Event Notification Report for June 10, 2011
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/09/2011 - 06/10/2011
EVENT NUMBERS
46958469444694646947
Agreement State
Event Number: 46958
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISSION HOSPITAL REGIONAL MEDICAL CENTER
Region: 4
City: MISSION VIEJO State: CA
County:
License #: 2278-30
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: MISSION HOSPITAL REGIONAL MEDICAL CENTER
Region: 4
City: MISSION VIEJO State: CA
County:
License #: 2278-30
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/14/2011
Notification Time: 15:58 [ET]
Event Date: 06/10/2011
Event Time: 00:00 [PDT]
Last Update Date: 06/14/2011
Notification Time: 15:58 [ET]
Event Date: 06/10/2011
Event Time: 00:00 [PDT]
Last Update Date: 06/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG WERNER (R4DO)
LARRY CAMPER (FSME)
GREG WERNER (R4DO)
LARRY CAMPER (FSME)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE FOR PROSTATE IMPLANT
The following information was received via e-mail:
"On Tuesday, June 14, 2011 Mission Hospital notified the Department [California Department of Public Health] that a reportable medical event occurred on June 10, 2011. This event was discovered on June 13, 2011. A patient underwent prostate seed implantation of Pd-103 seeds. Two sets of Pd-103 seeds had been ordered for this patient, and the older set was mistakenly used in surgery. The licensee estimates that this resulted in under treatment of the target organ by 70%. Follow-up information will be provided within 15 days, per 10 CFR 35.3045. This investigation is on-going."
California Event: 061411
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.
The following information was received via e-mail:
"On Tuesday, June 14, 2011 Mission Hospital notified the Department [California Department of Public Health] that a reportable medical event occurred on June 10, 2011. This event was discovered on June 13, 2011. A patient underwent prostate seed implantation of Pd-103 seeds. Two sets of Pd-103 seeds had been ordered for this patient, and the older set was mistakenly used in surgery. The licensee estimates that this resulted in under treatment of the target organ by 70%. Follow-up information will be provided within 15 days, per 10 CFR 35.3045. This investigation is on-going."
California Event: 061411
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.
Agreement State
Event Number: 46944
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: HSA ENGINEERS AND SCIENTISTS
Region: 1
City: VARNVILLE State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: CHARLES TEAL
Licensee: HSA ENGINEERS AND SCIENTISTS
Region: 1
City: VARNVILLE State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/10/2011
Notification Time: 11:29 [ET]
Event Date: 06/10/2011
Event Time: 00:00 [EDT]
Last Update Date: 06/10/2011
Notification Time: 11:29 [ET]
Event Date: 06/10/2011
Event Time: 00:00 [EDT]
Last Update Date: 06/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN ROGGE (R1DO)
DENNIS ALLSTON (ILTA)
ANGELA MCINTOSH (FSME)
JOHN ROGGE (R1DO)
DENNIS ALLSTON (ILTA)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE
The following was received via fax:
"The South Carolina Department of Health and Environmental Control (SCDHEC) was notified on Friday, June 10, 2011, at 0955 hrs., that a Troxler 3411-B gauge, s/n 4793, containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be had been stolen during the armed theft of a company vehicle at approximately 0530 hrs. on June 10, 2011. The RSO called to report the theft of the material. He stated that the Varnville police had been notified and were handling the incident. The SCDHEC inspector took the initial report and proceeded to call the South Carolina Fusion Center to report the incident.
"The RSO was advised by the SCDHEC inspector to submit a written report detailing this event to the SCDHEC within 30 days. The event is open and pending the licensee's investigation and report to the SCDHEC, updates will be made through the national NMED system."
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
The following was received via fax:
"The South Carolina Department of Health and Environmental Control (SCDHEC) was notified on Friday, June 10, 2011, at 0955 hrs., that a Troxler 3411-B gauge, s/n 4793, containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be had been stolen during the armed theft of a company vehicle at approximately 0530 hrs. on June 10, 2011. The RSO called to report the theft of the material. He stated that the Varnville police had been notified and were handling the incident. The SCDHEC inspector took the initial report and proceeded to call the South Carolina Fusion Center to report the incident.
"The RSO was advised by the SCDHEC inspector to submit a written report detailing this event to the SCDHEC within 30 days. The event is open and pending the licensee's investigation and report to the SCDHEC, updates will be made through the national NMED system."
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
Power Reactor
Event Number: 46946
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: RICHARD ALEXANDER
HQ OPS Officer: DONALD NORWOOD
Region: 1 State: NY
Unit: [2] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: RICHARD ALEXANDER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/10/2011
Notification Time: 15:19 [ET]
Event Date: 06/10/2011
Event Time: 11:45 [EDT]
Last Update Date: 06/14/2011
Notification Time: 15:19 [ET]
Event Date: 06/10/2011
Event Time: 11:45 [EDT]
Last Update Date: 06/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOHN ROGGE (R1DO)
JOHN ROGGE (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
TECHNICAL SUPPORT CENTER NON-FUNCTIONAL DUE TO MALFUNCTIONING VENTILATION SYSTEM
"The Technical Support Center (TSC) has been rendered non-functional due to a malfunctioning ventilation system. Investigation into elevated TSC temperature led to the discovery of a malfunctioning compressor. Repairs to TSC ventilation have commenced.
"Per Emergency Plan Procedure IP-EP-220, an alternate location for the TSC staff has been identified and communicated to the TSC staff if the Emergency Director determines that the TSC is uninhabitable during an event."
The licensee notified the State of New York Public Service Commission. The licensee will notify the NRC Resident Inspector.
* * * UPDATE FROM CHARLES BRIAN ROAKES TO DONALD NORWOOD AT 1209 EDT ON 6/14/2011 * * *
"On June 11, 2011, at 1300 hours, repairs to the TSC Ventilation / AC were completed and the TSC ventilation system returned to service and declared functional. The TSC is now functional as a result of returning the TSC ventilation system to service."
The licensee notified the State of New York Public Service Commission and the NRC Resident Inspector.
Notified R1DO (Joustra).
"The Technical Support Center (TSC) has been rendered non-functional due to a malfunctioning ventilation system. Investigation into elevated TSC temperature led to the discovery of a malfunctioning compressor. Repairs to TSC ventilation have commenced.
"Per Emergency Plan Procedure IP-EP-220, an alternate location for the TSC staff has been identified and communicated to the TSC staff if the Emergency Director determines that the TSC is uninhabitable during an event."
The licensee notified the State of New York Public Service Commission. The licensee will notify the NRC Resident Inspector.
* * * UPDATE FROM CHARLES BRIAN ROAKES TO DONALD NORWOOD AT 1209 EDT ON 6/14/2011 * * *
"On June 11, 2011, at 1300 hours, repairs to the TSC Ventilation / AC were completed and the TSC ventilation system returned to service and declared functional. The TSC is now functional as a result of returning the TSC ventilation system to service."
The licensee notified the State of New York Public Service Commission and the NRC Resident Inspector.
Notified R1DO (Joustra).
Power Reactor
Event Number: 46947
Facility: OCONEE
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: SANDRA SEVERANCE
HQ OPS Officer: BILL HUFFMAN
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: SANDRA SEVERANCE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/10/2011
Notification Time: 15:55 [ET]
Event Date: 06/10/2011
Event Time: 08:02 [EDT]
Last Update Date: 06/10/2011
Notification Time: 15:55 [ET]
Event Date: 06/10/2011
Event Time: 08:02 [EDT]
Last Update Date: 06/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEVEN RUDISAIL (R2DO)
STEVEN RUDISAIL (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 50 | Power Operation | 50 | Power Operation |
ALL FOUR CHANNELS OF RPS OVERPOWER FLUX/FLOW IMBALANCE PROTECTION TRIP DISCOVERED TO BE INOPERABLE
"Event: During startup of Unit 1 on June 10, 2011, after increasing power to approximately 50 percent, it was noticed that power range nuclear instrumentation was not responding adequately to power imbalance differences. At 0802 EDT, all four channels of Reactor Protective System instrumentation were declared inoperable. TS 3.3.1., Reactor Protective System (RPS) instrumentation, Condition A, B, and C were entered. RPS Channel D was placed in trip per Condition A. Trouble shooting efforts were immediately initiated.
"Initial Safety Significance: This issue constitutes a loss of safety function because the nuclear overpower flux/flow imbalance trip function of RPS was not operable.
"Corrective Action(s): Trouble-shooting commenced. A wiring error was identified that affected all four RPS channels. At this time, all four channels have been restored to operability. All conditions of TS 3.3.1, Conditions A, B, and C have been exited as of 1438 EDT hours when all four channels of RPS were restored."
The licensee stated that the wiring error is associated with a modification package that was completed during the recent refueling outage.
The licensee has notified the NRC Resident Inspector.
"Event: During startup of Unit 1 on June 10, 2011, after increasing power to approximately 50 percent, it was noticed that power range nuclear instrumentation was not responding adequately to power imbalance differences. At 0802 EDT, all four channels of Reactor Protective System instrumentation were declared inoperable. TS 3.3.1., Reactor Protective System (RPS) instrumentation, Condition A, B, and C were entered. RPS Channel D was placed in trip per Condition A. Trouble shooting efforts were immediately initiated.
"Initial Safety Significance: This issue constitutes a loss of safety function because the nuclear overpower flux/flow imbalance trip function of RPS was not operable.
"Corrective Action(s): Trouble-shooting commenced. A wiring error was identified that affected all four RPS channels. At this time, all four channels have been restored to operability. All conditions of TS 3.3.1, Conditions A, B, and C have been exited as of 1438 EDT hours when all four channels of RPS were restored."
The licensee stated that the wiring error is associated with a modification package that was completed during the recent refueling outage.
The licensee has notified the NRC Resident Inspector.