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U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/16/2007 - 02/20/2007
** EVENT NUMBERS **
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| General Information or Other |
Event Number: 43163 |
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: CHRISTUS SANTA ROSA SURGERY CENTER - LLP
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L05805
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: STEVE SANDIN |
Notification Date: 02/13/2007
Notification Time: 12:50 [ET]
Event Date: 02/12/2007
Event Time: [CST]
Last Update Date: 02/13/2007 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
LINDA SMITH (R4)
SCOTT MOORE (NMSS) |
Event Text
AGREEMENT STATE REPORT INVOLVING MULTIPLE PATIENTS RECEIVING >20% PRESCRIBED DOSE
The following information was received via email:
"On Tuesday, February 13, 2007, the Agency [Texas Department of Health] was notified of a series of at least five medical events that were discovered when an improper dose rate constant was used in the treatment planning of the therapeutic application of permanent implants. The radioisotope is I-125 and it was used exclusively for the treatment of prostate cancer. The range of misadministrations is 21-36% over that which was prescribed in the written directive. The licensee is investigating the situation that involved some 28 patients treated over the past year but only one patient complication has been reported thus far. The Agency is continuing to investigate the events with the licensee and will provide updated information as it is received."
Texas Incident No.: I-8391
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. |
| General Information or Other |
Event Number: 43167 |
Rep Org: MAINE DEPARTMENT OF RADIATION CONTR
Licensee: SAPPI
Region: 1
City: SAWHEGAN State: ME
County:
License #: 25709
Agreement: Y
Docket:
NRC Notified By: SHAWN SEALY
HQ OPS Officer: JASON KOZAL |
Notification Date: 02/15/2007
Notification Time: 11:41 [ET]
Event Date: 02/15/2007
Event Time: [EST]
Last Update Date: 02/15/2007 |
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE |
Person (Organization):
JOHN WHITE (R1)
MICHELE BURGESS (FSME) |
Event Text
AGREEMENT STATE REPORT - LEAKING SOURCE
The following was provided by the state via facsimile:
"On January 30, 2007 it came to [the licensee's] attention that a radioactive source on Paper Machine #3 is leaking. This source is listed on [the] Materials license (25709) under condition 9 : "Sealed Krypton 85 (85 Kr) sources ". The source is an ABB Industrial Systems Model TG-4, 1 Ci, s/n K-1331-R.
"The source is used as part of a scanning system on the paper machine. It is in a location not readily accessible to employees working in the area. Radiation levels at one foot around the source head are 0.1 mR/hour. The gas is leaking very slowly, as evidenced by a decrease over time in the process variable that it measures. The source has been labeled well with caution tape and a barricade tag is affixed to the tape.
"The plan for remediation is as follows:
" - A replacement source (loaner from ABB) is being shipped (2/1/07) and should arrive by overnight delivery (2/2/07). Upon arrival, [the] shipping department has been instructed to secure the new unit in a designated holding area for radioactive sources. The storage location is a heavy metal cabinet which is locked with a padlock to ensure the safety of the unit and of the workers. The cabinet is in an area not readily accessible to employees, in a building away from production areas.
" - The damaged source will stay in place in its frame on the paper machine until early next week when a specialist from ABB will arrive, repackage it and ship it back to ABB. The replacement source will be installed at that time.
" - A new source is in the process of being purchased. Delivery is expected in 8-12 weeks. At that time, [the state's] department will be notified there is a new source onsite."
ME report number: ME070002 |
| Power Reactor |
Event Number: 43171 |
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: DAVID DUNCAN
HQ OPS Officer: MARK ABRAMOVITZ |
Notification Date: 02/19/2007
Notification Time: 10:14 [ET]
Event Date: 02/19/2007
Event Time: 08:00 [EST]
Last Update Date: 02/19/2007 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE |
Person (Organization):
MARK RING (R3) |
| 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
EOF NOT AVAILABLE DURING RENOVATION
"Fermi 2 commenced an upgrade to the Emergency Operations Facility (EOF) on February 19, 2007 at 0800. The upgrade consists of furniture replacement and rearrangement of the seating layout. During this work, some floor panels will be removed for cable routing and accordingly the facility will not be available for emergency use. Fermi is making this notification in accordance with 10 CFR 50.72(b)(3)(xiii). In the event EOF activation is necessary, the Alternate EOF will be utilized. Activation and use of the alternate EOF is included in Fermi's Radiological Emergency Response Preparedness Plan. Fermi will notify the NRC upon completion of this work, which is scheduled for Friday February 23, 2007."
The licensee will notify the NRC Resident Inspector. The state has been notified. |
| Power Reactor |
Event Number: 43172 |
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ELLIS VANN
HQ OPS Officer: JEFF ROTTON |
Notification Date: 02/19/2007
Notification Time: 15:34 [ET]
Event Date: 02/19/2007
Event Time: [CST]
Last Update Date: 02/19/2007 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION |
Person (Organization):
MARK RING (R3) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
N |
N |
0 |
Refueling |
0 |
Refueling |
Event Text
DEGRADED CONDITION - 30% THROUGH WALL INDICATION ON REACTOR RECIRC NOZZLE
"Information from a Phased Array UT examination of RRF-17002 (Reactor Recirc 'F' Nozzle to Safe-end weld) indicates that a linear indication approximately 7" long (centered at the bottom of the weld) and approximately 30% through wall extent (ID connected) exists. The Phased Array UT examination of RRF-17002 (Reactor Recirc 'F' Nozzle to Safe-end weld) was performed as part of scheduled outage activities.
"TRM LCO 3.7.3 for Structural Integrity, Condition B has been entered for the Recirc nozzle/piping.
"This event is reportable under § 50.72(b)(3)(ii), 'Any event or condition that results in: (A) The condition of the nuclear power plant, including its principal safety barriers, being seriously degraded', when there are welding or material defects in the primary coolant system which cannot be found acceptable under ASME Section XI, IWB-3600, 'Analytical Evaluation of Flaws' or ASME Section XI, Table IWB-3410-1, 'Acceptance Standards.'"
The licensee informed the NRC Resident Inspector. |
| Power Reactor |
Event Number: 43173 |
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: TIM GAFFNEY
HQ OPS Officer: STEVE SANDIN |
Notification Date: 02/19/2007
Notification Time: 19:14 [ET]
Event Date: 02/19/2007
Event Time: 14:57 [MST]
Last Update Date: 02/19/2007 |
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS |
Person (Organization):
ANTHONY GODY (R4) |
| Unit |
SCRAM Code |
RX CRIT |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
M/R |
Y |
100 |
Power Operation |
0 |
Hot Standby |
Event Text
UNIT 2 PERFORMED A TS REQUIRED SHUTDOWN
"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On 02/19/2007 at approximately 14:57 hours Mountain Standard Time (MST), Palo Verde Nuclear Generating Station (PVNGS) Unit 2 initiated a plant shutdown as required by Condition 'C' of Technical Specification (TS) LCO 3.5.3 to be in Mode 3 with Pressurizer pressure < 1837 psia and Reactor Coolant System (RCS) Tc < 485 degrees F.
"Limiting Condition for Operability (LCO) 3.5.3 requires that two ECCS trains be Operable. High Pressure Safety Injection Pump (HPSI) 2A was declared inoperable on 02/16/2007 at 13:01 MST and was not restored to Operable status within the TS 72 hour Completion Time due to pump bearing oil leakage exceeding the allowable leakage limit. Efforts are in progress to correct the oil leakage issue.
"The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public."
The observed pump bearing oil leakage is approximately 3 drops/hr. Unit 2 completed a normal reactor shutdown with a manual reactor trip at 20% power. All rods fully inserted. Decay heat is currently being removed via the Main Condenser.
The licensee informed the NRC Resident Inspector. |
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