT - ACTUAL DOSE LESS THAN SCHEDULED DOSE

Two patients were scheduled for treatment using Tc-99m. One patient was scheduled to receive a dosage of 8 mCi and the other patient a 25 mCi dose of a different Tc-99m chemical make-up. However, the wrong patient was given the 8 mCi (versus the 25 mCi). Both the patient and physician were notified of the wrong dosage. The critical organ of concern is the upper intestine and the exposure is calculated to be 1.44 Rem which is below the administrative limit.

There is no expected medical effects to the patient.

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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Hospital Event Number: 45294
Rep Org: ALLEGIANCE HEALTH
Licensee: ALLEGIANCE HEALTH
Region: 3
City: JACKSON State: MI
County: JACKSON
License #: 21-00258-06
Agreement: N
Docket:
NRC Notified By: ANAS ORFALI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/25/2009
Notification Time: 14:50 [ET]
Event Date: 08/24/2009
Event Time: 13:47 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
GREG SUBER (FSME)

Event Text

MEDICAL EVENT - D90 DOSE LESS THAN PRESCRIBED DOSE

On April 16, 2009, a patient received a permanent prostate implant of I-125 seeds. On August 24, 2009, post-implant dosimetry analysis, performed multiple times using multiple modalities, determined the D90 dose was 76.3% of prescribed dose. The prescribed dose was 145 Gy using 0.679u/seed and 54 seeds.

The referring physician and patient have been notified.

The licensee is conducting an investigation and will be determining corrective actions.

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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Hospital Event Number: 45295
Rep Org: ALLEGIANCE HEALTH
Licensee: ALLEGIANCE HEALTH
Region: 3
City: JACKSON State: MI
County: JACKSON
License #: 21-00258-06
Agreement: N
Docket:
NRC Notified By: ANAS ORFALI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/25/2009
Notification Time: 14:50 [ET]
Event Date: 08/24/2009
Event Time: 13:47 [EDT]
Last Update Date: 08/25/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
STEVE ORTH (R3DO)
GREG SUBER (FSME)

Event Text

POTENTIAL MEDICAL EVENT - D90 DOSE LESS THAN PRESCRIBED DOSE

On April 16, 2009, a patient received a permanent prostate implant of I-125 seeds. On August 24, 2009, post-implant dosimetry analysis, performed multiple times using multiple modalities, determined the D90 dose was 46.8% of prescribed dose. The prescribed dose was 145 Gy using 0.577 u/seed and 57 seeds.

The referring physician and patient have been notified. The physician will be conducting a corrective implant.

The licensee is conducting an investigation and will be determining corrective actions.

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: 45296
Rep Org: GENERAL ATOMICS
Licensee: GENERAL ATOMICS
Region: 4
City: SAN DIEGO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEITH ASMUSSEN
HQ OPS Officer: VINCE KLCO
Notification Date: 08/25/2009
Notification Time: 15:17 [ET]
Event Date: 06/30/2009
Event Time: [PDT]
Last Update Date: 08/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN WHITE (R1DO)
SCOTT SHAEFFER (R2DO)
STEVE ORTH (R3DO)
GEOFFREY MILLER (R4DO)
OMID TABATABAI (NRO)
JOHN THORP (NRR)

Event Text

PART 21 - RADIATION MONITOR DEFECT

"The defect is contained in the General Atomics Electronic Systems, Inc (GA-ESI) radiation monitoring system model RM-80 firmware. The RM-80 firmware anomaly was initially identified at the St. Lucie Nuclear Power Plant. The radiation monitor was part of the control room outside air intake ventilation radiation monitors.

"More specifically, if the radiation monitor is already in a high and or alert alarm state, and subsequently suffers a loss of power, then upon restoration of power to the unit, the RM-80 high and or alert alarm relays are not reenergized by the RM-80 firmware. This in turn prevents the relays that are located in the [RM]-80 from performing their safety related function.

"This error in the firmware only affects those plant sites that connect annunciator panels or other safety related equipment to the RM-80 Alert and High Alarm relays.

"Plant sites that use RM-80 radiation monitors will be advised to test their systems for this anomaly. When so requested, GA-ESI will provide all necessary information to plants on how to test their RM-80 radiation monitors, and how to receive firmware upgrades if the condition is found during testing."

General Atomics will notify the following affected plants: Beaver Valley, Braidwood, Byron, Callaway, Indian Point 2 &3, Limerick, River Bend, Shearon Harris, South Texas, St. Lucie, Waterford, and Wolf Creek.


* * * UPDATE FROM KEITH E. ASMUSSEN TO C. TEAL AT 1900 ON 8/31/2009 * * *

"This notification is an update to a notification made on 1506 Hrs. EST on August 25, 2009 regarding the existence of a defect. This notification is being provided in compliance with the requirements of Title 10 Code of Federal Regulations Part 21.21.

"In the initial notification, under the section titled 'Locations affected by the reported condition,' General Atomics Electronic Systems, Inc. (GA-ESI) provided a table (Table1) that listed sites and corresponding firmware sets having safety related RM-80 software that had been found to contain the reported firmware anomaly. GA-ESI has now identified one additional firmware set that should be included in Table 1. The site is Braidwood and the firmware set is bhr165/01.

"Accordingly, Table 1 has been revised to include this firmware set for the Braidwood site. The revised Table 1 is attached to this update notification.

"Also, please note that earlier today, August 31, 2009, GA-ESI emailed a notification letter to its customer contact at the Braidwood site.

"All other information remains the same as was initially reported on August 25, 2009"

Notified R3DO (Lipa). Also notified NRR and NRO via email.

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General Information or Other Event Number: 45301
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: KAISER PERMANENTE
Region: 1
City: JONESBORO State: GA
County: CLAYTON
License #: GA1276-1
Agreement: Y
Docket:
NRC Notified By: ERIC JAMESON
HQ OPS Officer: DAN LIVERMORE
Notification Date: 08/26/2009
Notification Time: 16:00 [ET]
Event Date: 08/22/2009
Event Time: 07:30 [EDT]
Last Update Date: 08/26/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
LANCE ENGLISH (ILTA)
GREG SUBER (FSME)

Event Text

AGREEMENT STATE REPORT - EXTERIOR ACCESS DOOR TO RADIOLOGY LAB FOUND OPEN

While responding to an audible alarm, the Clayton County Police Department found an exterior door open to the Radiology Lab at the Kaiser Permanente Nuclear Medicine Clinic located in Jonesboro, Georgia. The Clayton County Police Department notified the Federal Bureau of Investigations and the Georgia Information Sharing and Analysis Center. The Georgia Information Sharing and Analysis Center then contacted the Georgia Radioactive Materials Program.

The licensee is authorized to possess diagnostic imaging isotopes. At this time, no information is available whether radiological material is missing, or if the open door was the cause of the alarm. The investigation is ongoing.

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General Information or Other Event Number: 45303
Rep Org: OHIO DEPARTMENT OF HEALTH
Licensee: MERIDIAN AUTOMOTIVE SYSTEMS, INC.
Region: 3
City: JACKSON State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/27/2009
Notification Time: 10:58 [ET]
Event Date: 08/25/2009
Event Time: [EDT]
Last Update Date: 08/27/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
ANGELA MCINTOSH (FSME)

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

Event Text

AGREEMENT STATE REPORT - DISCOVERY OF ABANDONED RADIOACTIVE SOURCE

The following information was received from the State of Ohio via e-mail:

"The Ohio Bureau of Radiation Protection was informed on 8/25/09 of the discovery of an abandoned radioactive source at the Meridian Automotive Systems, Inc. plant in Jackson, Ohio. Investigation on 8/26/09 revealed that the source is a 500 mCi Am-241/Be source in a generally licensed RMD Compuglass Analyzer. The EPA was notified and will pick up the source for disposal. The source is secure at the site."

Ohio reference number: Ohio 2009-025

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Power Reactor Event Number: 45311
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BEN HUFFMAN
HQ OPS Officer: ERIC SIMPSON
Notification Date: 08/31/2009
Notification Time: 08:00 [ET]
Event Date: 08/31/2009
Event Time: 07:21 [EDT]
Last Update Date: 08/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVE ORTH (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

TSC POTENTIALLY OUT OF SERVICE

"At 0721 on Monday, August 31, 2009, a portion of the Cook Nuclear Plant (CNP) Technical Support Center (TSC) ventilation system and Technical Support Center (TSC) air conditioning system was removed from service for maintenance on the electrical power supply Motor Control Center (MCC).

"The MCC being removed supports 3 of the 4 air conditioning units for the Technical Support Center, as well as the filtration system. The remaining air conditioning unit which is not supported by the MCC will remain in service.

"Under certain accident conditions the TSC may become unavailable due to the inability of the ventilation system to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary based upon results of procedurally required monitoring of TSC radiological conditions.

"The TSC ventilation system maintenance is scheduled to complete at 2100 on Monday, August 31, 2009. The licensee has notified the NRC Senior Resident Inspector. This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE AT 2147 EDT ON 8/31/09 FROM BRUCK TO HUFFMAN * * *

"The TSC ventilation system air conditioning was returned to functional status at 21:37 on Monday, August 31, 2009.

"This follow up notification is being made to provide closure from the initial notification under 10 CFR 50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

The licensee has notified the NRC Resident Inspector. R3DO (Lipa) notified.

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Power Reactor Event Number: 45313
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: PATRICK RYAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/31/2009
Notification Time: 14:51 [ET]
Event Date: 08/31/2009
Event Time: 09:44 [EDT]
Last Update Date: 08/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JAMES DWYER (R1DO)

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

FITNESS FOR DUTY - SUPERVISOR TESTED POSITIVE FOR ALCOHOL

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's unescorted access to the plant has been revoked. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45314
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ED BENDIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/31/2009
Notification Time: 16:04 [ET]
Event Date: 08/31/2009
Event Time: 09:45 [CDT]
Last Update Date: 08/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
CHRISTINE LIPA (R3DO)

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

FITNESS FOR DUTY - LICENSED EMPLOYEE CONFIRMED POSITIVE FOR ALCOHOL

A licensed employee had a confirmed positive for alcohol during a fitness-for-duty test. The employee's access to the plant has been suspended. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45315
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/31/2009
Notification Time: 18:03 [ET]
Event Date: 08/31/2009
Event Time: [CDT]
Last Update Date: 09/01/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

EMERGENCY SIRENS INOPERABLE

"At 1546 CDT the control room at the Fort Calhoun Power Station was notified that a siren test conducted at 1440 CDT had failed. At this time none of the station's emergency sirens are capable of being sounded. Utility personnel are troubleshooting the problem and expect to restore siren capability. Compensatory measures have been implemented. The NRC will be notified when siren capability has been restored."

Harrison and Pattawattamie counties in Iowa, and Washington county in Nebraska have been notified.

The NRC resident inspector has been notified.

* * * UPDATE ON 08/31/09 AT 2055 EDT FROM ALAN PALLAS TO HUFFMAN * * *

The licensee has reset a communications device that activates the sirens and restored operability to 38 out of the 103 total sirens around the site. To re-establish operability of the remaining sirens, the licensee will need to dispatch personnel to each siren to relink with the communications system. The time frame to complete this effort is estimated to be approximately 5 hours. The compensatory notification measures will remain in place until the sirens have been restored.

The licensee will notify the Resident Inspector of this updated information.

* * * UPDATE ON 09/01/09 AT 0236 EDT FROM ALAN PALLAS TO PARK * * *

The licensee has restored 101 of 103 total sirens to service. Two sirens that are not in service are currently not accessible. They will be automatically restored to service at approximately 0330 CDT and verified in the morning.

The licensee has notified the Resident Inspector of this updated information.

Notified R4DO (Farnholtz).

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Power Reactor Event Number: 45316
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: TERRY HOLCOMBE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/31/2009
Notification Time: 18:16 [ET]
Event Date: 08/31/2009
Event Time: 10:14 [CDT]
Last Update Date: 08/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

SECONDARY CONTAINMENT BOUNDARY DOOR INOPERABLE

"During normal entry / exit through secondary containment boundary door 1A401, it was discovered that the door would not latch closed due to interferences between the door and its frame. The door was unable to be latched closed for approximately 5 minutes which represented a possible path for uncontrolled release of radioactive material. No release of radioactive material occurred as a result of this event.

"The time during which the door would not latch was spent diligently troubleshooting to determine why the door would not secure. When discovered, the interference was immediately removed and the door was secured (latched). Door 1A401 is now operable as a secondary containment boundary but is currently deactivated and posted by security to prevent use as a conservative measure until further inspection and maintenance can be preformed on the door to prevent this issue from reoccurring.

"At this time secondary containment is operable with boundary door 1A401 closed and latched."

The licensee has notified the NRC Resident Inspector.

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