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Event Notification Report for September 30, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/29/2010 - 09/30/2010

** EVENT NUMBERS **


46254 46259 46272 46273 46276 46277 46278 46287 46289 46290

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46254
Facility: FT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: NATHAN SEID
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/15/2010
Notification Time: 21:00 [ET]
Event Date: 09/15/2010
Event Time: 17:40 [CDT]
Last Update Date: 09/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JEFF CLARK (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

BOTH CONTAINMENT HYDROGEN ANALYZERS OUT OF SERVICE DUE TO FAILED SURVEILLANCES

"At 1740 CDT, VA-81A, Hydrogen Analyzer Panel, was declared not functional due to failing surveillance test OP-ST-VA-0006, Containment Hydrogen Monitor Monthly Check. VA-81B, Hydrogen Analyzer Panel, was previously not functional due to performance of surveillance test IC-ST-VA-0033, 18 Month Channel Calibration of Containment Hydrogen Analyzer, VA-81B.

"This results in no Hydrogen Analyzers being available to monitor containment, which prevents being able to assess for potential loss of containment barrier for Emergency Action Level purposes via the containment hydrogen greater than 3% method.

"USAR [Updated Safety Analysis Report] section 9.10.2.5 allows for both Hydrogen Analyzers to be out of service for up to 72 hours. "

The licensee informed the NRC Resident Inspector.


* * * RETRACTION FROM ERICK MATZKE TO JOHN KNOKE AT 1152 EDT ON 9/29/10 * * *

"Fort Calhoun Station had previously reported that the loss of both hydrogen monitors on September 15, 2010, constituted a major loss of emergency response assessment capability. Additional investigation has determined that other methods of assessment were available that would have provided sufficient indication to make the proper emergency classification. Therefore, this event is being retracted."

The licensee has notified the NRC Resident Inspector. Notification was sent to R4DO (Thomas Farnholtz).

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Power Reactor Event Number: 46259
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JIM PRIEST
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/20/2010
Notification Time: 00:10 [ET]
Event Date: 09/20/2010
Event Time: 07:00 [EDT]
Last Update Date: 09/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GLENN DENTEL (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

ERDS AND SPDS OUT OF SERVICE FOR COMPUTER UPGRADE

"On 9/20/2010 at approximately 0700 EDT, the Hope Creek Safety Parameter Display System (SPDS) and the Emergency Response Data System (ERDS) will be taken out of service for approximately nine days to support a planned modification which will install a new (upgraded) computer system. During this timeframe, ERDS and SPDS will be unavailable. Should the need arise, plant status information will be communicated to the NRC, State and local responders using other available communication systems. SPDS and ERDS are expected to be restored on 9/29/2010. This event is reportable under 10 CFR 50.72(b)(3)(xiii) as a 'Major Loss of Assessment Capability'."

The licensee has notified Lower Alloways Creek Township and the NRC Resident Inspector of the planned outage.

* * * UPDATE AT 1540 ON 9/29/2010 FROM DAVID HALL TO ERIC SIMPSON * * *

"SPDS and ERDS systems were removed from service to support planned computer upgrade. Planned work which resulted in the removal from service of the SPDS and ERDS has been completed. The SPDS system has been returned to service. During the ERDS testing, a problem was discovered with the NRC's communication link supplied by Verizon. An update will be provided when ERDS testing is completed."

Notified R1DO (Gray).

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General Information or Other Event Number: 46272
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: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/23/2010
Notification Time: 15:56 [ET]
Event Date: 12/02/2004
Event Time: [EDT]
Last Update Date: 09/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - UNREPORTED MEDICAL PROSTATE THERAPY UNDERDOSES DISCOVERED DURING AUDIT

The following information received via email is historical and was discovered/reported to the State of Ohio on 04/27/2010:

"NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [NMED Item Number: 100113 - Ohio Agreement State Report EN #45750]

"On 12/2/04 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [107.4 Gray actually delivered] to the prostate. A post implant dose calculation showed a underdose to the prostate greater than 20% of the prescribed dose; however, the licensee determined the dose to be clinically adequate. No further therapy was planned at that time. [Ohio NMED Item # OH100012]

"On 12/14/04 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 108 Gray [66.27 Gray actually delivered] to the prostate. Post implant dosimetry showed a low dose distribution to the base of the prostate, which was not felt to be clinically significant. No further therapy was recommended at that time, since the patient also received external beam radiotherapy. [Ohio NMED Item # OH100013]

"On 7/3/07 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [101.82 Gray actually delivered] to the prostate. A post implant dose calculation showed a underdose to the prostate greater than 20% of the prescribed dose; however, the licensee determined the dose to be clinically adequate. There was limited dose distribution at the gland base. No further therapy was planned at that time. [Ohio NMED Item # OH100014]

"On 1/11/05 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [101.7 Gray actually delivered] to the prostate. A post implant dose calculation revealed a suboptimal dose distribution to the base of the prostate gland. No further therapy was planned at that time. [Ohio NMED Item # OH100015]

"On 7/14/05 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 160 Gray [57.4 Gray actually delivered] to the prostate. Following the final dosimetry testing in 2005, the patient and the referring urologist were notified of a clinically suboptimal dose to the base of the prostate. Post implant prostate volume on which the dosimetry was calculated was 40% greater than the intraoperative prostate volume. Thus, dosimetry was inaccurate due to gland edema. The patient and the referring urologist opted for close monitoring of the prostate and PSA levels without additional therapy. No further therapy was planned at that time. [Ohio NMED Item # OH100016]

"On 4/17/07 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 108 Gray [58.6 Gray actually delivered] to the prostate. Seed implant was utilized as a boost to the prostate gland following IMRT. Post implant dosimetry showed a suboptimal dose distribution at the base; however, satisfactory dose was observed about the mid gland where biopsy proven adenocarcinoma was present. No further therapy was planned at that time. [Ohio NMED Item # OH100017]

"On 9/23/05 the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 108 Gray [79.4 Gray actually delivered] to the prostate. The patient received external beam radiation therapy (4500cGy) and seed implant was utilized as a boost to the prostate gland following IMRT. Post implant dosimetry indicated a clinically satisfactory dose distribution. No further therapy was planned at that time. [Ohio NMED Item # OH100018]"

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: 46273
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: TIFFIN MERCY HOSPITAL
Region: 3
City: TIFFIN State: OH
County:
License #: 02120750001
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/23/2010
Notification Time: 15:56 [ET]
Event Date: 12/10/2008
Event Time: [EDT]
Last Update Date: 09/23/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - UNREPORTED MEDICAL PROSTATE THERAPY UNDERDOSE DISCOVERED DURING AUDIT

The following information received via e-mail is historical and was discovered/reported to the State of Ohio on 05/04/2010:

"NOTE: The information entered in this event notice was received from the licensee as a result of an audit ordered by the Ohio Department of Health for all brachytherapy procedures performed by the licensee since November 2004. This incident was referenced in Ohio NMED Item # OH100003. [See EN # 46272]

"On 12/10/08 the licensee performed a prostate seed implant with fifty-four (54) I-125 seeds prescribed to deliver a dose of 145 Gray [104.76 Gray actually delivered] to the prostate. During the procedure, six (6) seeds were 'stuck' in one needle, and inadvertently placed inferior to the prostate. The post implant dosimetry calculation performed on 2/12/09 showed a D90 of 72.25%, resulting in an underdose to the prostate greater than 20% of the prescribed dose."

Ohio NMED Item # OH100019.

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46276
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: KEVIN DOUGHERTY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/24/2010
Notification Time: 11:18 [ET]
Event Date: 09/24/2010
Event Time: 10:58 [EDT]
Last Update Date: 09/29/2010
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DAVID LEW (R1RA)
JACK GROBE (NRR)
JANE MARSHALL (IRD)
LAURA PEARSON (ILTA)
MIKE CHEOK (NRR)
FRED HILL (DHS)
DENNSI VIA (FEMA)
73.71 GROUP (EMAI)

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

UNUSUAL EVENT DECLARED BASED ON SHORT DURATION LOSS OF SECURITY EQUIPMENT

The licensee declared an Unusual Event at 1053 EDT based on a short duration loss of a security system. The basis for the Unusual Event is Emergency Action Level (EAL AU6.1.1.) for a security process issue. Compensatory issues were implemented. The equipment has been restored and proper function is being verified.

The licensee has notified the NRC Resident Inspector, State and local authorities. Contact the HOO for additional details.

* * * UPDATE AT 1323 ON 9/24/2010 FROM JAMES HUBER TO MARK ABRAMOVITZ * * *

The licensee exited the Unusual Event at 1315 EDT on 9/23/2010.

Notified the R1DO (Dentel), NRREO (Lee), IRD (Marshall), ILTAB (Pearson), DHS (Hill), FEMA (Biscoe), and 73.71 group (e-mail).

* * * UPDATE AT 1403 ON 9/29/2010 FROM JOE GIOFFRE TO ERIC SIMPSON * * *

"While performing planned maintenance on the security computer, the computer unexpectedly froze. As a result, compensatory actions were implemented and a site unusual event was declared. Further review has determined that the security event was misclassified. The security computer froze due to equipment malfunction caused by a hardware issue, not a security threat. Unusual event criteria was not met. Therefore, this notification is being retracted. This event has been entered in our corrective action program. The NRC Resident Inspector has been notified."

Notified the R1DO (Gray).

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General Information or Other Event Number: 46277
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: SAINT JOHN MEDICAL CENTER
Region: 4
City: TULSA State: OK
County:
License #: OK-00376-02
Agreement: Y
Docket:
NRC Notified By: MORGEN BUCKNER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/24/2010
Notification Time: 12:25 [ET]
Event Date: 01/10/2008
Event Time: [CDT]
Last Update Date: 09/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following report was submitted via e-mail:

"On January 16, 2008, Saint John Medical Center (SJMC) Lic. # OK-00376-02, of Tulsa, OK notified the Oklahoma Department of Environmental Quality (ODEQ) that on January 10, 2008 a patient had been administered a dose of I-131 that differed from the intended dose by greater than 20%. The intended dose was 100 mCi. The administered dose was 25 mCi. The misadministration occurred because the 100 mCi dose provided by Nuclear RX, PC (NRX) Lic. # OK-31035-01MD of Tulsa, OK was divided among three capsules. Two capsules contained 25 mCi, while the third contained 50 mCi I-131. The bottle received by SJMC was opaque and stated that it contained one capsule of 309 mCi because of a software error at NRX. When the dose was administered to the patient, one capsule was dispensed from the bottle, while the other two stuck in the bottom of the bottle. The presumed empty bottle was then repackaged and shipped back to NRX where it was discovered that two capsules remained in the bottle. It was determined that the capsules contained a total of 75 mCi I-131. The capsules were not discovered before shipping because the tech at SJMC errantly surveyed the package before placing the bottle inside. Corrective actions by SJMC involve surveying the bottle prior to returning it to the transport shielding, refresher training on transport requirements in 49 CFR, and determining the transport index (TI) by survey outside of the hot lab. Corrective actions by NRX included contacting the software developer for an update that would ensure that all shipments are accurately labeled. NRX also agreed to write the number of capsules contained in each bottle on the lid of the bottle.

"Due to an oversight, this event was not reported at the time it was received by ODEQ."

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: 46278
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: SPACE SCIENCE SERVICES, INC.
Region: 1
City: ORLANDO State: FL
County:
License #: 140-2
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/24/2010
Notification Time: 17:24 [ET]
Event Date: 09/22/2010
Event Time: [EDT]
Last Update Date: 09/24/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
DUNCAN WHITE (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following report was received via e-mail:

"During the last radiographic exposure on 9/22/10 the source did not fully retract. The workers did not do a survey and did not have their rate alarms turned on. They noticed that their dosimeters were off scale and discovered the problem. The film badges were processed on 9/24/10 by Landauer and found the assistant radiographer received 0.742 Rem and the lead [radiographer] received 114.4 Rem. Since they were both together this is questionable. Landauer reports the lead's badge shows an uneven surface reading which is an indication it has been damaged by dropping. Licensee calculations show 0.750 REM for both. The lead has been sent for a blood test. Licensee will send a written report. Florida is investigating."

The camera contained a 71 Ci Ir-192 source.

Florida report number: FL10-101

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Power Reactor Event Number: 46287
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: DAVID LANYI
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/29/2010
Notification Time: 10:43 [ET]
Event Date: 09/29/2010
Event Time: 10:24 [EDT]
Last Update Date: 09/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK LESSER (R2DO)

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 84 Power Operation 84 Power Operation

Event Text

LOSS OF COMM/ASMT/RESPONSE CAPABILITY

"On September 29, 2010, at 1024 EDT, the Control Room Emergency Ventilation system on St. Lucie Unit 1 was declared out of service due to pre-planned maintenance on the Unit 1 Control Room ventilation system. This maintenance renders the control room envelope out of service for a portion of the maintenance. The Technical Support Center (TSC) ventilation system is part of the Unit 1 Control Room Emergency Ventilation system, therefore, the TSC ventilation system has been rendered non-functional during the course of the work activities. The TSC ventilation is expected to be returned to service later today.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. Should the TSC become uninhabitable, the TSC staff will relocate to an alternate TSC location in accordance with applicable site procedures.

"This notification is being made in accordance with 10CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility (ERF). An update will be provided once the TSC ventilation system has been restored to normal operation. The NRC Resident Inspector has been notified."


* * * UPDATE AT 1547 ON 9/29/2010 FROM DAVID LANYI TO ERIC SIMPSON * * *

"The maintenance has been completed and the Control Room Ventilation System has been declared operable. The TSC has been deemed to be fully functional."

The NRC Resident Inspector has been notified.

The R2DO (Lesser) has been notified.

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General Information or Other Event Number: 46289
Rep Org: DRESSER MASONEILAN
Licensee: DRESSER MASONEILAN
Region: 1
City: AVON State: MA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FRANK WHEELRIGHT
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/29/2010
Notification Time: 15:00 [ET]
Event Date: 09/29/2010
Event Time: [EDT]
Last Update Date: 09/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
MEL GRAY (R1DO)
MARK LESSER (R2DO)
STEVE ORTH (R3DO)
THOMAS FARNHOLTZ (R4DO)
PART 21 GROUP (EMAI)

Event Text

POTENTIAL ISSUES WITH CERTAIN REGULATOR MODEL 77N-40 AIR REGULATORS

Dresser Masoneilan initiated a 10 CFR Part 21 investigation because of the failure of three (3) Air Regulators (model number 77N-40) at the PSE&G Salem Station within three months of being installed. Upon testing and evaluation, Dresser Masoneilan concluded that the internal O-ring used for pressure isolation in the Air Regulators were damaged during factory assembly contributing to the failure of the units to regulate pressure. Dresser Masoneilan has developed a corrective action plan and an in-service test method and acceptance criteria to determine if a unit is experiencing pressure loss due to the issue. Due to the volume, age and distribution of these models, Dresser Masoneilan is issuing a general notice to all utilities.

Contact Bill Comeau of Dresser Masoneilan at (508) 941-5477 with any questions concerning this notification.

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Power Reactor Event Number: 46290
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK CHRISTOPHER
HQ OPS Officer: JOHN KNOKE
Notification Date: 09/29/2010
Notification Time: 20:04 [ET]
Event Date: 09/29/2010
Event Time: 15:25 [EDT]
Last Update Date: 09/29/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MEL GRAY (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER HVAC EMERGENCY DAMPER FAILED QUARTERLY TEST

"During quarterly testing of the Technical Support Center (TSC) HVAC System, Emergency Damper MD-1 failed to fully close when the system was placed into the Emergency mode of operation. This damper being not fully closed allows outside air to bypass the filter train and renders the Emergency mode of operation unavailable.

"At 1725 the Emergency Damper MD-1 was failed to the closed position which makes the Emergency mode of the TSC HVAC system available.

"Troubleshooting and restoration of Emergency Damper MD-1 will continue on dayshift 9/30/2010."

The licensee has notified the NRC Resident Inspector.

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Thursday, March 29, 2012