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Event Notification Report for July 12, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/11/2011 - 07/12/2011

** EVENT NUMBERS **


47028 47029 47040 47041 47042

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Agreement State Event Number: 47028
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UW-MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: ROYSTON NGWAYAH
HQ OPS Officer: CHARLES TEAL
Notification Date: 07/06/2011
Notification Time: 16:47 [ET]
Event Date: 06/30/2011
Event Time: [CDT]
Last Update Date: 07/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following information was received from the State of Wisconsin via fax:

"Wisconsin Department of Health Service (DHS) received notification by voicemail from the licensee on July 5, 2011 about an incident that occurred on June 30, 2011. A patient was to receive 25.6 mCi of Samarium-153 (Sm-153) for bone pain; but the patient received 14.8 mCi (58%) of the planned dose. During administration of the Sm-153 to the patient, the staff used a three-way stopcock connected to the IV line. The syringe containing the radioactive material was connected to the stopcock. During the procedure the syringe was mistakenly removed from the stopcock and a few drops of the radioactive materials dripped on the absorbent pad before a member of the staff reconnected the syringe. The event was reported to the RSO within minutes, and a voicemail was left with DHS the following day (July 1, 2011). The patient was notified the same day.

"On July 6, 2011, DHS inspectors conducted a reactive inspection. The licensee is instituting corrective actions. The corrective actions are as follows: 1) Conduct a dry run before administration of doses. 2) Use syringe shields previously used by the hospital, which fits syringes better. 3) Inform the nuclear pharmacy to add saline to the radioactive materials, which serves two purposes; first, decrease the radioactive material per volume of total material in the syringe so that administrations to the patient contain small amounts of radioactive materials, and second, if there is a spill, there will be only a small quantity of radioactive material in the spill. The licensee will send DHS an official report of the incident within 15 working days."

WI Event #: WI110008

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: 47029
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEXAS QA SERVICE, INC
Region: 4
City: GRAND PRAIRIE State: TX
County:
License #: 04601
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/06/2011
Notification Time: 17:18 [ET]
Event Date: 06/27/2011
Event Time: [CDT]
Last Update Date: 07/06/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
RICHARD TURTIL (FSME)

Event Text

AGREEMENT STATE REPORT - IRIDIUM SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

The following information was received from the State of Texas via e-mail:

"On July 6, 2011, the Agency [Texas Department of Health] received a written report from the licensee's Radiation Safety Officer (RSO) that on June 27, 2011, there was a source disconnection at a temporary field site [Dralco, Inc] in Weatherford, Texas. Upon discovering the disconnection, the radiographers roped off the area at the 2 millirem/hour boundary and notified the RSO.

"The RSO arrived on site and confirmed that the source was disconnected. The RSO performed the retrieval by removing the source tube from the camera, shaking the source out of the source tube and placing a lead shield and shot bag(s) over the source with the pigtail exposed. He reconnected the drive cable and the source was cranked back into the camera. The camera was disconnected so that the drive cable and the pigtail connectors could be inspected. No damage was noted and the camera was immediately returned to service.

"The RSO stayed on site approximately one hour to make sure there were no more issues. The RSO stated that the radiographers had failed to connect the pigtail to the drive cable before cranking out the source. The RSO received a dose of 52 mrem. Corrective action includes the event being discussed at the next safety meeting, the radiographers (who were trainers) were instructed to pay attention to safety and the process of connecting the drive cable to the source."

Camera: Amersham Model 660B, SN: 4894
Source: QSA Global Model A424-9, SN: 69176B, Iridium-192, 22 curies

Texas Incident #: I-8867

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Power Reactor Event Number: 47040
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BEN HUFFMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/11/2011
Notification Time: 03:00 [ET]
Event Date: 07/11/2011
Event Time: 04:00 [EDT]
Last Update Date: 07/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID HILLS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNAVAILABILITY OF TSC VENTILATION SYSTEM DUE TO SCHEDULED MAINTENANCE

"At 0400 EDT on Monday, July 11, 2011, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems will be removed from service for scheduled maintenance.

"Under certain accident conditions the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance is scheduled to be completed by 2000 EDT on Monday, July 11, 2011.

"The licensee has notified the NRC Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM DAN KURTH TO JOE O'HARA AT 2151 ON 7/11/11 * * *

"TSC ventilation system maintenance was completed satisfactorily and the system restored to service at 1800 EDT on 7/11/11. The NRC Resident Inspector will be notified."

Notified R3DO(Bloomer)

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Power Reactor Event Number: 47041
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEPHEN SEILHYMER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/11/2011
Notification Time: 04:00 [ET]
Event Date: 07/11/2011
Event Time: 01:25 [CDT]
Last Update Date: 07/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DAVID HILLS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

INADVERTENT EMERGENCY SIREN ACTIVATION COINCIDENT WITH ADVERSE WEATHER

"At approximately 0125 CDT on July 11, 2011 licensee was notified by Goodhue County Sheriff's Department of an inadvertent emergency siren activation (R17) in the city of Red Wing, MN. The Sheriff's Department deactivated the siren and notified the siren vendor. Siren initiation was coincident with severe storm activity in the area, including lighting strikes. Siren remains out of service and is the only siren out of service within the 10 mile Emergency Planning Zone (EPZ)."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 47042
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN A WALKOWIAK
HQ OPS Officer: KARL DIEDERICH
Notification Date: 07/11/2011
Notification Time: 10:58 [ET]
Event Date: 07/11/2011
Event Time: 10:22 [EDT]
Last Update Date: 07/11/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES DWYER (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

Event Text

TEMPORARY LOSS OF ERDS AND SPDS DUE TO PLANNED MAINTENANCE

"The Emergency Plant Information Computer (EPIC) has been shutdown for planned maintenance. The maintenance is expected to last less than six (6) hours. The shutdown of EPIC has caused a loss of the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS). This is determined to be a partial, but significant Loss of Emergency Assessment Capability, and is an 8-hr. Non-Emergency 10 CFR 50.72(b)(3)(xiii) required notification.

"There are no plant transients or power maneuvers in progress or planned.

"Actions taken include: performance of the site specific Computer Out-of-service Surveillance (ST-40C) which provides for enhanced Control Room parameter monitoring, additional operating rounds in-plant on a recurring basis, and restriction of scheduled activities that could cause a plant transient. Members of the JAF [James A Fitzpatrick] Emergency Response Organization (ERO) have been briefed on contingencies required during an E-Plan [Emergency Plan] activation. A contingency plan for around the clock maintenance coverage to recover the EPIC if it is not restored as scheduled does exists."

The licensee has notified the State, the County, and the NRC Resident Inspector.

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