United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2010 > February 24

Event Notification Report for February 24, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/23/2010 - 02/24/2010

** EVENT NUMBERS **


45563 45708 45713 45717 45718 45719

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
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: 02/23/2010
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

* * * RETRACTION FROM DAVID ALLARD to DAN LIVERMORE AT 1601 ON 02/23/2010 * * *

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

"Retraction of A.O. [abnormal occurrence]. Licensee calculations note patient dose below reporting / A.O. criteria. There will be no external NMED report."

Notified R1DO (Schmidt) and FSME EO (Chang)

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.

To top of page
General Information or Other Event Number: 45708
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L-00457
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/18/2010
Notification Time: 10:58 [ET]
Event Date: 12/10/2008
Event Time: [CST]
Last Update Date: 02/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SOURCE STUCK IN CATHETER TUBE

The following information was obtained from NMED:

"The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence."

The State of Texas discovered that the event was reported to NMED but not to the NRC Headquarters Operations Center as required therefore they are making a late report.

Texas Report Number: I-8590

To top of page
General Information or Other Event Number: 45713
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SHELL LUBRICANTS
Region: 4
City: VICKSBURG State: MS
County:
License #: GL-154
Agreement: Y
Docket:
NRC Notified By: BRANDY FRAISER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/19/2010
Notification Time: 14:56 [ET]
Event Date: 02/01/2010
Event Time: [CST]
Last Update Date: 02/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
ANGELA MCINTOSH (FSME)
ILTAB (via email) ()

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

Event Text

AGREEMENT STATE REPORT INVOLVING AN UNACCOUNTED FOR GENERAL LICENSE SOURCE

The following information was received from the State of Mississippi Division of Radiological Health (DRH) via email:

"Description of Incident: The licensee contracted with a disposal company to dispose of one (1) Industrial Dynamic Model C1-2C FILTEC source holder, Serial No. 555, source. During the disposal company's visit, it was discovered that the source was not in the source holder and could not be accounted for. The facility has changed ownership in the previous years and the records were not well maintained of receipt/transfer and leak tests. The Industrial Dynamic Model C1-2C FILTEC source holder, contained a 100 millicurie Americium-241 source, Serial No. not known.

"Isotope(s): Americium-241
"Activity: 100 millicuries
"Date of Incident : unknown
"Date Reported To DRH: 02-01-10

"Mississippi Incident No.: MS-10001"

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source.

To top of page
Fuel Cycle Facility Event Number: 45717
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/23/2010
Notification Time: 14:05 [ET]
Event Date: 02/23/2010
Event Time: 11:00 [EST]
Last Update Date: 02/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
BRIAN BONSER (R2DO)
JACK DAVIS (NMSS)

Event Text

UNANALYZED CONDITION - INCOMPLETE LIST OF SAFETY CONTROLS IN INTEGRATED SAFETY ANALYSIS SUMMARY

"During a [Global Nuclear Fuel, Americas] GNF-A ongoing review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), it was discovered at 3pm yesterday (2/22/2010) that the list of safety controls associated with the handling of hydrofluoric material may be incomplete in the ISA Summary.

"After further review, it was determined this morning that the list of Items Relied on for Safety (IROFS) was incomplete, and as a result, the UF6 conversion area has been shut down pending revision of the ISA to document IROFS for these processes. UF6 conversion will remain shutdown until IROFS have been identified and implemented.

"While this discovery did not result in an unsafe condition, it is being reported on 2/23/2010 pursuant to the reporting requirements of 10CFR70 Appendix A (b)(1) within 24 hours."

The licensee notified NRC Region 2 (Rich) and will notify the state and local authorities.

To top of page
Power Reactor Event Number: 45718
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: BRIAN VANGOR
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/23/2010
Notification Time: 16:00 [ET]
Event Date: 02/23/2010
Event Time: 01:00 [EST]
Last Update Date: 02/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
WAYNE SCHMIDT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation

Event Text

ERDS NOT AVAILBLE DUE TO PLANT COMPUTER MALFUNCTION

"The Emergency Response Data System (ERDS) link from the Critical Function Monitoring System (CFMS) was lost at approximately 0100 hours on February 23, 2010 due to a malfunction of the plant computer. Other systems such as Safety Parameter Display System (SPDS), RECS, and ENS remain available. In accordance with the site reporting procedure, a loss of ERDS for greater than 16 hours is reportable as a major loss of emergency assessment capability. Troubleshooting is in progress."

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

To top of page
Power Reactor Event Number: 45719
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: ROBERT MARTIN
HQ OPS Officer: DAN LIVERMORE
Notification Date: 02/23/2010
Notification Time: 16:58 [ET]
Event Date: 02/23/2010
Event Time: 15:12 [EST]
Last Update Date: 02/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
WAYNE SCHMIDT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

DEGRADED CONDITION - WELD LEAK DUE TO VIBRATING VALVE ATTACHMENT WIRE

"On 2/22/10, we determined that there was pressure boundary leakage on Unit 2 from the leak off line associated with a pressurizer spray valve (2-RC-220). The source of leakage associated with a boron deposit discovered earlier on 2/18/10. The boron deposit formed based on a leak in a Class 1 manual valve packing leak-off line. The leak location was determined to be in the packing leak-off pipe fillet weld to the stem retaining structure of the valve in the packing gland area. The valve (2-RC-220) is a Class 1 pressure boundary. The packing leak-off line is considered an auxiliary connection in the stem retaining structure of the valve.

"At this time, we believe the most probable cause of the 2-RC-220 leak-off line socket weld leak was based on two factors, a small pore in the original socket weld metal and the location of a valve tag attachment wire. The leak location coincided with the location where a valve tag attachment wire laid across the weld. It is possible this wire, vibrating against the weld, opened up a subsurface pore in the weld metal which began to leak sometime after startup from the 2009 RFO [Refueling Outage] (March 2009). Since the failure may have occurred due to a material problem that resulted in abnormal degradation of a principal safety barrier (i.e., it is necessary to take corrective actions to restore the weld's integrity), this event is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A). The valve was overhauled in the 2009 RFO and subsequently passed VT-2 inspection. The overhaul did not include any welding on the affected joint.

"Unit 2 is in Mode 5 to allow repairs to be made to this weld."

The licensee will notify the NRC Resident Inspector.

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