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Event Notification Report for December 17, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/16/2009 - 12/17/2009

** EVENT NUMBERS **


45563 45566 45570 45574 45575 45576 45577

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General Information or Other Event Number: 45563
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GRAND VIEW HOSPITAL
Region: 1
City: SELLERSVILLE State: PA
County: BUCKS
License #: PA-0220
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/11/2009
Notification Time: 18:40 [ET]
Event Date: 12/11/2009
Event Time: [EST]
Last Update Date: 12/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"Medi-Physics [PA license PA-0515] prepared a 30 ml kit of Myoview at approximately 2:30 a.m. on December 11, 2009. The radiochemical purity was determined to be 91%. They consider 90% on the center as passing.

"On December 11, 2009, Grand View Hospital reported a problem with a nuclear medicine scan. Medi-Physics confirmed with BRP [Pennsylvania Bureau of Radiation Protection] that they dispensed 50 doses from the vial of Myoview in question. They believed 13 of these doses were administered to patients in PA and NJ. They thought the doses that were administered were resting doses of 8 to 10 mCi each. They assured BRP that they have a system in place to track their doses and contacted all the recipients once they were notified of the problem.

"Initially, Grand View, one of the hospitals that received a Myoview dose, called Medi-Physics to advise them they saw thyroid and no cardiac uptake in a patient they injected with Myoview. This suggests free 99mTC04. Therefore, at approximately 8:30 a.m., they repeated [the quality check] on the Myoview left in the vial and determined the tag was less than 1%. Medi-Physics is still investigating the problem and will send the vial to the United Kingdom for chemical analysis once it is no longer radioactive. BRP feels this is an [abnormal occurrence] because there was (fundamentally) the wrong radiopharmaceutical given to a patient.

"BRP has been in contact with all parties, will continue to investigate and enter in NMED."

PA Report ID No.: PA090035

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: 45566
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: MCLEOD REGIONAL MEDICAL CENTER
Region: 1
City: FLORENCE State: SC
County:
License #: 139
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/14/2009
Notification Time: 01:40 [ET]
Event Date: 12/09/2009
Event Time: [EST]
Last Update Date: 12/14/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
REBECCA NEASE (R2DO)
CHRISTIAN EINBERG (FSME)
SAM COLLINS (R1)
DONNA JANDA (R1)
JOHN KINNEMAN (R1)
DIANE SCRENCI (R1PA)
ROBERT LEWIS (FSME)
CHARLES MILLER (FSME)
JOE DECICCO (FSME)

Event Text

AGREEMENT STATE REPORT - Cs-137 BRACHYTHERAPY SOURCE LEAKING

The following information was communicated to the NRC via a telephone notification on December 14, 2009:

On Wednesday, December 9, 2009, Bionomics personnel were at McLeod Regional Medical Center in Florence, SC to package several old sources for disposal. These packages remained at McLeod until the following day when Bionomics personnel picked them up for transport to the Bionomics facility in Oak Ridge, TN.

On Friday, December 11, 2009, a Bionomics worker reported that he had radioactive contamination on his clothing. On Sunday, December 13, 2009 it was ascertained that this radioactive contamination had come from the sources picked up at McLeod. A brachytherapy source containing 38 mCi of Cs-137 was found to be leaking. Bionomics contacted an HP consultant from the University of SC to have him perform radiation surveys at the McLeod facility. Radiation surveys found contamination in treatment areas, supply rooms, offices, and hallways. Highest contact readings were localized and were approximately 100 mR/hr. At this time it is believed that no radioactive contamination had been tracked outside of the McLeod facility.

The McLeod Radiation Safety Officer has surveyed all staff personnel - except for two individuals - that had been in the contaminated areas. No radioactive contamination was found on any of these individuals. The other two individuals will be surveyed today, Monday, December 14, 2009.

Bionomics personnel are presently on-site at the McLeod Medical Center performing decontamination. The Medical Center has closed the area to personnel and patients until decontamination is completed.

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General Information or Other Event Number: 45570
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BECTON DICKINSON INFUSION THERAPY SYS
Region: 4
City: BROKEN ARROW State: NE
County:
License #: 04-01-01
Agreement: Y
Docket:
NRC Notified By: JIM DEFRAIN
HQ OPS Officer: VINCE KLCO
Notification Date: 12/15/2009
Notification Time: 16:45 [ET]
Event Date: 12/14/2009
Event Time: 19:00 [CST]
Last Update Date: 12/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
REBECCA TADESSE (FSME)

Event Text

AGREEMENT STATE REPORT - IRRADIATOR SAFETY INTERLOCKS BYPASSED

While engaged in production, the irradiator source was brought down due to an electrical fault. To verify the source was in the shielded position, an operator was sent to the roof and verified that there was no slack in the cables and the position of the cables indicated the source as in the shielded position. The interlocks were bypassed and an operator entered the cell. A damaged wire was discovered and repaired. Operators did not receive any radiation dose from this event.

Previously, a flex conduit was discovered with damaged insulation that had caused a short (Ref: EN # 45486).

* * * UPDATE ON 12/16/09 AT 1724 FROM TRUDY HILL TO MARK ABRAMOVITZ * * *

The Nebraska item number for this event is NE090018.

Notified the R4DO (Whitten).

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General Information or Other Event Number: 45574
Rep Org: HYDROAIRE
Licensee: HYDROAIRE
Region: 3
City: CHICAGO State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SESHA GIRI
HQ OPS Officer: VINCE KLCO
Notification Date: 12/16/2009
Notification Time: 17:11 [ET]
Event Date: 09/29/2009
Event Time: 09:02 [CST]
Last Update Date: 12/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
TAMARA BLOOMER (R3DO)
PART 21 COORDINATOR (NRR)
RICHARD BARKLEY (R1DO)

Event Text

PART 21 INVOLVING A PUMP SHAFT COUPLING FAILURE

A service water pump failed during operation on 9/29/2009. Upon disassembly it was detected that a shaft coupling installed on a repaired service water pump failed while in service. The failed coupling was replaced with a new coupling of a different heat code. According to the manufacturer, the threaded coupling design was only supplied for Palisades.

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Power Reactor Event Number: 45575
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: FARA ORESHACK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/16/2009
Notification Time: 17:30 [ET]
Event Date: 12/16/2009
Event Time: 06:11 [MST]
Last Update Date: 12/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JACK WHITTEN (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
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - NON-LICENSED SUPERVISOR

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

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45576
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: FARA ORESHACK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/16/2009
Notification Time: 17:30 [ET]
Event Date: 12/16/2009
Event Time: 10:39 [MST]
Last Update Date: 12/16/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JACK WHITTEN (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
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY - LICENSED OPERATOR

A licensed operator supervisor had a confirmed positive for alcohol during a "for cause" test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 45577
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JASON WEATHERSBY
HQ OPS Officer: KARL DIEDERICH
Notification Date: 12/16/2009
Notification Time: 17:30 [ET]
Event Date: 12/16/2009
Event Time: 14:15 [EST]
Last Update Date: 12/16/2009
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):
CHARLIE PAYNE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 45 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP FOLLOWING A FAILURE OF THE STEAM DUMP SYSTEM

"VC Summer Nuclear Station (VCSNS) was performing a preplanned turbine shutdown in order to perform maintenance on a faulty turbine control valve. After the manual turbine trip, the steam dump system failed to operate and the crew manually tripped the reactor. The cause of the failure of the steam dump system is unknown, and is currently being investigated. Both motor driven Emergency Feedwater pumps were manually started at 40% Steam Generator Level. Preliminary review indicates all other primary and secondary systems responded as required. The plant is in mode 3 at normal RCS [Reactor Coolant System] pressure and temperature. Decay heat is being removed by dumping steam via the secondary [steam generator] power operated relief valves. The station will remain in mode 3 until repairs are complete. Estimated restart date has not been determined."

All rods fully inserted. There is no known primary to secondary leakage. Off site power supply configuration is normal. The turbine trip was performed at 45% power due to a stuck open turbine control valve.

The licensee has notified the NRC Resident Inspector and will notify state and local contacts.

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