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Event Notification Report for June 21, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/20/2011 - 06/21/2011

** EVENT NUMBERS **


46958 46962 46963 46971 46972 46973 46974

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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
Notification Date: 06/14/2011
Notification Time: 15:58 [ET]
Event Date: 06/10/2011
Event Time: [PDT]
Last Update Date: 06/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
LARRY CAMPER (FSME)

Event Text

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.

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Agreement State Event Number: 46962
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2885-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/15/2011
Notification Time: 18:53 [ET]
Event Date: 09/22/2006
Event Time: [EDT]
Last Update Date: 06/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
LARRY CAMPER (FSME)

Event Text

PATIENT RECEIVED RADIATION THERAPY AND LATER DETERMINED TO BE PREGNANT

The following report was received via e-mail:

"Patient had thyroidectomy in 2005 and came into nuclear medicine dept. on Sept. 8, 2006 for consultation for I-131 treatment, the nuclear medicine [NM] resident interviewed her, explained precautions, stated importance of not becoming pregnant. A pregnancy test was performed on September 21, 2006 and the results were negative. The patient was then treated with 95 mCi of I-131 on September 22, 2006.

"After missing one of her Endocrine clinic appointments following the radioactive iodine therapy treatment, on December 22, 2006, the patient went to the Endocrine clinic for a follow up visit. Following that visit, NM was informed by endocrinology that the patient was pregnant. NM contacted OB/GYN and learned that the patient visited her OB/GYN physician and that ultrasound confirmed that the patient was pregnant. The ultrasound revealed that the patient was approximately 8-weeks pregnant, putting the date of conception at approximately September 1-6, so the patient was already 2-3 weeks pregnant at the time of the pregnancy test.

"It was estimated that the fetus received about 25 rad of radiation exposure. Upon discovery of the incident, patient was advised to see a genetic specialist immediately at the Montefiore Medical Park to discuss the radiation exposure to the fetus and possible consequences as a result of the radiation exposure.

"An update will be provided when an investigation is done by an inspector from the New York City Office of Radiological Health."

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Agreement State Event Number: 46963
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN-KETTERING CANCER CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2968-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/15/2011
Notification Time: 18:22 [ET]
Event Date: 10/06/2009
Event Time: [EDT]
Last Update Date: 06/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
LARRY CAMPER (FSME)

Event Text

MEDICAL UNDERDOSE DURING BONE RADIATION THERAPY

The following report was received via e-mail:

"A patient was treated in the nuclear medicine department on October 6, 2009 with Quadramet (Sm-153 EDTMP) for bone pain administered by the user. The Nuclear Pharmacy prepared, assayed and dispensed 43.5 mCi of Quadramet. The dose was prepared with a needle attached to a syringe. After administration, the syringe and additional materials were returned to the Nuclear Pharmacy for re-assay to determine the activity remaining in the administering materials. Reassaying is a standard procedure. The assay revealed that 12.7 mCi of the Sm-153 remained in the syringe cap and the needle itself. The administered dose was determined to be 30.8 mCi, an underdose of approximately 30%.

"[The] attending physician in consultation with the Authorized User agreed not to bring the patient back to add to the dose already administered and to await the result of response. In their opinion, there will be no adverse affect on the patient.

"The Nuclear pharmacy will review whether a needle needs to be present on the dose syringe when dispensed. Nuclear pharmacy will also investigate availability and use of three-way lock to facilitate flushing of the syringe.

"An update will be provided when an investigation is done by an inspector from the New York City Office of Radiological Health."

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: 46971
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: FRED PERKINS
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/20/2011
Notification Time: 13:01 [ET]
Event Date: 06/20/2011
Event Time: 11:52 [EDT]
Last Update Date: 06/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 60 Power Operation 0 Hot Standby

Event Text

UNIT 2 REACTOR TRIP FOLLOWING THE LOSS OF THE "B" MAIN FEEDWATER (MFW) PUMP

At 1152 EDT on 6/20/11 while operating at 60% power, the "B" MFW Pump tripped for reasons unknown. There was no maintenance or I&C work on-going at the time involving this pump. Operators initiated a manual reactor trip, however, [they] are not certain whether the automatic reactor trip setpoint of 49.5% Steam Generator Water Level Narrow Range (SGWL NR) was reached first. SGWL decreased to the Auxiliary Feedwater (AFW) setpoint of 26.8% NR causing the initiation of both motor-driven AFW Pumps. All Control Rods fully inserted.

Unit 2 is currently stable in Mode 3, Hot Standby, removing decay heat via the Main Steam line to the Condenser. Operators secured AFW and will initiate feed to the Steam Generators using the "A" MFW Pump. Unit 2 is in a normal post-trip electrical lineup with all sources of offsite power available. The licensee has the cause of the "B" MFW Pump trip under investigation.

The licensee informed both state/local (Waterford Dispatch) and the NRC Resident Inspector

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Power Reactor Event Number: 46972
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: RICK GARCIA
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/20/2011
Notification Time: 13:30 [ET]
Event Date: 04/21/2011
Event Time: 13:10 [PDT]
Last Update Date: 06/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RICK DEESE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

INVALID PRIMARY CONTAINMENT ISOLATION SYSTEM ACTUATION DUE TO CONFLICTING WORK ACTIVITIES

"This event is reportable under 10 CFR 50.73(a)(2)(iv)(A) as an automatic actuation of general containment isolation signals affecting containment isolation valves in more than one system. This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) for invalid actuations reported under 10 CFR 50.73(a)(2)(iv)(A). This actuation was invalid since it was caused by maintenance activities and not by any actual plant condition warranting containment isolation.

"On April 21, 2011, at 1310 hours, upon de-energization of the Reactor Protection System (RPS) Bus A for maintenance, an unexpected actuation of the Groups 3 and 4 outboard containment isolation valves occurred. Outboard isolations occurred in the reactor building drain and ventilation systems, and reactor closed cooling systems. Control room emergency ventilation and standby gas treatment systems also started. All systems functioned as designed, excluding those components that were already removed from service. Following the event, the RPS Bus A was re-energized and the plant was restored to normal operating condition for the current configuration per plant procedures.

"The subsequent investigation found that personnel involved with work planning and control did not recognize that de-energizing RPS Bus A would create a condition which completed the Nuclear Steam Supply Shutoff System outboard isolation logic. An associated relay for the second channel had been previously de-energized to support ongoing maintenance. The cause of allowing this conflicting work to occur was determined to be inadequate procedural guidance. Planned corrective actions will enhance procedures to identify logic impacts, conflicting equipment and recommended protection schemes.

"There were no actual safety consequences associated with this event since all affected equipment responded as designed. The NRC Resident Inspectors have been notified."

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Power Reactor Event Number: 46973
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BRANDON SHULTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/20/2011
Notification Time: 16:59 [ET]
Event Date: 06/20/2011
Event Time: 11:56 [EDT]
Last Update Date: 06/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTOPHER CAHILL (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER CHARCOAL FAILED TESTING FOR METHYL IODINE

"During 24 month Technical Support Center (TSC) Ventilation System Charcoal Analysis testing, the charcoal failed due to Methyl Iodine penetration of 3.1%, which is above the procedural limit of 1%.

"The TSC non-emergency ventilation system remains functional. Charcoal replacement is planned.

"If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing Emergency Planning procedures and checklists. If radiological conditions require TSC facility evacuation prior to completion of charcoal replacement; the Station Emergency Director will evacuate and relocate the TSC staff in accordance with applicable site procedures."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 46974
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JEFF TUFTS
HQ OPS Officer: PETE SNYDER
Notification Date: 06/20/2011
Notification Time: 17:10 [ET]
Event Date: 06/20/2011
Event Time: 09:45 [EDT]
Last Update Date: 06/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ERIC DUNCAN (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

Event Text

UNPLANNED POWER OUTAGES AFFECT EMERGENCY RESPONSE SYSTEMS

"On June 20, 2011, at approximately 0945 hours, electrical power was lost to non-essential 120 volt busses V-1-F and V-2-F. The busses supply electrical power to the plant integrated computer system (ICS). As a result of the power loss, the Safety Parameter Display System (SPDS), the Emergency Response Data System (ERDS), and the automatic mode calculation of the Computer Aided Dose Assessment Program (CADAP) were unavailable.

"Preliminary investigation indicates the power loss was caused by receipt of a spurious high temperature alarm (greater than 95 degrees F) in the Technical Support Center (TSC) facility where the electrical busses are located. The alarm signal is believed to be invalid because the high temperature alarm came in for two minutes and reset, and the ambient temperature in the TSC remained steady at 65 degrees F. Electrical busses V-1-F and V-2-F were re-energized and restored to service at 1505 hours.

"The ICS, SPDS, ERDS, and CADAP systems were fully restored at 1652 hours on June 20, 2011. In the event of an emergency while these systems were unavailable, contingency plans were in place to transmit plant parameter data and perform the dose assessment function.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii), as a condition that results in a major loss of emergency assessment and communications capability. The NRC Resident Inspector has been notified."

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Thursday, March 29, 2012