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Event Notification Report for September 24, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/23/2009 - 09/24/2009

** EVENT NUMBERS **


45355 45363 45365 45380

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General Information or Other Event Number: 45355
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: GREENVILLE MEMORIAL HOSPITAL
Region: 1
City: GREENVILLE State: SC
County:
License #: 257
Agreement: Y
Docket:
NRC Notified By: MELINDA BRADSHAW
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/17/2009
Notification Time: 12:11 [ET]
Event Date: 09/15/2009
Event Time: [EDT]
Last Update Date: 09/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT GIVEN WRONG DOSE

The following information was faxed in by the State:

"The South Carolina Department of Health and Environmental Control was notified on September 17, 2009, by the licensee, that a medical event occurred. A patient who was scheduled for a Yttrium-90 Microsphere therapy was given the wrong dose. The patient was scheduled for 25.38 millicuries but was administered 45.9 millicuries according to the initial report by the licensee.

"The event took place on the 15th and was verified by the licensee on the 17th of September. The referring physician has been notified as well as the patient. The licensee knew no additional details at this point. The licensee will provide additional information in a written report within 15 days. Updates to this event will be made through the NMED system as further information is received."


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: 45363
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CARDINAL HEALTH
Region: 1
City: BELTSVILLE State: MD
County:
License #: 33-198-01
Agreement: Y
Docket:
NRC Notified By: AL JACOBSON
HQ OPS Officer: JASON KOZAL
Notification Date: 09/19/2009
Notification Time: 09:49 [ET]
Event Date: 07/21/2009
Event Time: [EDT]
Last Update Date: 09/19/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
JACK FOSTER (FSME)

Event Text

AGREEMENT STATE - POTENTIAL EXTREMITY OVEREXPOSURE

A licensee radio-pharmacist was preparing Flourine-18 (F-18) doses for use, when a manipulator malfunction occurred. The radio-pharmacist continued to prepare the F-18 manually instead of securing the process. This led to a potential dose to the radio-pharmacist's right hand of greater than 50 rem. This dose is a rough estimate from whole body dose values and reconstruction of the event due to the fact the radio-pharmacist was not wearing any dosimetry on the extremity.

The State will continue to investigate this event and provide additional information as it become available.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 45365
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: JOE BARLETTO
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/19/2009
Notification Time: 21:04 [ET]
Event Date: 09/19/2009
Event Time: 13:23 [CDT]
Last Update Date: 09/23/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
BRIAN BONSER (R2DO)

Event Text

HIGH VOLTAGE PROCESS GAS LEAK DETECTOR RENDERED INOPERABLE

"At 1323 CST, on 09-19-09 the Plant Shift Superintendent (PSS) was notified that C-315 (Tails Withdrawal facility) High Voltage Process Gas Leak Detector (PGLD) YE-10-2-6 was rendered inoperable during asbestos abatement activities. This PGLD system contains detectors that cover the C-315 UF6 condensers, accumulators, and piping heated housing. At the time of this failure, these areas were operating above atmospheric pressure. TSR 2.3.4.4 requires that all detector heads in this system be operable during operations above atmospheric pressure. This PGLD System was declared operable and returned to service at 1359 hours, which is within the one hour required by TSR LCO 2.3.4.4.A.1 to enter a continuous smoke watch. This event is reportable as a 24 hour event in accordance with 10 CFR 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 reason for the failure was identified, the detector was repaired, the C-315 High Voltage PGLD system was tested and declared operable.

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

PGDP Assessment and Tracking Report No. ATR-09-2284
PGDP Event Report No. PAD-2009-15

* * * RETRACTION FROM DERRICK WARFORD TO DONG PARK ON 9/23/2009 AT 1553 EDT * * *

"After review, it was determined that a redundant operable PGLD detector was available to perform the intended safety function. Therefore according to 10CFR76.120, this event is not reportable. The NRC Resident Inspector has been notified of this retraction. "

Notified the R2DO (Rudisail) and NMSS (Waters).

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Power Reactor Event Number: 45380
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MICHAEL BRANSCUM
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/24/2009
Notification Time: 03:45 [ET]
Event Date: 09/24/2009
Event Time: 01:30 [CDT]
Last Update Date: 09/24/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GREG WERNER (R4DO)

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

Event Text

OFFSITE NOTIFICATION OF INADVERTENT SIREN SOUNDING

"At time 0130 CDT the Louisiana Governor's Office of Homeland Security and Emergency Preparedness was notified of an inadvertent sounding of one siren (WF39) at River Bend Station. The Louisiana Governor's Office of Homeland Security and Emergency Preparedness initiated their procedure for inadvertent siren sounding which includes a broadcast of an EAS [Emergency Alert System] message of the inadvertent sounding. West Feliciana Parish Sheriff Office 911 center was also contacted."

The cause of the siren actuation is under investigation and the siren has been disabled until the problem is identified and repaired. The licensee has notified State and local authorities and the NRC Resident Inspector.

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