| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
10/02/2009 - 10/05/2009 ** EVENT NUMBERS ** |
 | Hospital | Event Number: 45383 | Rep Org: VETERANS ADMINISTRATION SAN DIEGO
Licensee: VETERANS ADMINISTRATION
Region: 4
City: SAN DIEGO State: CA
County: SAN DIEGO
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN M LEIDHOLDT JR
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 09/26/2009
Notification Time: 16:31 [ET]
Event Date: 09/21/2009
Event Time: [PDT]
Last Update Date: 09/26/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
PATTY PELKE (R3DO)
MICHAEL SHANNON (R4DO)
KEVIN HSUEH (FSME)
| Event Text MEDICAL EVENT - PATIENT UNDER DOSE
"This is a notification, pursuant to 10 CFR 35.3045, of a medical event that occurred at the VA San Diego Healthcare System in San Diego, California.
"A dosage of 194 millicuries of I-131 sodium iodide was administered to a patient through a feeding tube on September 21, 2009. The patient was kept in a shielded room at the facility. Daily measurements of the exposure rate at one meter from the patient showed only a small decrease, consistent with radioactive decay, but not the expected biological elimination. The feeding tube was replaced on September 25, 2009. The activity in the feeding tube after removal from the patient was estimated as over 80 millicuries. At this time, it is estimated that the patient received less than half of the administered dose.
"The basis for the medical event is that the total dosage delivered differs from the prescribed dosage by more than 20 percent. The facility has notified the patient of the medical event and is in the process of notifying the referring physician. The facility is in the process of assessing any possible medical effects on the patient.
"The NHPP will perform a reactive inspection regarding the medical event. A 15-day written report for the medical event will be submitted to NRC Region III. National Health Physics Program will notify the NRC Project Manager, Cassandra Frasier, NRC Region III, of the medical event.
Additional information
"The Department of Veterans Affairs holds NRC License No. 03-23853-01VA, a master materials license. Permits are issued under the license to Veterans Health Administration facilities. The VHA permit number for the facility involved in this medical event is 04-15030-01. National Health Physics Program makes required notifications to NRC."
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: 45387 | Rep Org: ALABAMA RADIATION CONTROL
Licensee: RONAN ENGINEERING
Region: 1
City: DEMOPOLIS State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID TURBERVILLE
HQ OPS Officer: JOHN KNOKE | Notification Date: 09/29/2009
Notification Time: 15:00 [ET]
Event Date: 09/14/2009
Event Time: [CDT]
Last Update Date: 10/01/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
MARIE MILLER (R1DO)
ANGELA MCINTOSH (FSME)
ILTAB (Email) ()
|
| This material event contains a "Category 3" level of radioactive material. | Event Text MISSING SHIPMENT OF GENERAL LICENSED DEVICES
This information was received from the State via facsimile:
"On the afternoon of September 28, 2009 at approximately 12:15 pm CDT, the Alabama Office of Radiation Control received a phone call from a representative of the Kentucky Radiation Health Program advising the Agency [Alabama Office of Radiation Control] of the discovery of two missing general licensed devices containing radioactive material. The representative of the Kentucky Radiation Health Program indicated that he was advised from Ronan Engineering representatives that two Ronan model RLL-1 source holders each containing 0.63 millicuries of Cs-137 were lost in transit by a commercial carrier. The shipment originated at Southfresh Feed, Demopolis, Alabama on September 14, 2009 with destination to Ronan Engineering, Florence, Kentucky scheduled for delivery on September 17, 2009. The carrier is YRC [Yellow Transportation Inc].
"According to Ronan Engineering representatives, the RLL-1 source holders are bolted to a pallet. The devices are eight inches wide, including mounting flange and twelve inches long. The housing is 4" x 4" x 12" long. Radioactive material labels, UN identification labels, and Ronan address labels are on the skid and devices.
"According to YRC representatives, YRC has sent out notifications to over 30 dispatch centers and are contacting customers in an attempt to locate the shipment. The shipment was last accounted for on September 18, 2009 at the YRC, Nashville, TN terminal.
"This is all the information that this Agency [Alabama Office of Radiation Control] has at this time and is current as of 2:00 pm CDT, September 29, 2009."
* * * UPDATE AT 0926 EDT ON 10/01/09 FROM DAVID TURBURVILLE TO S. SANDIN * * *
At 0750 CDT on 10/01/09, the Alabama Office of Radiation Control was informed that the missing shipment had been misrouted to the YRC Columbus, OH terminal. The shipment is currently enroute to its final destination, i.e., Ronan Engineering located in Florence, KY.
Notified R1DO (Miller), FSME (Villamar) and ILTAB via email.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| General Information or Other | Event Number: 45393 | Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: ACCURATE NDE & INSPECTION
Region: 4
City: BROUSSARD State: LA
County:
License #: LA-10207-L01
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: VINCE KLCO | Notification Date: 09/30/2009
Notification Time: 09:41 [ET]
Event Date: 08/25/2009
Event Time: [CDT]
Last Update Date: 09/30/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
MICHAEL SHANNON (R4DO)
GLENDA VILLAMAR (FSME)
| Event Text AGREEMENT STATE REPORT - POTENTIAL EXCESSIVE EXPOSURE
This information was received from the State by facsimile
"On September 23, 2009, Accurate NDE reported an over-exposure to an industrial radiographer. On August 25, 2009, Accurate NDE was informed by Landauer that an employee's badge showed a dose of 4990 mrem for the July 2009 wear period. This put the radiographer's yearly dose up to 6243 mrem for 2009. The employee stated to Accurate NDE that there was no equipment malfunctions or unusual circumstances during the month of July. The radiographer also stated that his pocket dosimeter did not go off scale during radiographic operations. A review of the daily radiation dose revealed nothing abnormal according to Accurate NDE. This incident is under investigation."
Louisiana Incident Number: LA090018 |
| Power Reactor | Event Number: 45403 | Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK HANSEN
HQ OPS Officer: STEVE SANDIN | Notification Date: 10/02/2009
Notification Time: 04:18 [ET]
Event Date: 10/01/2009
Event Time: 22:39 [EDT]
Last Update Date: 10/02/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
| Person (Organization):
MARIE MILLER (R1DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown | Event Text UNIT EXPERIENCED A VALID RPS ACTUATION DURING PLANT COOLDOWN ON LOW STEAM GENERATOR LEVELS
"On Thursday, October 1, 2009 @ 2239 hrs EDT Seabrook Station Unit 1 was in Mode 4 in the process of removing feedwater heating and raising steam generator levels during a plant cooldown. A valid actuation of the reactor protection system occurred when both the A and C steam generator [SG] levels were reduced to the SG low level reactor trip setpoint of less than 20%. This occurred twice on both the A and C steam generators approximately 10 minutes apart. Steam generator levels have since been restored to normal operating levels and plant is now in Mode 5.
"This is reportable under 50.72 (b)(3)(iv) as an event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation. The reactor trip breakers were open and the emergency feedwater system removed from service when the event occurred.
"The licensee notified the NRC Resident Inspector." |
| Power Reactor | Event Number: 45404 | Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JASON WEATHERSBY
HQ OPS Officer: STEVE SANDIN | Notification Date: 10/02/2009
Notification Time: 10:28 [ET]
Event Date: 10/02/2009
Event Time: 06:49 [EDT]
Last Update Date: 10/02/2009 | 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):
MIKE ERNSTES (R2DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby | Event Text AUTOMATIC REACTOR TRIP ON TURBINE TRIP POSSIBLY CAUSED BY A FAULTED MAIN GENERATOR BREAKER
"At 0649 [EDT] The VC Summer Nuclear Station automatically tripped due to a turbine trip. The cause of turbine trip is under investigation. Preliminary review indicates a possible failure of one phase of the main generator breaker. The three emergency feedwater pumps automatically started on Lo-Lo steam generator level. Preliminary review indicates all primary and secondary systems responded as required.
"The plant is in mode 3 with normal RCS pressure and temperature. Decay heat is being removed by dumping steam to the condenser. The station will remain in mode 3 until repairs are complete. Estimated restart date has not been determined."
All control rods fully inserted. The plant is in a normal post-trip electrical lineup with the exception of the balance of plant buses which are on the alternate electrical source.
The licensee will inform State and local agencies and has informed the NRC Resident Inspector. |
| Other Nuclear Material | Event Number: 45405 | Rep Org: TENNESSEE VALLEY AUTHORITY
Licensee: WIDOWS CREEK FOSSIL PLANT
Region: 1
City: CHATTANOOGA State: TN
County:
License #: 01-25207-01
Agreement: Y
Docket:
NRC Notified By: KEVIN CASEY
HQ OPS Officer: CHARLES TEAL | Notification Date: 10/02/2009
Notification Time: 12:53 [ET]
Event Date: 10/02/2009
Event Time: [EDT]
Last Update Date: 10/02/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
MIKE ERNSTES (R2DO)
DENNIS DAMON (NMSS)
TERRENCE REIS (FSME)
| Event Text SHUTTER ON NUCLEAR GAUGE FAILED TO CLOSE
"It was discovered on October 1, 2009, that a twenty-four hour event notification was not reported. The notification was required per 10 CFR 30.50(b)(2) due to [the] inability to close a fixed gauge shutter at TVA's (Tennessee Valley Authority) Widows Creek Fossil Plant. The gauge is a Texas Nuclear unit and contains 100 mCi of Cesium-137. The gauge is used to monitor the slurry surge tank in the U7 and U8 Limestone Ball Mill Building."
This gauge is used under an NRC license to TVA at the Widows Creek Fossil Plant in Stevenson, Alabama.
"The shutter failure discovery was made during a routine shutter check on August 4, 2009. Corrective actions were taken to repair the shutter and the shutter check was successfully completed on August 17, 2009. No personnel radiation exposure was received. These corrective actions were reported in the Corrective Action Program." |
| Power Reactor | Event Number: 45406 | Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: DONALD NORWOOD | Notification Date: 10/02/2009
Notification Time: 15:14 [ET]
Event Date: 10/02/2009
Event Time: 11:49 [CDT]
Last Update Date: 10/02/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
ROBERT DALEY (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | N | 0 | Refueling | 0 | Refueling | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text OFFSITE NOTIFICATION DUE TO INADVERTENT ACTIVATION OF EMERGENCY SIRENS
"At approximately 1149 CDT, on October 2, 2009, a Goodhue County Dispatch Supervisor inadvertently activated the Red Wing [Minnesota] sirens from the backup unit during conduct of a silent siren test. The backup unit was being tested to ensure proper siren function prior to work on the primary unit.
"Twenty-six of the 117 sirens in the 10-mile Emergency Planning Zone (EPZ) were activated for less than 10 seconds. No press release is planned by Goodhue county or Xcel Energy.
"The NRC Resident Inspector was notified." |
| Fuel Cycle Facility | Event Number: 45407 | Facility: AREVA NP INC RICHLAND
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION
FABRICATION & SCRAP
COMMERCIAL LWR FUEL
Region: 2
City: RICHLAND State: WA
County: PENTON
License #: SNM-1227
Agreement: Y
Docket: 07001257
NRC Notified By: ROBERT LINK
HQ OPS Officer: CHARLES TEAL | Notification Date: 10/02/2009
Notification Time: 17:14 [ET]
Event Date: 10/02/2009
Event Time: 13:30 [PDT]
Last Update Date: 10/02/2009 | Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
| Person (Organization):
MIKE ERNSTES (R2DO)
DENNIS DAMON (NMSS)
| Event Text 24 HOUR REPORT ON PROCESS EXHAUST HEPA FILTER DAMAGE
"At approximately 1330 hours on 10/1/09 during a follow-up investigation of an event which occurred at mid-day on 9/27/09, conditions were discovered that may have met the criteria for reporting in accordance with 10 CFR 70.50.b.2.
"The incinerator was shutdown on 9/25/09 in preparation for performing dioctyl sebacate (DOS) efficiency testing on 9/27/09 of the final HEPA filters in K50 Solid Waste Uranium Recovery (SWUR) exhaust gas treatment system. At approximately noon that Sunday, an event occurred that, in hindsight, was a probable fire in the packed column scrubber in the exhaust gas treatment system. This event was terminated in a timely fashion by reinitiating water flow to the packed column. Indications of high heat and possible fire in the packed column included high temperatures and observed 'smoke' from mechanical flanges on the downstream ducting of the packed column. Subsequent to the observed high heat event in the packed column, high temperatures of the downstream north HEPA housing (in-service) were observed. The high temperatures in the HEPA housing were believed to be from the high heat event in the packed column. The continuous airborne effluent sample for the K50 stack (downstream of HEPA filters) was counted to evaluated whether a release had occurred. The results of the sample were at the low end of the normal range for this stack, indicating no active release had occurred.
"Continuous monitoring of the system assured the termination of the packed column and HEPA housing high heat events. The systems were continuously monitored and cooled down to near ambient conditions on Monday, 9/28/09. On Monday morning a valve was removed between the quench column and the packed column of the scrubber system. The valve on the packed column side showed high heat damage. A visual inspection on the bottom of the packed column indicated significant degradation of the internals, including the lower fiberglass distribution plate and high surface area polypropylene balls. This evidence points to a high heat event/fire within the packed column. The ignition source is still under investigation as the furnace was completely cold. There is an electric re-heater mounted immediately above the packed column which may have been the ignition source. Disassembly of the packed column is awaiting access platform construction.
"Continuing the investigation on 10/1/09 at approximately 1330 hours the HEPA filter housing was opened for inspection. This inspection found significant deterioration of one of the two HEPA units in each of the primary and final banks. The loss of both the primary and final HEPA units constituted a loss of equipment in accordance with 10 CFR 70.50.2.
"A Condition Report in the Corrective Action Program has been initiated and a causal analysis is being performed. The system continues to be in a shutdown condition." |
| Power Reactor | Event Number: 45409 | Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [ ] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: FRANK WINTER
HQ OPS Officer: BILL HUFFMAN | Notification Date: 10/03/2009
Notification Time: 20:26 [ET]
Event Date: 10/03/2009
Event Time: 17:34 [CDT]
Last Update Date: 10/03/2009 | 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):
ROBERT DALEY (R3DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | A/R | Y | 99 | Power Operation | 0 | Hot Shutdown | Event Text AUTOMATIC REACTOR SCRAM FOLLOWING MSIV CLOSURE
"On 10/03/09 at 1734 CDT, Unit 3 scrammed due to a Group 1 MSIV closure. The cause of the event is being investigated. The 2/3 Emergency Diesel Generator also auto-started during the event. The cause of the auto start is also being investigated."
All rods fully inserted. The reactor is currently stable in Mode 3 with makeup water coming from the control rod drive system and decay heat removal from the isolation condenser. All systems functioned as required with the exception of the unexplained MSIV closure and the auto start of the 2/3 EDG. There was no impact on Unit 2 and the plant is in a normal post-scram electrical lineup. There was no need for the 2/3 EDG to auto-start and it did not load. Group 2 and 3 isolations were also received during the transient which is expected and normal. Reactor water level is being maintained between 8 and 48 inches and pressure between 800 and 1060 psi.
Investigation of the cause of the MSIV closure is in progress The licensee stated that there were no activities or surveillances in progress at the time that could have caused the MSIV closure.
The NRC Resident Inspector has been notified. | |