| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
09/08/2010 - 09/09/2010 ** EVENT NUMBERS ** |
 | Hospital | Event Number: 46224 | Rep Org: PROVIDENCE HOSPITAL
Licensee: PROVIDENCE HOSPITAL
Region: 3
City: NOVI State: MI
County:
License #: 21-02802-03
Agreement: N
Docket:
NRC Notified By: BRINDA NARAYANA
HQ OPS Officer: ERIC SIMPSON | Notification Date: 09/02/2010
Notification Time: 13:30 [ET]
Event Date: 08/30/2010
Event Time: 14:00 [EDT]
Last Update Date: 09/02/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)
| Event Text MISPLACED PALLIATIVE SOURCE IMPLANTS
On August 30, 2010, a patient was implanted with I-125 seeds in the anus for a palliative procedure. Two days later, September 1, 2010, a follow-up CT scan on the patient showed that the implants had been inserted 4 cm superior to the intended location which would lead to less dose at the target location. The intended dose was 90 Gy to the anus.
More imaging studies are planned to estimate the actual dose to the intended target area. The patient will be implanted again after the imaging study is complete. A decision will be made at that time whether to correct the original implants.
The reason for the error is believed to be twofold: The tumor had progressed markedly since the original planning and the decision was made to correct the plan for the additional growth based on palpation indications. Also, the 10 cm mark on the needle may have been mistaken for the 5 cm mark.
No long term complications are anticipated.
Both patient and physician have been informed.
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. |
| General Information or Other | Event Number: 46228 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CRYOVAC
Region: 4
City: IOWA PARK State: TX
County:
License #: TX - 01736
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: ERIC SIMPSON | Notification Date: 09/03/2010
Notification Time: 11:26 [ET]
Event Date: 09/02/2010
Event Time: 10:00 [CDT]
Last Update Date: 09/03/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RICK DEESE (R4DO)
ANGELA MCINTOSH (FSME)
| Event Text AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE
The following was received from the State of Texas via e-mail:
"On September 3, 2010, the [State of Texas] was notified by the licensee that on September 2, 2010 the shutter on a NDC Model 103 nuclear gauge failed to fully open during a routine maintenance check. The gauge contains a 150 milliCurie Americium - 241 source. The gauge shutter has been locked closed. The gauge has been removed from the vessel and placed into storage. The dose rate measured at 3 feet from the gauge was 0.4 milliRem per hour. No significant radiation exposure was received by an individual during this event. The manufacturer was contacted and intends to be on site on September 3, 2010 to repair the gauge."
Texas Incident No. I - 8778. |
| General Information or Other | Event Number: 46231 | Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHEVRON PHILLIPS CHEMICAL
Region: 4
City: BORGER State: TX
County:
License #: 05181
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER | Notification Date: 09/03/2010
Notification Time: 15:30 [ET]
Event Date: 09/02/2010
Event Time: [CDT]
Last Update Date: 09/03/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
RICK DEESE (R4DO)
BILL VON TILL (FSME)
| Event Text AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE
The State of Texas submitted the following information via e-mail:
"On September 3, 2010, the [State of Texas] received a phone call from the licensee informing them that on September 2, 2010, while conducting routine gauge inspections, the shutter on an Ohmart Vega model SH-F1-A nuclear gauge failed to close. The gauge contains two milliCuries of Cesium (Cs) 137. Open is the normal operating position for the gauge. Radiation surveys in the area of the gauge were measured and were normal. The licensee tried to free the shutter operating mechanism using light oil, but it did not respond. The licensee stated that the gauge is 11 feet off of the ground and there is no access to it without the use of scaffolding and it does not pose a risk of exposure to anyone. The licensee will contact the manufacturer to request repairs on the gauge."
Texas Incident No. I-8779. |
| Power Reactor | Event Number: 46234 | Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: HOWIE CROUCH | Notification Date: 09/08/2010
Notification Time: 11:00 [ET]
Event Date: 09/08/2010
Event Time: 07:47 [EDT]
Last Update Date: 09/08/2010 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
CHRISTINE LIPA (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 OFFSITE NOTIFICATION DUE TO BODY DISCOVERED IN THE OWNER CONTROLLED AREA
"At 0747 hours on September 8, 2010, a body was discovered on the beach along the Owner Controlled Area at the Cook Nuclear Plant.
"Local law enforcement agencies have been notified. It is expected that a press release will be issued from local law enforcement.
"The NRC Senior Resident Inspector was notified. Plant operation was not impacted by the event. The fatality did not occur on site.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies and expected media involvement related to the discovery."
Although unconfirmed, the licensee believes that the body belongs to a person that went missing on the lake last week. The licensee notified Lake Township, Berrien County Sheriffs Office, Federal Bureau of Investigation and the U.S. Coast Guard. Either Berrien County or Lake Township will be issuing a press release. |
| Power Reactor | Event Number: 46235 | Facility: TURKEY POINT
Region: 2 State: FL
Unit: [ ] [4] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: EDWARD NIELSEN
HQ OPS Officer: BILL HUFFMAN | Notification Date: 09/08/2010
Notification Time: 15:52 [ET]
Event Date: 09/08/2010
Event Time: 13:45 [EDT]
Last Update Date: 09/08/2010 | 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):
ROBERT HAAG (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 4 | A/R | Y | 100 | Power Operation | 0 | Hot Standby | Event Text AUTOMATIC REACTOR TRIP DURING MAINTENANCE ON A REACTOR PROTECTION SYSTEM RELAY
"At 1345 [EDT] on 9/8/10, Turkey Point Unit 4 automatically tripped during the repair of a failed Turbine Stop Valve Relay which inputs into the Reactor Protection System. During the replacement of this relay, the logic condition was met causing a Reactor Trip and Turbine Trip.
"At the time of the trip, reactor power was 100%. Auxiliary Feedwater was automatically initiated when Steam Generator levels lowered below the actuation setpoint. Steam Generator levels are now stable at their normal band and Auxiliary Feedwater is now secured.
"Additionally, the Source Range Detectors did not automatically energize and were manually energized and are operating correctly.
"Unit 4 has been stabilized in Mode 3 on normal off-site power. This event is reportable per 10CFR50.72(b)(2)(iv)(B) - actuation of the Reactor Protection System with the reactor critical and 10CFR50.72(b)(3)(iv)(A) - valid actuation of an ESF system (AFW)."
The trip was characterized as uncomplicated. All rods fully inserted. No relief valves lifted during the transient. Normal feedwater has been re-established to the steam generators and decay heat is being removed via the turbine bypass valves to the condenser. The unit is in a normal shutdown electrical lineup. There was no impact on Unit 3.
The license has notified the NRC Resident Inspector. | |