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Event Notification Report for August 25, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/24/2010 - 08/25/2010

** EVENT NUMBERS **


46189 46193 46201 46202 46203

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General Information or Other Event Number: 46189
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: RUSH PRESBYTERIAN ST. LUKES MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County: COOK
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2010
Notification Time: 16:56 [ET]
Event Date: 08/18/2010
Event Time: [CDT]
Last Update Date: 08/19/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK VALOS (R3DO)
MARK DELLIGATTI (FSME)

Event Text

ILLINOIS AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING YTTRIUM-90 UNDER DOSE

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

"On the afternoon of August 18, [REDACTED], the licensee's Radiation Safety Officer [RSO] called the Agency [Illinois Emergency Management Agency] to report a medical event in accordance with 32 Ill. Adm. Code 336.1080. The licensee was conducting a treatment involving the use of colloidal Y-90 'SIR-Spheres' under consultation with the manufacturer's representative. A dose of 15.4 milliCi was prescribed by the authorized user and the entire volume of material appeared to be delivered without any unexpected complications, including a complete repeated flushing of the delivery line. However, measurements of the associated tubing, vial and other contaminated items in accordance with accepted procedures showed a notable quantity of Y-90 remained. It was subsequently determined that the dose received was less than 80% of the intended dose. [The RSO] contacted the Agency within the prescribed notification period after verifying the measurements and calculations. The Medical Center also notified the attending physician and the patient the same day. Estimates are that 72% [11.1 milliCi] of the intended dose was delivered.

"[The RSO] was advised of the regulatory reporting requirements and was beginning preparations for providing that information. Initially, it is believed that the underdose will not have any adverse effect on the patient. The prescribed treatment was intended as a palliative measure for liver tumors secondary to colon cancer. [The RSO] was asked to obtain the opinion of the manufacturer's rep as to the cause of the underdose and any recommended corrective actions the manufacturer suggests in these treatments. [The RSO] was also requested to provide the initial corrective action the hospital intends to take for this and subsequent treatments.

"A separate conversation was held with the authorized physician user [REDACTED] who attended and oversaw the patient treatment. [The physician] advised that there were no spills, leaks, adverse patient reactions or shunting of the dose outside of the hepatic artery that led to the underdose. Comments from all involved at the time of the treatment, including the manufacturer's representative, was that the administration of the palliative treatment was as good as could be expected and there were no visual indications that any anomalies were present in delivery of the dose. Patient will undergo PET and CT scans in 6 weeks and 12 weeks respectively to determine if any additional actions are warranted such as making up the difference in dose, conducting a repeat of the treatment or if taking no action at all is appropriate. The overriding issue will be the patient's general quality of life. At this point, preliminary indications are that no changes in procedures or processes are necessary and that general delivery system design, coupled with characteristics of material to be administered, resulted in the unintended coagulation and accumulation of microspheres either within the Sir-Sphere three way stopcock or the microcatheter despite routine agitation of the suspension delivery vial."

Illinois Case Number: IL10055

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: 46193
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA - STANFORD
Region: 4
City: STANFORD State: CA
County:
License #: 0676-43
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/20/2010
Notification Time: 21:00 [ET]
Event Date: 08/16/2010
Event Time: [PDT]
Last Update Date: 08/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
MARK DELLIGATTI (FSME)
ILTAB VIA EMAIL ()

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

Event Text

CALIFORNIA AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following information was received from the State of California via email:

"On 08/20/10, the ARSO at Stanford University called and informed RHB [California Department of Public Health - Radiologic Health Branch] of the following:

"On 8/16/10, it was discovered that one of our Contractors, Vance Brown, lost control of 28 signs they removed from two buildings (Building 05-600 Moore South (row 475) and Building 05-610 Moore North (row 493). The signs were placed into a plastic bin and Vance Brown cannot determine what happened to them.

"Representatives from Vance Brown and Redwood City Electric, the electrical subcontractor who removed the signs, conducted an investigation to determine the fate of the signs. They determined that while the signs had been removed and stored properly awaiting disposal by EH&S [Stanford University Environmental Health and Safety], they vanished from the secured construction site at an undetermined time between 6/28/2010 and 8/16/10.

"EH&S met with representatives from Vance Brown and Redwood City Electric on 8/19/10. Several avenues were explored during the meeting. Vance Brown explained that the site was broken into on 7/29/2010 and several tools and other valuables were stolen. Vance Brown filed a police report, but did not notice the signs missing at that time. Vance Brown and Redwood City Electric also questioned their employees, reviewed truck logs, and looked through both construction site storage containers and their off-site warehouses.

"Stanford EH&S has also conducted an internal investigation to determine if any Stanford employees had picked up the signs. None had. Stanford EH&S also queried the waste hauler used by Redwood City Electric (Quick Light Recycle) who stated they had not picked up the signs.

"At this time Vance Brown and Stanford EH&S has exhausted potential locations for the plastic bin of 28 tritium exit signs and considers them to be lost and/or missing. "

California Report No.: 5010-082010

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

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Power Reactor Event Number: 46201
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MYERS
HQ OPS Officer: JOE O'HARA
Notification Date: 08/24/2010
Notification Time: 16:57 [ET]
Event Date: 08/24/2010
Event Time: 08:14 [CDT]
Last Update Date: 08/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
WAYNE WALKER (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

Event Text

LOSS OF OFFSITE POWER TO EMERGENCY STATION SERVICE TRANSFORMER

"During planned maintenance on the Startup Station Service Transformer (SSST), an undervoltage condition occurred on the 69 kV offsite power supply to the Emergency Station Service Transformer (ESST). At the time of this event, utility personnel were isolating 161 kV offsite power to the SSST from the grid. As a result, the offsite power voltage to the ESST lowered below the level where the essential 4160 VAC buses are automatically prevented from loading on the ESST.

"From 0814 to 0816, BKR IFS and 1GS Auto Closure Not Permitted alarms were received when the system control operator was switching out the 161 kV line which supplies the SSST. ESST Secondary Winding voltage lowered to 4309 V and the 69 kV line voltage lowered to 69.4 kV. The nominal setpoint for the Closure not Permitted action is 4330 V. Actions were taken per the alarm response procedures.

"The ESST was declared inoperable as the automatic closure of the supply breakers to the 4160 V essential buses was precluded. With the SSST already inoperable, LCO 3.8.1 Condition C (two offsite circuits inoperable) was entered for the ESST inoperability. Required action C.1 directs declaring required features inoperable when the redundant required features are inoperable within 12 hours of discovery; and required action C.2 directs restoring one offsite circuit to operable status within 24 hours.

"At 0816, the system control operator placed the 69 kV capacitor bank in service, restoring the 69 kV line voltage to 71.5 kV and ESST Secondary Winding voltage to 4461 V.

"At 0846, the ESST was declared Operable following restoration of supply voltage, and meeting acceptance criteria of SR 3.8.1.1, and exited the above LCO required actions for the ESST. The plant remains in LCO 3.8.1, Condition A for the SSST inoperability for planned maintenance.

"This condition is being reported in accordance with 10CFR50.72(b)(3)(v) as a condition that could have prevented fulfillment of a safety function. Per the discussion in NUREG 1022, both offsite electrical power and onsite power are considered to be separate functions by GDC 17. Per the GDC, the offsite sources must be capable of automatically connecting to the essential buses within a few seconds. Due to the automatic transfer to the ESST being prevented, the auto transfer function described in the GDC was prevented. The lowest voltage recorded by the system control operator was 69.4 kV, corresponding to 4309 V on the essential 4160 V buses. The 69 kV line voltage was promptly restored, and the Closure not Permitted alarms cleared. The ESST could have been manually aligned to the essential buses during this event. "

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46202
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DAVE GEEVER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2010
Notification Time: 17:09 [ET]
Event Date: 08/24/2010
Event Time: 09:22 [CDT]
Last Update Date: 08/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KENNETH RIEMER (R3DO)

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

Event Text

LOSS OF OFFSITE COMMUNICATIONS

"At 0922 hours [CDT] on August 24, 2010, it was identified that offsite telecommunications capability was lost (including ENS, HPN, and ERDS) for Quad Cities Station when a fiber optic phone cable was cut during offsite work activities.

"A commercial communication link with the NRC Operations Center was re-established at 1105 hours when site offsite telecommunications were re-routed through the Exelon network to an available commercial system.

"A follow-up notification will be provided when normal offsite telecommunications have been reestablished.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a major loss of communications capability.

"The NRC Resident Inspector has been notified."

* * * UPDATE FROM DAVE GEEVER TO JOE O'HARA AT 1925 EDT ON 8/24/10 * * *

"ERDS has been restored as of 1815 CDT."

Notified R3DO(Riemer)

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Power Reactor Event Number: 46203
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES MURAIDA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2010
Notification Time: 20:02 [ET]
Event Date: 08/24/2010
Event Time: 11:40 [CDT]
Last Update Date: 08/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
KENNETH RIEMER (R3DO)

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

Event Text

ESSENTIAL SERVICE WATER PLACED IN A LINE-UP THAT MAY HAVE PREVENTED ITS SAFETY FUNCTION

"At 1140 [CDT] on August 24th, Unit 2 received Essential Service Water (SX) discharge header pressure low and SX strainer delta pressure high alarms indicative of high flow. At the time, a 2B SX ASME surveillance was in progress which involved field operations by Equipment Operators (EO's). At the time of the event, SX discharge header pressure dropped to 65 psig, less than the 89 psig necessary for operability. The Control Room responded by directing the EO's to restore SX discharge header pressure, which was promptly restored.

"The 2B SX ASME surveillance sets initial conditions prior to data collection. The surveillance has the total SX flow be adjusted to 24000 gpm via the U2 Component Cooling Water (CC) heat exchanger outlet throttle valve, 2SX007. The subject flow was intended to be measured via an installed ultrasonic flow gauge 2FE-SX147. The EO's, instead used the U2 CC heat exchanger flow gauge 2FE-SX031. As a result, in an attempt to achieve 24000 gpm through the U2 CC heat exchanger, total SX flow exceeded the 24000 gpm since the U2 CC heat exchanger is but one of many loads the 2B SX pump is serving.

"For the 5 minutes described above, the SX system was in a lineup that may have prevented it to fulfill its safety function and placed Unit 2 in a potentially unanalyzed condition. This condition is still being evaluated."

Site Engineering has determined no runout conditions existed. The licensee notified the NRC Resident Inspector.

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