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Event Notification Report for December 9, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/08/2009 - 12/09/2009

** EVENT NUMBERS **


45401 45538 45539 45540 45548 45549 45550

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 45401
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ONCOLOGY HEMATOLOGY CONSULTANTS PA
Region: 4
City: FORT WORTH State: TX
County:
License #: 05919
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/01/2009
Notification Time: 18:11 [ET]
Event Date: 10/01/2009
Event Time: [CDT]
Last Update Date: 12/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
TERRENCE REIS (FSME)

Event Text

AGREEMENT STATE - ADMINISTERED RADIATION TREATMENT TO WRONG AREA

The following was received via email:

"On October 1, 2009, the Agency was notified by the licensee that a patient had received 13 of 25 fractions to the wrong breast. The patient received 2,340 centigrays by the time the error was discovered. The Radiation Safety Officer stated that he had just fount out about the event and no additional information was available. Additional information will be provided as it is obtained."

Texas Incident #: I-8676

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.

* * * RETRACTION FROM ART TUCKER TO DAN LIVERMORE ON 12/08/2009 AT 1705 * * *

The following was received via email:

"This event involved an exposure to a patient from a linear accelerator and should not have been reported to the NRC; therefore, the Agency [Texas Department of Health] is retracting this report."

Notified R4DO (Spitzberg) and FSME EO (Einberg)

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General Information or Other Event Number: 45538
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY
Region: 4
City: BEBEE State: AR
County:
License #: ARK-1010-3320
Agreement: Y
Docket:
NRC Notified By: ROBERT PEMBERTON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/03/2009
Notification Time: 15:18 [ET]
Event Date: 06/16/2009
Event Time: [CST]
Last Update Date: 12/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
BILL VONTILL (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE FAILED TO FULLY RETRACT

The following report was provided by the Arkansas Department of Health via facsimile:

"On October 26, 2009, during a routine inspection of Desert Industrial X-Ray, ARK-1010-3320, in Beebe AR it was discovered that an INC IR-100 exposure device (SN#4520, Source Model#32, SN#N478, IR-192, 26 Ci) had failed to retract the source to the fully shielded position. The failure to retract had occurred on June 16, 2009. The Radiation Safety Officer for the location was properly trained and had to disassemble and clean the locking mechanism in order to retract the source to the fully shielded position. INC informed Desert Industrial X-Ray that this failure to retract occurs when the exposure devices are getting dirty. The licensee reports that there have been no further problems with this device. Desert Industrial X-Ray personnel reported no unusual survey readings, and no personnel exposures occurred during this incident.

"The Department [ Arkansas Department of Health] has concluded that the root cause of this incident is improper maintenance of the INC IR-100 exposure device. The licensee has implemented corrective action by introducing an enhanced maintenance program. The Department considers this incident to be closed."

See similar report EN#45539.

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General Information or Other Event Number: 45539
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: DESERT INDUSTRIAL X-RAY
Region: 4
City: BEEBE State: AR
County:
License #: ARK-1010-3320
Agreement: Y
Docket:
NRC Notified By: ROBERT PEMBERTON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/03/2009
Notification Time: 15:20 [ET]
Event Date: 05/15/2009
Event Time: [CST]
Last Update Date: 12/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
BILL VONTILL (FSME)

Event Text

AGREEMENT STATE REPORT- RADIOGRAPHY CAMERA SOURCE FAILED TO FULLY RETRACT

The following report was provided by the Arkansas Department of Health via facsimile:

"On October 26, 2009, during a routine inspection of Desert Industrial X-Ray, ARK-1010-3320, in Beebe AR it was discovered that an INC IR-100 exposure device (SN#4772, Source Model#32, SN#N475, Ir-192, 32 Ci) had failed to retract the source to the fully shielded position. The failure to retract had occurred on May 15, 2009. The Radiation Safety Officer for the location was properly trained and had to disassemble and clean the locking mechanism in order to retract the source to the fully shielded position. INC informed Desert Industrial X-Ray that this failure to retract occurs when the exposure devices are getting dirty. The licensee reports that corrective actions have been taken to that there have been no further problems with this device. Desert Industrial X-Ray personnel reported no unusual survey readings, and no personnel exposures occurred during this incident.

"The Department [Arkansas Department of Health] has concluded that the root cause of this incident is improper maintenance of the INC IR-100 exposure device. The licensee has implemented corrective action by introducing an enhanced maintenance program. The Department considers this incident to be closed."

See similar report EN#45538.

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General Information or Other Event Number: 45540
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: FOX CHASE CANCER CENTER
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0293
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: VINCE KLCO
Notification Date: 12/03/2009
Notification Time: 17:19 [ET]
Event Date: 09/02/2009
Event Time: [EST]
Last Update Date: 12/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
BILL VONTILL (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL DOSE DIFFERENT THAN PRESCRIBED

The following information was received via facsimile:

"This incident was reported to the DEP [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] Eastern Regional Office by the licensee via a phone call on September 3, 2009, but wasn't considered a ME [Medical Event] by DEP at the time. On September 2, 2009 a patient was prescribed a dose of 150 millicuries (mCi) of radioactive iodine-131 (I-131) for a therapeutic treatment of thyroid cancer. The nuclear medicine technologist took the 150 mCi dose to the patient's room in a lead container and made the appropriate tube connections. The connections were checked with water prior to administration of the I-131 and no leaks were present. The dose was administered. During the flushing process, the technologist noted some leakage of liquid on the absorbent material that was placed under the tubing. The syringe, tubing, and absorbent material were immediately removed and assayed in the dose calibrator. It was determined that 57.6% of the prescribed dose had been administered to the patient. A second written directive for an additional dose prescribed by the authorized user was delivered to provide assurance that the patient received the appropriate complete amount of radioactive iodine for treatment of the thyroid cancer.

"During an inspection of Fox Chase on December 1, 2009, this incident was reviewed by the DEP. At this point the licensee informed DEP that they considered this a ME, had notified the patient, thus, the reason for this fax ME notification to the NRC HOO [Headquarter Operation Officer] at this point in time. Additional details will be provided in the NMED report."

Pennsylvania Event Report: PA090034.

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: 45548
Rep Org: ENGINE SYSTEMS, INC.
Licensee: ENGINE SYSTEMS, INC.
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PAUL STEPANTSCHENKO
HQ OPS Officer: DAN LIVERMORE
Notification Date: 12/08/2009
Notification Time: 11:22 [ET]
Event Date: 12/08/2009
Event Time: [EST]
Last Update Date: 12/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
REBECCA NEASE (R2DO)
BLAIR SPITZBERG (R4DO)
PART 21 COORDINATOR (NRR)

Event Text

WOODWARD GOVERNOR SERVO FAILURE DUE TO SILVER SULFIDE CORROSION OF SURFACE MOUNT RESISTORS

"Woodward failure analysis report #85572-R001, dated 10/9/09, addressed two separate [model] PGPL remote servo failures. The failure analysis report discusses a silver sulfide corrosion issue with surface mount resistors used in the PGPL remote servo feedback transmitter circuitry. Woodward part number 9903-539 consists of a PGPL actuator and a remote servo. The PGPL actuator is mounted on the turbine's governor drive and the remote servo (Woodward part number 5296-044) is mounted at the steam valve. Hydraulic lines interconnect the PGPL to the remote servo. The PGPL actuator and remote servo was supplied by Engine Systems, Inc. (ESI) to the Callaway and Vogtle nuclear plants as part of a digital governor upgrade (Woodward 505 control) on their steam turbine generators. These are the only nuclear plants that use the P/N 9903-539 actuator remote servo assembly.

"LISTING OF WOODWARD PIN 9903-539 PGPL ACTUATORS WITH SUSPECT RESISTORS

"Serial Number Born Date Shipped to
12369963 Nov 2000 Callaway
13305595 July 2002 Callaway
13798414 May 2004 Vogtle
13798415 May 2004 Callaway
14141720 Feb 2005 Vogtle
14409400 Sep 2005 Vogtle

"Note: Serial numbers 12369963 and 13798414 recently had the feedback board replaced during the failure analysis; these require no further corrective action."

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Power Reactor Event Number: 45549
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: GREG HUDNALL
HQ OPS Officer: DAN LIVERMORE
Notification Date: 12/08/2009
Notification Time: 12:19 [ET]
Event Date: 12/08/2009
Event Time: 08:42 [CST]
Last Update Date: 12/08/2009
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):
BLAIR SPITZBERG (R4DO)

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

Event Text

MANUAL REACTOR TRIP DUE TO LOW STEAM GENERATOR LEVEL CAUSED BY LOSS OF MAIN FEED WATER PUMP

"Arkansas Nuclear One - Unit 2 experienced a high temperature on the 'A' Main Feedwater Pump thrust bearing which required the pump to be manually tripped . Steam Generator levels lowered as a result of the Main Feedwater Pump trip to the point that operators initiated a manual reactor trip. The Emergency Feedwater System automatically actuated on low Steam Generator level as a result of the Steam Generator level transient.

"The manual reactor trip requires 4-Hr non-emergency notification IAW 10CFR 50.72(b)(2)(iv)(B).

"The automatic actuation of Emergency Feedwater requires 8-Hr non-emergency notification IAW 10CFR 50.72(b)(3)(iv)(A)."

All rods fully inserted. After the trip, decay heat was being removed using steam dumps to the condenser. Steam generator level was being maintained with the emergency feedwater pumps.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 45550
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: FRANK WINTER
HQ OPS Officer: VINCE KLCO
Notification Date: 12/08/2009
Notification Time: 14:56 [ET]
Event Date: 12/08/2009
Event Time: 13:28 [CST]
Last Update Date: 12/08/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MONTE PHILLIPS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 83 Power Operation 83 Power Operation
3 N Y 99 Power Operation 99 Power Operation

Event Text

TECHNICAL SUPPORT CENTER OUT OF SERVICE FOR PLANNED PREVENTATIVE MAINTENANCE

"At 1328 [CST] on Tuesday, December 8, 2009, the Dresden Nuclear Power Station (DNPS) Technical Support Center (TSC) emergency ventilation system was removed from service for planned preventative maintenance activities on the damper flow controller and air filtration charcoal system. During the maintenance, the non-emergency ventilation system will be functional. The TSC air filtration fan and dampers will be non-functional, rendering the TSC HVAC accident mode non-functional. This maintenance is scheduled to minimize out of service time. The planned TSC ventilation outage is scheduled to be completed within 48 hours. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing EP [Emergency Planning] procedures and checklists. If radiological conditions require TSC facility evacuation during ventilation system restoration; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with, EP-AA-112-200-F-01."

The licensee notified the NRC Resident Inspector.

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