United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2011 > March 8

Event Notification Report for March 8, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/07/2011 - 03/08/2011

** EVENT NUMBERS **


46601 46651 46661

To top of page
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: 03/07/2011
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.

* * * UPDATE FROM DR. VIVIAN ARTERBERY TO JOHN SHOEMAKER AT 1507 EST ON 03/07/11 * * *

There were a total of eleven breast cancer patients involved. Seven of the eleven patients had small areas of unintended target that received unplanned dose.

The doctors and patients have been notified.

Notified R3DO (Riemer) and FSME (McIntosh)

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.

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 46651
Rep Org: DEFENSE LOGISTICS AGENCY
Licensee: DEFENSE LOGISTICS AGENCY
Region: 4
City: RED RIVER State: TX
County: RED RIVER
License #: 37-30062-01
Agreement: Y
Docket:
NRC Notified By: DAVID COLLINS
HQ OPS Officer: JOE O'HARA
Notification Date: 03/02/2011
Notification Time: 15:20 [ET]
Event Date: 03/01/2011
Event Time: [CST]
Last Update Date: 03/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
BOB HAGAR (R4DO)
ROBERT LEWIS (FSME)
ILTAB EMAIL ()
MEXICO ()

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

Event Text

LOST CHEMICAL DETECTION EQUIPMENT CONTAINING NI-63 SOURCES

"As part of a mass turn in of Chemical Detection Equipment (CDE) containing radioactive sources, an Air Force (AF) unit located in Fort Leonard Wood, MO. reported that it had shipped 52 CDE systems, each containing Ni-63 with 20 milli Curie sources, to the Defense Logistics Agency (DLA) Distribution Center at Red River Texas. The CDE systems were shipped in 7 separate packages and confirmation of 7 separate packages was provided which showed the receipt by DLA on 21 May 2010. An inventory, conducted on 2 February 2011, of the 7 packages at the DLA Distribution Center could only account for 40 of the 52 CDE systems. The AF Radiation Safety Office contacted the DLA Radiation Safety Office indicating that there was a discrepancy in the number of items receipted compared to the number of items identified as shipped by the unit. The AF Radiation Safety Office provided the list of serial numbers for the 52 items reportedly shipped which were compared to the current inventory on hand. It was confirmed that there were 12 serial numbers identified on the shipping list that were not in the current inventory. An initial search of the designated Radioactive Material Storage area did not locate the items.

"It has been identified that a major issue with the turn-in process was the lack of prior notification of transfer of the CDE from the AF units to the DLA Distribution Site at Red River. A global instruction was provided by the AF PM to ship the material, without the PM providing the turn-in documents. Had the AF PM directed all of the shipment, a document would have been generated and the number of items to be shipped would have been provided to the depot. In the current process, the depot could only act reactively based on available material and paperwork.

"The transfer of CDE systems to the DLA Distribution Centers has been suspended until a more accountable process can be determined. Additionally the AF will, in the future, direct all shipments directly to Wright Patterson AFB for demilitarization and disposal. A continued effort to search the hazardous material warehouses for these items will continue."


* * * RETRACTION FROM DAVID COLLINS TO JOE O'HARA AT 1642 ON 03/07/11 * * *

"DLA Distribution is retracting the initial report of potential loss (Event # 46651) as the 12 Chemical Agent Detectors have been accounted for at Pine Bluff Arsenal, another Department of Defense facility and the ultimate destruction site. The materiel was shipped from DLA Distribution Red River to Pine Bluff Arsenal on October 8, 2010, under a different NSN [National Stock Number] than the one originally sent to DLA. The Chemical Agent Detection (CDE) Equipment can be in multiple configurations, each with their own NSN. In this case they shipped from the AF unit under one NSN (entire detection system) and we subsequently shipped under a corrected NSN (detector component only)."

Notified R1DO(Hansell), R4DO(Farnholtz), FSME(Reis), Mexico, and ILTAB via e-mail.

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

To top of page
Power Reactor Event Number: 46661
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ALTON DEWEESE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/07/2011
Notification Time: 10:31 [ET]
Event Date: 03/07/2011
Event Time: 01:40 [CST]
Last Update Date: 03/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MALCOLM WIDMANN (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

Event Text

INADVERTANT AUTO-START SIGNAL TO THE 1B DIESEL GENERATOR DURING TESTING

"Farley Unit One was conducting FNP-1-STP-80.8, [test procedure for] 1B DG [Diesel Generator] 1000 KW load rejection. After successfully completing the load rejection portion of the procedure, the control room staff was restoring the 1B diesel to a normal auto start alignment. With the 1B diesel running, the plant operator was required to reset the 1B DG loading sequencer. He incorrectly pressed the Emergency Start reset push-button instead of the Sequencer reset push-button. As a result, the Emergency Diesel generator stop light illuminated for a brief few seconds and then extinguished. Subsequently due to the test configuration, the 1B diesel received an auto-start signal and returned to the running condition prior to the Emergency Start reset. Although further investigation is continuing, this report is being made due to an apparent valid actuation of ESF equipment."

This event had no impact on other equipment or the plant electrical alignment. The Sequencer reset push-button and the Emergency Start reset push-button are not in close proximity to each other. The plant operator was assessed for fatigue and it was determined that fatigue was not a factor. The plant operator was removed from duties pending remedial training and assessment.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012