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Event Notification Report for March 16, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/15/2011 - 03/16/2011

** EVENT NUMBERS **


46665 46673 46674 46676

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Hospital Event Number: 46665
Rep Org: UNIVERSITY OF MICHIGAN HOSPITAL
Licensee: UNIVERSITY OF MICHIGAN HOSPITAL
Region: 3
City: Ann Arbor State: MI
County:
License #: 21-00215-04
Agreement: N
Docket:
NRC Notified By: MARK DRISCOLL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/10/2011
Notification Time: 11:15 [ET]
Event Date: 03/09/2011
Event Time: 10:00 [EST]
Last Update Date: 03/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BILLY DICKSON (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT INVOLVING ADMINISTRATION OF GREATER THAN ORDERED DOSE

"An Authorized User physician from the University of Michigan Department of Radiation Oncology planned two liver infusion treatments for a patient with unresectable hepatocellular carcinoma using Y-90 Theraspheres. As part of treatment preparation, an MRI was performed on the patient to determine the patient's liver segment volumes. Liver segment volumes are used in calculating the Y-90 activity needed to deliver the prescribed radiation dose to particular segments of the liver. The first treatment was to the right lobe and medial segment of the patient's liver and was performed on 12/15/2010. It proceeded without incident and in accordance with the written directive.

"The Authorized User physician scheduled a second separate treatment to the patient's left lobe to be performed on 3/9/2011. The Authorized User ordered a 74.4 Gy dose to the left lobe of the liver. The medical physicist calculated a corresponding dosage of 60.5 mCi of Y-90 to be infused into the left lobe of the liver.

"However, in arriving at the Y-90 activity needed, a medical physicist used the liver segment volumes for the right lobe and medial segment combined instead of that for the left lobe. The volume of the right lobe and medial segment is much larger than that for the left lobe. As a result, the Y-90 dosage of 60.5 mCi exceeded what was actually needed to deliver the prescribed dose of 74.4 Gy. The Y-90 was infused into to the left lobe on 3/9/2011 at approximately 10 [EST]. Based on the Authorized User's reassessment of the left lobe volume, the dose to the left lobe is calculated, post-administration, to be 159.4 Gy.

"The patient was notified of the event on 3/9/2011. The referring physician was also notified on the morning of 3/10/2011. The Authorized User physician has concluded that the elevated radiation dose to the patient's liver will not result in permanent medical damage or loss of function. Upon initial investigation this event appears to possibly be due to a problem in transcription however causes and corrective actions are still being evaluated."

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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Power Reactor Event Number: 46673
Facility: CRYSTAL RIVER
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: WILLIAM KISNER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/15/2011
Notification Time: 15:16 [ET]
Event Date: 03/14/2011
Event Time: 13:11 [EST]
Last Update Date: 03/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
REBECCA NEASE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

ADDITIONAL DELAMINATED CONTAINMENT CONCRETE DISCOVERED

"Crystal River Unit 3 is currently shutdown. Final tendon re-tensioning activities were being conducted following repair of delaminated (separated) concrete at the periphery of the containment wall. At approximately 1311 [EDT] on March 14, 2011, an indication was received from acoustic monitoring instrumentation located on the containment wall outside the previously repaired area. Re-tensioning activities were stopped and Plant Operations verified that there were no changes in plant parameters. Non-destructive examinations were initiated and preliminary indications are that there is delaminated concrete in the area identified by the acoustic monitoring. An assessment concluded that the containment continues to maintain the closure-pressure retaining capability required for Mode 5. There continues to be no threat to the public heath and safety.

"Delaminated concrete at the periphery of the containment wall was created in late 2009 during the process of creating an opening in the structure to remove and replace the steam generators inside (Reference Event Report 45416). The unit was already shut down for refueling and maintenance at the time the damage was found and has remained shut down."

The extent of newly discovered delaminated has not yet been determined.

The licensee plans to make a press release.

The licensee has notified the NRC Resident Inspector and the Florida Public Service Commission.

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Power Reactor Event Number: 46674
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/15/2011
Notification Time: 16:25 [ET]
Event Date: 03/15/2011
Event Time: 14:56 [CST]
Last Update Date: 03/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHUCK CAIN (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

FLOOD BARRIER PENETRATION NOT SEALED

"During investigations of flood barrier penetrations, a 4 inch conduit has been identified that is not sealed. This conduit penetrates the South wall of the auxiliary building near the transformers into room 19. Flooding through the penetrations could have impacted the ability of the station's auxiliary feedwater (AFW) pumps to perform their design accident mitigation functions.

"This eight-hour notification is being made pursuant to 10 CFR 50.72 (b)(3)(v).

"The penetration is at an elevation of 1007'-8". The river level has been less than 995 feet Mean Sea Level (MSL) since prior to December 1, 2010. The AFW pumps are operable. There are not any indications of conditions that might result in a flood. Actions are in progress to plug the penetration."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46676
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DON TAYLOR
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/15/2011
Notification Time: 17:38 [ET]
Event Date: 03/15/2011
Event Time: 11:31 [EDT]
Last Update Date: 03/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
REBECCA NEASE (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 100 Power Operation 100 Power Operation

Event Text

LOSS OF POWER TO TECHNICAL SUPPORT CENTER VENTILATION SYSTEM

"On 03/15/2011 at 1131 EDT, the Technical Support Center (TSC) ventilation system was rendered nonfunctional as a result of loss of power to the system. System power was lost approximately one hour after returning the normal power supply to service following maintenance. This condition has the potential to render the TSC unavailable due to the inability of the ventilation and filtration system to maintain a habitable atmosphere. Compensatory measures exist to relocate the TSC to alternate locations.

"On 03/15/2011 at 1545 EDT, after verifying the bus supplying the TSC ventilation was satisfactory for return to service, power was restored using an alternate feed. This notification is being made in accordance with 10CFR50.72(b)(3)(xiii) due to the potential loss of an emergency response facility.

"The NRC Senior Resident Inspector was notified."

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Thursday, March 29, 2012