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Event Notification Report for March 25, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/24/2011 - 03/25/2011

** EVENT NUMBERS **


46548 46683 46691 46693 46694 46695 46696

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Power Reactor Event Number: 46548
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BRAD BISHOP
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/18/2011
Notification Time: 10:48 [ET]
Event Date: 01/19/2011
Event Time: 02:00 [EST]
Last Update Date: 03/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARVIN SYKES (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 N 0 Refueling 0 Refueling

Event Text

EMERGENCY RESPONSE DATA ACQUISITION AND DISPLAY SYSTEM (ERDADS) REMOVED FROM SERVICE FOR MAINTENANCE

"On 1/19/11, St Lucie Unit 1 and Unit 2 will lose the computer trains associated with Emergency Response Data Acquisition and Display System (ERDADS). Unit 1 will be removed for corrective maintenance, and Unit 2 will be removed for system modification. It is expected that Unit 1 will be restored by 1/21/11, and Unit 2 will be returned to a functional status prior to core reload and fully operational by March 20, 2011. Further, neither Unit 1 nor Unit 2 ERDADS will be removed from service until Unit 2 has defueled (currently scheduled for 1/19/2011 at 0200). This is an advance notification of a planned loss of emergency assessment capability, which will be reportable under 10CFR50.72(b)(3)(xiii). Other means to monitor critical data exists. Notification will be made when each unit is restored to available status."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM REESE KILIAN TO HOWIE CROUCH @ 0952 EST ON 1/19/11 * * *

"Unit 1 and 2 ERDADS have been removed from service at 0955 [EST]."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM TIMOTHY KUDO TO JOHN SHOEMAKER @ 1527 EST ON 01/20/11 * * *

Unit 1 ERDADS has been returned to available status as of 1520 EST on 01/20/11. Unit 2 ERDADS remains out of service.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM BISHOP TO HUFFMAN AT 2013 EDT ON 3/24/11 * * *

Unit 1 and Unit 2 ERDADS have both been restored to service as of 1600 EDT on 3/24/11.

The licensee has notified the NRC Resident Inspector. R2DO (Rich) notified.

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Agreement State Event Number: 46683
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-209-27
Agreement: Y
Docket:
NRC Notified By: BRYCE ARMSTRONG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/18/2011
Notification Time: 16:13 [ET]
Event Date: 03/17/2011
Event Time: [CDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED AT 150% OF PRESCRIBED DOSE

"A medical event took place at Abbott-Northwestern Hospital involving a Yttrium-90 (Y-90) SIR microsphere therapy patient treated on 3/17/2011. It was discovered on 3/18/11, by the radiation oncologist covering the SIRS procedure from the day before, that the delivered amount of Y-90 SIRS wasn't 105% above the prescribed dose as intended, but actually 150% above the prescribed dose. She then brought this error to the attention of the lead medical physicist who was the attending medical physicist responsible for this treatment delivery, for further clarification. Upon investigation, it was deduced that the medical physicist had not read the patient's SIRS therapy (utilizing Y-90 radioactive isotope) written directive prescription correctly. A higher than intended dosage was administered to the patient (1.66 GBq). The correct dosage that was intended to be administered per the written directive was 1.11 GBq. After calculation was made after the incident it was determined that the intended dose to the liver was 30.72 Gy and the actual dose to the liver was 45.93 Gy.

"Contributing factors to the above error identified by the licensee are as follows:
"1. The amount of information presented in the SIRS written directive and the prescribed amount of isotope is hard to discern and is not set apart from all the other numbers presented.
"2. The prescribed activity is manually transferred to a secondary worksheet used in Nuclear Medicine to draw the dose to be administered and this secondary activity worksheet is not verified by a secondary party.

"The licensee stated that to prevent such an event from occurring in the future, the SIRS written directive document will be modified to display the prescribed activity more predominantly on the form as well as a space for initializing by a secondary party that the prescribed dose has been transferred/entered properly on the secondary activity worksheet that is used in Nuclear Medicine to draw the dose to be administered.

"The referring physicians as well as the patient have been or are in the process of being notified of this event.

"According to the licensee's Radiation Oncologist and Interventional Radiologist that were asked to consult, this higher dose would slightly increase the patient's risk of radiation-induced liver disease. The patient, as is standard for all SIRS (Y-90) patients, will receive liver function follow-up testing to track her status."


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: 46691
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: APPLIED GEOTECHNICAL ENGINEERING CONSULTANTS INC
Region: 4
City: LINDON State: UT
County:
License #: UT1800298
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/22/2011
Notification Time: 20:45 [ET]
Event Date: 03/22/2011
Event Time: 17:35 [MDT]
Last Update Date: 03/22/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
JIM WHITNEY (ILTA)
ANGELA MCINTOSH (FSME)

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

Event Text

MOISTURE DENSITY GAUGE STOLEN AND RECOVERED

"A Troxler Electronic Laboratories, Inc. Model 3430, portable gauging device [serial number 22936, containing approximately 8.0 millicuries of cesium-137, and approximately 40 millicuries of americium-241/beryllium] was stolen from the licensee's vehicle while parked at the Home Depot in Lindon, Utah. The Cs-137 source was in the safe shielded position when it was stolen and the transportation case was also secured. The device had been secured by two independent physical barriers, but both barriers were breached. The device was recovered at approximately 5:55 p.m. MST by licensee personnel. The transportation case had been opened, but the source rod was still secured in the shielded position.

"The licensee's vehicle was an open bed pickup truck with a mechanism to secure the device as required."

Utah Report: UT110001

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

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Power Reactor Event Number: 46693
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: DAVID HURT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/24/2011
Notification Time: 06:02 [ET]
Event Date: 03/23/2011
Event Time: 23:54 [CDT]
Last Update Date: 03/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GREG PICK (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

PRESSURE TRANSMITTERS NEEDED FOR AUXILIARY FEEDWATER SUCTION PATH NOT ANALYZED FOR POTENTIAL HIGH ENERGY LINE BREAK

"While performing an extent of condition review of high energy line break (HELB) analyses, a detailed review of the auxiliary steam system was being performed. During this review, sections of pipe that run through rooms 1206/1207 in the Auxiliary Building were identified that have design ratings indicating that they could possibly be classified as high energy lines.

"The pipes were verified to have not been considered in the current HELB analyses. This condition affects pressure transmitters ALPT0037, 38, & 39 which are not qualified for operation in a harsh environment. These pressure transmitters provide the Auxiliary Feedwater Pump [AFW] Suction Transfer signal on low suction pressure from the non safety Condensate Storage Tank to the Safety Related supply (Essential Service Water).

"Technical Specification [TS] 3.3.2-6.h bases state: "since these detectors are in an area not affected by HELBs or high radiation, they will not experience any adverse environmental conditions and the Trip Setpoint reflects only steady state instrument uncertainties."

"Based upon the above bases, with the identified aux steam lines in service, the pressure transmitter's operability could not be assured. This represented an unanalyzed condition and had the potential to affect equipment used for accident mitigation. TS 3.0.3 was entered at time 2354 [CST] on 3/23/2011. At 0009 [CST] on 3/24/2011, Aux Steam valves FBV0158, FBV0I48, FAV0002, and FAV0003 were isolated, removing the HELB concern [TS 3.0.3 was exited at this time]. These are the active feed [isolation valves] to the lines passing through the Aux Building Rooms 1206/1207."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46694
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SCOTT BUTLER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/24/2011
Notification Time: 11:39 [ET]
Event Date: 03/24/2011
Event Time: 10:18 [CDT]
Last Update Date: 03/24/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JAMNES CAMERON (R3DO)
WILLIAM GOTT (IRD)
ERIC LEEDS (NRR)
CYNTHIA PEDERSON (R3)
JOHN KNOX (DHS)
LORI BURCKART (FEMA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNEXPECTED LOSS OF ANNUCIATORS DURING PLANNED MAINTENANCE

"During a planned maintenance activity on the Unit 2 main control room alarm cabinets, it was identified that all Unit 2 safety system annunciators were lost. This was identified at 1006 [CDT]. Main Control Board indicators remained functional. At 1018 [CDT], the Shift Manager declared an Unusual Event under Emergency Action Level MU6. This was due to an unplanned loss of most (approximately 75%) safety system annunciators for > 15 minutes. The planned maintenance activity was not expected to affect the amount of annunciators that were lost.

"At 1030 [CST], the [planned maintenance] clearance order was cleared and power was restored to the Unit 2 annunciators."

There was not transient on other plant equipment and the plant remained stable before and after this event. The cause for the unexpected loss of annunciators is not clearly understood and is still under investigation.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM SCOTT BUTLER TO JOHN SHOEMAKER AT 1216 EDT ON 03/24/11 * * *

The Unusual Event was terminated at 1047 CDT on 03/24/11. All annunciators have been restored and an investigation will be conducted to determine the cause.

Notified R3DO (Cameron)

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Non-Agreement State Event Number: 46695
Rep Org: GRADY MEMORIAL HOSPITAL
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTSVILLE State: VA
County:
License #: 45-30957-01
Agreement: Y
Docket:
NRC Notified By: RICHARD PICCOLO
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/24/2011
Notification Time: 16:20 [ET]
Event Date: 03/23/2011
Event Time: 03:00 [EDT]
Last Update Date: 03/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN ROGGE (R1DO)
KEVIN HSUEH (FSME)

Event Text

EMERGENCY RETRACT MECHANISM FAILURE

The Varian equipment representative provided notification of the following event that occurred at the Grady Memorial Hospital in Atlanta, GA.

A technician was installing a Varisource IX high-dose afterloader when the active wire composed of a 10 Ci Ir-192 source failed to extend. After troubleshooting it was discovered that the wire was stuck on the wedge block which is part of the emergency retract mechanism. The active wire was removed and the emergency retract mechanism was replaced.

The technician received 0.2 mrem during the repair work.

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Fuel Cycle Facility Event Number: 46696
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
                   GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: JACK ROLLINS
HQ OPS Officer: PETE SNYDER
Notification Date: 03/24/2011
Notification Time: 19:02 [ET]
Event Date: 01/28/2011
Event Time: [MDT]
Last Update Date: 03/24/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DANIEL RICH (R2DO)
PART 21 MATERIALS GR (EMAI)

Event Text

TURNBUCKLE COLLAR THREADS OUT OF TOLERANCE

"Name of firm constructing or supplying the basic component which fails to comply or contains a defect: OFI Fabrication, Richmond, VA.

"Safety Hazard: Failure of turnbuckles could ultimately cause a failure of IROFS41 (i.e. breach of UF6 piping) during a seismic event resulting in release of licensed material, but this release would not exceed 10 CFR 70.61 requirements for the public or workers.

"The date on which the information or such defect or failure to comply was obtained: January 28, 2011.

"In a case of a basic component which contains a defect or a failure to comply, the number and location of all such components in use at or supplied for the URENCO USA Facility: Currently there are 164 non-defective components installed and 96 non-defective components in storage.

"The corrective action which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action: Replacement NQA-1 turnbuckles were installed; and the Receipt Inspection Plan (RIP) for turnbuckles (collar as well as paddle assembly) was revised to include 100 percent verification of thread tolerances. All out of tolerance turnbuckle collars were returned to the vendor.

"Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees: Implement 100 percent verification of turnbuckle collar thread tolerances using appropriate 'Go-No Go' thread gauges."

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Thursday, March 29, 2012