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Event Notification Report for February 15, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/14/2011 - 02/15/2011

** EVENT NUMBERS **


46601 46602 46608 46613 46614

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Non-Agreement State Event Number: 46601
Rep Org: CRITTENTON HOSPITAL MEDICAL CENTER
Licensee: CRITTENTON HOSPITAL MEDICAL CENTER
Region: 3
City: ROCHESTER State: MI
County:
License #: 21-13562-01
Agreement: N
Docket:
NRC Notified By: V. ARTERBERY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/08/2011
Notification Time: 12:05 [ET]
Event Date: 02/07/2011
Event Time: 16:00 [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ERIC DUNCAN (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENTS - ACTUAL DOSE LESS THAN PRESCRIBED DOSE

Nine breast cancer patients were treated with a multi-channel high dose rate afterloader with the incorrect dwell positions input into the afterloader controller. The intended prescription was for 5 mm between dwell positions. The actual input was 2.5 mm between dwell positions. The prescribed dose was for 3400 cGy and the actual dose delivered was approximately 25% less. No adverse clinical effects are expected.

The doctors and patients will be notified.

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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Agreement State Event Number: 46602
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: REX HOSPITAL
Region: 1
City: Raleigh State: NC
County:
License #: 092-0160-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/08/2011
Notification Time: 13:51 [ET]
Event Date: 02/08/2011
Event Time: [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE RECEIVED DURING BRACHYTHERAPY PROCEDURE

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

"A patient undergoing a HDR [High Dose Rate] brachytherapy procedure received an under dose on three fractions.

"The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site.

"The patient has been notified and they are trying to contact the prescribing physician to notify him."

An investigation has been initiated to determine the cause of this event and corrective actions.

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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Fuel Cycle Facility Event Number: 46608
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RIK DROKE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/11/2011
Notification Time: 13:42 [ET]
Event Date: 02/10/2011
Event Time: 17:02 [EST]
Last Update Date: 02/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
74.57 - ALARM RESOLUTION
Person (Organization):
GERALD MCCOY (R2DO)
DAVID PSTRAK (NMSS)
FUELS OUO GRP EMAIL ()

Event Text

MATERIAL CONTROL AND ACCOUNTABILITY (MC&A) ALARM RESOLUTION

"10 CFR 74.57 (f) (2) requires notification within 24 hours that an MC&A alarm resolution procedure has been initiated. In the solvent extraction area of Building 333, the input minus output value exceeded the MC&A limit. Because the alarm investigation procedure has been initiated, this notification is being made. There is no indication that a material loss has occurred.

"There were no actual or potential safety consequences to workers, the public, or the environment."

The licensee has notified NRC Region 2 and the NRC Resident Inspector.

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Power Reactor Event Number: 46613
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DAVID RICHARDSON
HQ OPS Officer: JOE O'HARA
Notification Date: 02/14/2011
Notification Time: 03:09 [ET]
Event Date: 02/14/2011
Event Time: 07:00 [EST]
Last Update Date: 02/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RONALD BELLAMY (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

TECHNICAL SUPPORT CENTER VENTILATION OUT OF SERVICE FOR PLANNED MAINTENANCE

"A planned maintenance evolution at the James A. FitzPatrlck (JAF) Nuclear Power Plant will remove the Technical Support Center (TSC) ventilation system from service. Therefore, the TSC ventilation system will be rendered non-functional during the course of the work activities. The TSC ventilation is expected to be out of service for approximately 13 hours from 0700 to 2000 today.

"If an emergency Is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the station Emergency Plant Manager will relocate the TSC staff to an alternate TSC location in accordance with applicable site procedures giving first consideration to the Control Room. TSC facility leads have been made aware of this contingency.

"This notification Is being made in accordance 10 CFR 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 has been restored to normal operation."

The NRC Resident Inspector has been notified.


* * * UPDATE FROM DAVID RICHARDSON TO DONALD NORWOOD ON 2/14/2011 AT 1922 EST * * *

"As of 1839 hours today, the planned maintenance activity on the Technical Support Center (TSC) ventilation system is complete. Post-work testing is complete and the system has been restored to fully functional."

The NRC Resident Inspector has been notified.

Notified R1DO (Ferdas).

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Power Reactor Event Number: 46614
Facility: BYRON
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROB LAWLOR
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/14/2011
Notification Time: 15:12 [ET]
Event Date: 02/14/2011
Event Time: 09:20 [CST]
Last Update Date: 02/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
LAURA KOZAK (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

FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED SUPERVISOR

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been suspended. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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Thursday, March 29, 2012