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Event Notification Report for March 15, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/12/2010 - 03/15/2010

** EVENT NUMBERS **


45750 45755 45764 45765 45766

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General Information or Other Event Number: 45750
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: MERCY ST. VINCENT MEDICAL CENTER
Region: 3
City: TOLEDO State: OH
County:
License #: 02120490000
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/08/2010
Notification Time: 15:54 [ET]
Event Date: 11/08/2005
Event Time: [EST]
Last Update Date: 03/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3DO)
MARK DELLIGATTI (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY DOSAGE LESS THAN PRESCRIBED

The following information was obtained from the State of Ohio via email:

"ODH [Ohio Department of Health] received information on 3/3/10 of a unreported medical event that occurred at Mercy St. Vincent Medical Center in Toledo on 11/8/05. ODH performed an on-site investigation on 3/5/10 and confirmed the unreported medical event. On 11/8/05, the licensee performed a prostate seed implant with 67 I-125 seeds prescribed to deliver a dose of 160 Gray to the prostate. Thirteen seeds were removed from the bladder immediately after the procedure leaving 54 seeds in the patient. A post implant dose calculation showed an under dose to the prostate greater than 20% of the prescribed dose. The licensee then performed an external beam treatment with a linear accelerator to treat the tumor.

"ODH is continuing the investigation of this event along with other brachytherapy cases performed by the licensee. ODH is also requesting assistance from the NRC's contract medical expert in evaluating the event."

Ohio Report Number: OH100003

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: 45755
Rep Org: COLORADO DEPT OF HEALTH
Licensee: HACH COMPANY
Region: 4
City: LOVELAND State: CO
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EDGAR ETHINGTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/10/2010
Notification Time: 10:21 [ET]
Event Date: 03/10/2010
Event Time: [MST]
Last Update Date: 03/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (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 - POTENTIALLY LOST STATIC ELIMINATOR

The following information was obtained from the State of Colorado via email:

"A general licensee, Hach Company - Loveland Facility, has notified the Colorado Department of Health that it lost a Nuclestat (static eliminator) device containing 10 milliCuries of Polonium 210. The model number is P-2021, Serial Number A2FR969 which was shipped on May 17, 2007 from NRD, LLC.

"The licensee states that the facility has been audited and personnel questioned. No other details are available at this time.

"The Colorado Department of Health has initiated an investigation of this incident."

Colorado Report Number: I10-03

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

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Power Reactor Event Number: 45764
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: LARRY MYERS
HQ OPS Officer: VINCE KLCO
Notification Date: 03/13/2010
Notification Time: 04:45 [ET]
Event Date: 03/12/2010
Event Time: 21:43 [EST]
Last Update Date: 03/13/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MONTE PHILLIPS (R3DO)

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

Event Text

CONTROL ROD DRIVE MECHANISM NOZZLE INDICATIONS

"On March 12, 2010, during the Davis-Besse Nuclear Power Station Unit No. 1 (DBNPS) refueling outage, the documented results of planned ultrasonic (UT) examinations performed on the Control Rod Drive Mechanism (CRDM) nozzles penetrating the reactor vessel closure head (RVCH) identified that two of the nozzles inspected to date did not meet the applicable acceptance criteria. Each of these two nozzles have similar indications that appear to penetrate into the nozzle walls from a lack of fusion point at the outer diameter of the nozzle and the J-Groove weld. Leak path detection was performed on both nozzles with the results showing no leak path. Bare metal visual examinations are scheduled to be performed on all nozzles to determine if there is any pressure boundary leakage. Both indications will require repair prior to returning the vessel head to service. There are sixty-nine nozzles and all will be subject to these UT inspections.

"It is important to note that this notification is being provided prior to the completion of all of the required UT and VT [Visual Tests] examinations for these two nozzles and the remaining nozzles. The indications were detected with a blade probe used to detect axially-oriented indications. The remaining probe that is used to complete the UT examination in each of these two penetrations is a blade probe that is used to identify circumferentially-oriented indications.

"The examinations are being performed to meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1, to identify potential flaws/indications well before they grow to a size that could potentially affect the structural integrity of the reactor vessel head pressure boundary."

The licensee notified the NRC Resident Inspector and will notify the State of Ohio and both Lucas and Ottawa Counties.

* * * UPDATE ON 3/13/2010 AT 1903 FROM LARRY MEYERS TO MARK ABRAMOVITZ * * *

"On March 13, 2010, additional Control Rod Drive Mechanism nozzles (4 and 59) were identified that did not meet the applicable acceptance criteria. The indications on these nozzles are similar in nature and location to the indications previously reported for nozzles 28 and 33. These indications will also require repair prior to returning the vessel head to service.

"Like the two previously reported nozzles, this notification is being provided prior to the completion of all of the required examinations for the nozzle and the remaining nozzles. The indications were detected with a blade probe used to detect axially-oriented indications. The remaining probe that will be used to complete the examination in this penetration is a probe sensitive to circumferentially-oriented indications.

"Additionally, during the bare metal visual examination of the outer surface of the reactor vessel closure head, boric acid deposits were found at CRDM nozzles 4 and 33 that are indicative of primary water leakage. The visual examination of the RVCH is continuing."

The licensee notified the NRC Resident Inspector, State of Ohio, and local government.

Notified the R3DO (Phillips).

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Power Reactor Event Number: 45765
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: PHIL SANTINI
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/13/2010
Notification Time: 21:38 [ET]
Event Date: 03/13/2010
Event Time: 18:25 [EST]
Last Update Date: 03/13/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
CHRISTOPHER CAHILL (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

EMERGENCY DIESEL GENERATORS (EDGs) DECLARED INOPERABLE DUE TO SERVICE WATER TAGOUT

"At 1825 EST service water to '22' and '23' EDGs was isolated while applying a protective tagout to the service water '1-2-3' header. Previously, the supply from the other service water header '4-5-6' was also isolated. '21' EDG was out of service on a tagout.

"This resulted in a condition where no service water flow to the Emergency Diesel Generators was available for approximately three minutes. Service water flow was restored by opening the supply from the '1-2-3' service water header. During this condition, LCO 3.8.2 was not met. All required actions for LCO 3.8.2 were performed. LCO 3.8.2 was met when service water flow was restored to the Emergency Diesel Generators.

"The Emergency Diesel Generators were required to support residual heat removal in the event of a loss of offsite power. At no time was residual heat removal lost."

The licensee will inform the NRC Resident Inspector.

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Power Reactor Event Number: 45766
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: GARY FLESHER
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/14/2010
Notification Time: 15:54 [ET]
Event Date: 03/14/2010
Event Time: 10:27 [EDT]
Last Update Date: 03/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

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

Event Text

LOSS OF POWER TO EMERGENCY OPERATIONS FACILITY

"Loss of electrical power at the Emergency Operations Facility (EOF) in Toms River, NJ. Electrical power was not restored within the 60 minute staffing requirement for the ERF as defined in NUREG-0654. The loss of power only affects the EOF. Full assessment and communications capabilities remain available in the main control room and technical support center. ERDS and the Health Physics Network remain available.

"Power was restored to the EOF at 1530 EDT on 3/14/10."

The licensee has notified the NRC Resident Inspector.

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Thursday, March 29, 2012