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Event Notification Report for January 7, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/06/2010 - 01/07/2010

** EVENT NUMBERS **


45602 45609 45612

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Other Nuclear Material Event Number: 45602
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: RICHARD L. ROUDEBUSH VA MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: THOMAS HUSTON
HQ OPS Officer: PETE SNYDER
Notification Date: 12/31/2009
Notification Time: 12:18 [ET]
Event Date: 12/30/2009
Event Time: [EST]
Last Update Date: 12/31/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHN GIESSNER (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

UNDERDOSE TO PATIENT

The Richard L. Roudebush VA Medical Center holds VHA Permit Number 13-00694-03 under the VA's Master Material License (NRC License Number 03-23853-01VA).

"For a patient treatment on December 30, 2009, involving Yttrium-90 microspheres, the medical center discovered (on same date) that the total activity delivered to the treatment site was less than 80% of the total activity documented in the written directive.

"The medical event was discovered when a waste container, which contained used catheters, lines, gloves, tongs, tape, etc., from the treatment were assayed. The waste materials indicated a higher than expected residual activity equal to about 25 percent of the activity that was in the source vial prior to treatment. Examination of the waste materials revealed that nearly all of the residual activity was distributed somewhat uniformly along the length of the approximately 100 cm microcatheter tubing.

"The current estimate is that about 47.03 millicuries were delivered to the patient, and 15.67 millicuries were in the wastes. The prescribed activity was 63.2 millicuries. Therefore, the patient was under-dosed by about 25.6%. Because this deviation exceeds 20%, a medical event is considered to have occurred per 10 CFR 35.3045(a)(1).

"Although a lower-than-intended activity was administered, the permittee estimates that the absorbed dose to the target organ was around 109 gray and was within the therapeutic target range of 100 to 150 gray. Therefore, no adverse biological effects to the patient are expected."

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.test

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Other Nuclear Material Event Number: 45609
Rep Org: KAKIVIK ASSET MANAGEMENT
Licensee: KAKIVIK ASSET MANAGEMENT
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: CHARLES TEAL
Notification Date: 01/06/2010
Notification Time: 11:41 [ET]
Event Date: 01/06/2010
Event Time: 01:50 [YST]
Last Update Date: 01/06/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MICHAEL SHANNON (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

FAILURE TO FULLY RETRACT THE SOURCE OF A RADIOGRAPHY CAMERA

"On January 6th a radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device.

"When returning the source (Ir-192, 108 curies) the locking bar deployed prematurely. The crew reset the locking bar and was able to return the source to the safe and secure position. The crew was working a remote location using a Tucker (tracked machine for traveling over snow) and called for the night foreman. They met at a drill site where the exposure device was reconnected to the drive cables. The source was extended and then retracted. It was noticed that on the return the crank assembly became hard to turn. After the locking bar tripped, the exposure device was surveyed with no noticeable indication that the source was not in the safe and secure position. When the crank assembly was disconnected it was noted that the pig tail was not in its proper position. The exposure device was transported back to the main office.

"When the lock was disassembled there the technician noted: 'The lock chamber had a reasonable amount of grit coated to the internals.' It should be noted that the exposure device had just been received the day prior.

"The weather was minus 10 degrees with a wind speed of 10 knots. The lock assembly was cleaned and reassembled as was the crank assembly. There was no exposure to the crew or the general public during this incident."

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Power Reactor Event Number: 45612
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: JASON SAWYER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/07/2010
Notification Time: 04:38 [ET]
Event Date: 01/07/2010
Event Time: 01:00 [EST]
Last Update Date: 01/07/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARC FERDAS (R1DO)

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

Event Text

AUTOMATIC REACTOR SCRAM DURING TRANSMITTER VENTING

"At 0100, Nine Mile Point Unit 2 reactor scrammed [on low reactor water level]. The cause is currently under investigation. Maintenance activities were in progress on Residual Heat Removal (RHR) B & C systems. It is suspected that transmitter venting is the most probable cause of the trip. Reactor core isolation system (RCIC) injected on invalid level 2 signal. No safety relief valves (SRV's) actuated. B and C Residual Heat Removal systems (RHR) remain inoperable, all other ECCS systems and Emergency Diesel Generator are currently operable. Reactor water level is normal. No emergency core cooling system injection was required. The plant is currently in the hot shutdown condition. No emergency plan activation is required. Activation of forced outage plan is in progress.

"Lowest reactor water level reached during the transient was 140 inches. This is less than the reactor water level scram set point of 159.3 inches.

"Reactor pressure before scram was 1020 psig, current reactor pressure is 530 psig and reactor coolant temperature is 470 degrees F. Plant stack monitor is not available. Last grab sample reading at time 0257 is 857 micro-curies/sec.

"All systems functioned as required. All rods fully inserted on trip."

Decay heat is being removed by steaming to the main condenser. The plant is in its normal shutdown electrical lineup.

The licensee notified the NRC Resident Inspector.

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