Event Notification Report for November 01, 2006

WASHINGTON STATE AGREEMENT STATE REPORT

This event was received via e-mail

"On November 1, three workers were involved in separating sources, lead pigs (shielded containers) and trash from a barrel. Work was being conducted in a ventilated enclosure within a PEcoS waste processing building. Two workers inside the enclosure were wearing respirators and the supervisor (not wearing a respirator) was immediately outside the enclosure directing the work. At the end of the day, the supervisor noted he was contaminated. The supervisor was scheduled for whole-body counting at the Battelle facility early the next day. An uptake of approximately 11.7 nanocuries of Americium 241 was confirmed. The preliminary dose estimate to the individual's lung was 97.5 Rem CDE. The individual was started on chelation treatment. The other two workers were sent for whole body counting on November 3.

"The operation included opening one lead pig that contained three Am-241 sources. Contamination previously had not been detected outside the pig or in the trash. Sources were surveyed for dose rate and separated from the lead pig without contamination smears being taken. No release to the public or the environment occurred. Operations in this and adjacent areas were stopped once the situation was known. An investigation was initiated by PEcoS. The area was evacuated and is currently being ventilated. DOH has an inspector on-site performing an incident investigation.

"Media is aware of the incident.

"Notification Reporting Criteria: WAC 246-221-250(2) Notification of Incidents (24 hour notification)

"Isotope and Activity involved: Am-241 total activity from twelve drums was manifested at 6.8 GigaBq (184 millicuries). Only one drum was open at the time of the incident.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): Three workers were involved. One worker has an apparent over exposure of 97.5 Rem CDE to the Lung. No release to public or environment."

* * * UPDATE FROM WASHINGTON STATE (FRAZEE) TO HUFFMAN VIA E-MAIL AT 1746 ON 11/16/06 * * *

"On November 1, three workers were involved in separating sources, lead pigs (shielded containers) and trash from a barrel. Work was being conducted in a ventilated room, (previously reported as an enclosure within the room) within a PEcoS waste processing building. Two workers inside the room were wearing respirators and the supervisor (not wearing a respirator) was immediately outside the room directing the work. A very high contamination level was detected (greater than 2 million dpm/wipe) in the room at about 10:00, and the building was evacuated shortly after that. At about this time, an air sample that was in the area of the workers was counted and determined to have a very high alpha activity (10 E-9 µCi/ml). The supervisor and the workers were taken to a survey area and found to be contaminated on the face. Contamination was detected on the respirators. The workers were successfully decontaminated by the on site health physics department. The supervisor was scheduled for whole-body counting at the Battelle facility early the next day. An uptake of approximately 11.7 nanocuries of Americium 241 was confirmed. The preliminary dose estimate was 97.5 Rem CDE. The individual was started on chelation treatment. The other two workers were sent for whole body counting on November 3. Subsequent counts on the first individual were lower (about 9nCi), and the subsequent 2 workers follow-up counts decreased from about 6.9nCi to 3.2nCi and from 1.5nCi to 0.5nCi. The final dose received will depend on the efficiency of the chelate treatment and other factors. One additional person who was in the building was analyzed for internal Am-241 contamination, and was found to be <0.092nCi, below the detection limit of the instrument.

"The operation included opening one lead pig that contained three Am-241 sources. Contamination previously had not been detected outside the pig or in the trash. Sources were surveyed for dose rate and separated from the lead pig without contamination smears being taken. Operations in this and adjacent areas were stopped once the situation was known. An investigation was initiated by PEcoS. The area was evacuated and is currently being ventilated. DOH has an inspector on-site performing an incident investigation.

Update as of 14 November:

"The three employees are still being treated with a chelating agent. This week should be the last week. At this time, there is no update on the original activity or the activity left in the body, except that the amount of activity in the lung is decreasing. It will be several weeks before the final dose can be calculated by the licensee's consultants, which will be based on the initial lung count, the bioassay results (urine/fecal), and the effectiveness of the chelate at removing the americium from the body. At this point, we assume there are three individuals who may have exceeded their annual dose limit of 50 Rem to the bone. The final dose received by the three individuals will be calculated when sufficient information is accumulated. The three workers have returned to work exhibiting some emotional stress and slight effects from the medical treatments.

Plant Status

"The plant is being restarted incrementally after a safety shutdown imposed by the company. After DOH approval, two process lines have been restarted: the super compactor on the mixed waste side of operations and an inspection and sorting process, also on the mixed waste side. The licensee is completing items identified on the mixed waste thermal systems safety evaluation, and expects to restart those processes in the next few days. In addition, they are completing items identified on the low level thermal systems, but a restart date is pending. The low level processes that were affected by this accident are not being restarted, until the contamination in the building is controlled. The building that the material is in is being decontaminated, and continues to be a respirator area. The contaminated room is still inaccessible, however, a plan was completed to re-enter the room to assess the extent of the contamination. This initial entry was conducted on 11-14-06 by senior members of the Health Physics staff. As a result of the surveys conducted during the reentry, the extent of the problem they face is better understood. A plan is being developed to decontaminate the room.

"The investigation is continuing, and the actual cause of the event does not appear to be a single cause, but rather compounding mistakes, errors in judgment and complacency for the seriousness of this type material. Corrective actions that are being taken by the licensee at this time, are primarily based on self evaluation, using the workers and technical staff. In addition, at this time DOH is requiring the company to retrain the radiological technicians as well as the workers in the different waste processes prior to restart of any process. DOH is working with the company to identify the root causes of this incident.

"No release to public or environment. Air sample analysis results for a particulate sample in the building exhaust stack was 9.2E-3 µCi/ml gross alpha.

"The building is being decontaminated, and additional containment tents are being installed around the contaminated room.

"Media is aware of the incident. Tri-City Herald (Kennewick Washington) article was published November 4, 2006.

"Notification Reporting Criteria: WAC 246-221-250(2) Notification of Incidents (24 hour notification)

"Isotope and Activity involved: Am-241 total activity from twelve drums was manifested at 6.8 GigaBq (184 millicuries). Only one drum was open at the time of the incident.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): Three workers were involved. The first worker had an initial internal deposition result of 11.7 nCi. Two additional workers have been confirmed as having an internal deposition: initial results were 6.9 nCi and 1.5 nCi. Subsequent counts of all three involved personnel were lower. All three workers were given chelating treatment. The final dose will be calculated by the Battelle internal dosimetry program, following extensive testing. Other workers who were in the area are being tested. The estimated dose to the endosteal (white bone matter) from 11.7nCi is about 95 rem CDE."

R4DO (Johnson) and NMSS EO (Camper) notified.

Washington State Report # WA-06-063.


* * * UPDATE ON 02/06/07 AT 1600 EST VIA E-MAIL FROM MIKEL ELSEN TO MACKINNON * * *

"Update as of 5 February, 2007

"From the Department of Health's investigation into this incident, it appears that the root cause of the event was failure to adhere to procedures and plans set forth for the project, and inadequate training. Preliminary corrective actions taken by the licensee to prevent recurrence are disciplinary action to the employees involved for procedure and policy violations, a functional Alpha CAM was put in service, training performed for all staff working with radioactive material, with follow-up testing. Additionally, a reorganization of the facility which relieves the RSO of numerous tasks not related to Radiation Safety has taken place, and the facility has made a new position Special Project Lead who is assigned to work with HP and Operations Staff on special projects and compile lessons etc. The final exposure to the individuals has not yet been assigned. When the DTPA treatments have been determined done then exposures will be able to be assigned. Currently it is anticipated that the final dose calculation will be assigned by the end of February 2007. The amount of Am-241 activity in the involved drum was manifested as 71 millicuries Am-241."

R4DO (Nease) & NMSS (Greg Morell) notified.

* * * UPDATE ON 04/24/07 AT 1525 EDT VIA E-MAIL FROM MIKE ELSEN TO MACKINNON * * *

"Update as of April 23, 2007

"The final intake and internal dose evaluation of the PEcoS employees have been completed. The results are presented below, along with the anticipated dose they would have received if the employees did not receive the DTPA chelating treatments.
Employee 1: Intake was estimated at 17 nCi of Am241 The estimate of the actual 50-year committed internal dose equivalents for the respective organs and tissues

"Actual 50-year Committed Anticipated Dose
"Organ / Tissue Dose Equivalent (rem) Without Therapy (rem)
"Effective 3.8 7.3
"Bone Surface 78 150
"Liver 4.6 8.9
"Red Bone Marrow 6.2 12
"Gonads 1.1 2.1
"Lungs 1.7 1.7


"Employee 2: Intake was estimated at 4 nCi of Am241 The estimate of the actual 50-year committed internal dose equivalents for the respective organs and tissues

"Actual 50-year Committed Anticipated Dose
"Organ / Tissue Dose Equivalent (rem) Without Therapy (rem)
"Effective 1.0 1.7
"Bone Surface 22 36
"Liver 1.3 2.1
"Red Bone Marrow 1.7 2.8
"Gonads 0.29 0.48
"Lungs 0.39 0.39


"Employee 3: Intake was estimated at 48 nCi of Am241 The estimate of the actual 50-year committed internal dose equivalents for the respective organs and tissues

"Actual 50-year Committed Anticipated Dose
"Organ / Tissue Dose Equivalent (rem) Without Therapy (rem)
"Effective 4.9 21
'Bone Surface 95 430
"Liver 5.5 25
"Red Bone Marrow 7.5 34
"Gonads 1.3 5.8
"Lungs 4.7 4.7


"The licensee has taken the following corrective actions to help prevent reoccurrence:
"A Re-distribution of the RSO's work to other onsite personnel and hiring additional people to ensure adequate coverage.
"Management reorganization, to increase the oversight given to the radiation protection program.
"Increased training on procedures.
'Increased management interaction and surveillance by the RSO and other health physics staff.
'Inclusion of the engineering staff on all facility changes, such as ventilation changes.'Changes to the procedures for operation of the ventilation system in buildings 1 and 2.
"Hazard analysis on the ventilation system in buildings 1 and 2, and the changes that were discussed in the hazard analysis.
"Careful analysis of the internal dose received by the affected workers.
"Assurance PEcoS personnel will follow all of your procedures.
"Disciplinary action for culpable employees.
"Greater emphases to ensure that orders and instructions to the workers are clear and understood.


"Plant Status

"The plant is being restarted incrementally after a safety shutdown imposed by the company. After DOH approval, two process lines have been restarted: the super compactor on the mixed waste side of operations and an inspection and sorting process, also on the mixed waste side. The licensee is completing items identified on the mixed waste thermal systems safety evaluation, and expects to restart those processes in the next few days. In addition, they are completing items identified on the low level thermal systems, but a restart date is pending. The low level processes that were affected by this accident are not being restarted, until the contamination in the building is controlled. The building that the material is in is being decontaminated, and continues to be a respirator area. The contaminated room is still inaccessible, however, a plan was completed to re-enter the room to assess the extent of the contamination. This initial entry was conducted on 11-14-06 by senior members of the Health Physics staff. As a result of the surveys conducted during the reentry, the extent of the problem they face is better understood. A plan is being developed to decontaminate the room.

"The investigation is continuing, and the actual cause of the event does not appear to be a single cause, but rather compounding mistakes, errors in judgment and complacency for the seriousness of this type material. Corrective actions that are being taken by the licensee at this time, are primarily based on self evaluation, using the workers and technical staff. In addition, at this time DOH is requiring the company to retrain the radiological technicians as well as the workers in the different waste processes prior to restart of any process. DOH is working with the company to identify the root causes of this incident.


"No release to public or environment. Air sample analysis results for a particulate sample in the building exhaust stack was 9.2E-3 µCi/ml gross alpha.

"The building is being decontaminated, and additional containment tents are being installed around the contaminated room.

"Media is aware of the incident. Tri-City Herald (Kennewick Washington) article was published November 4, 2006.


"Notification Reporting Criteria: WAC 246-221-250(2) Notification of Incidents (24 hour notification)

"Isotope and Activity involved: Am-241 total activity from twelve drums was manifested at 6.8 GigaBq (184 millicuries). Only one drum was open at the time of the incident.

"Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): Three workers were involved. The first worker had an initial internal deposition result of 11.7 nCi. Two additional workers have been confirmed as having an internal deposition: initial results were 6.9 nCi and 1.5 nCi. Subsequent counts of all three involved personnel were lower. All three workers were given chelating treatment. The final dose will be calculated by the Battelle internal dosimetry program, following extensive testing. Other workers who were in the area are being tested. The estimated dose to the endosteal (white bone matter) from 11.7nCi is about 95 rem CDE.


"Lost, Stolen or Damaged? (mfg., model, serial number): N/A

"Disposition/recovery: N/A

"Leak test? N/A

"Vehicle: (description; placards; Shipper; package type; Pkg. ID number) N/A

"Release of activity? N/A

"Activity and pharmaceutical compound intended: N/A
"Misadministered activity and/or compound received: N/A
"Device (HDR, etc.) Mfg., Model; computer program: N/A
"Exposure (intended/actual); consequences: N/A
"Was patient or responsible relative notified? N/A
"Was written report provided to patient? N/A
"Was referring physician notified? N/A

"Consultant used? (deleted) at Battelle in vivo counter facility, (deleted) at Advanced Medical, and (deleted) at Pacific Northwest National Laboratory."


FSME (Greg Morell) & R4DO (Linda Smith).

POTENTIAL DEGRADATION IN THE OFFSITE EMERGENCY SIREN NOTIFICATION SYSTEM

"A potential loss of the ENS Siren System occurred on 11/1/2006 due to a degradation of the Radio Transmitter System. A successful siren silent test was performed at 0925 on 11/1/2006 to verify full siren operation. The system was returned to full functionality at 1127 on 11/1/2006 by restoring normal transmission capability."

The licensee will inform Calvert, Dorchester and St. Mary's Counties and has informed the NRC Resident Inspector.

UNIT SHUTDOWN REQUIRED DUE TO SERVICE WATER LEAK INVOLVING A CONTAINMENT AIR COOLER

"On November 1, 2006, at 1530 hours EST, a service water leak was identified in the cooling coil of Containment Air Cooler VHX-4. While this containment air cooler has no safety function for containment cooling, the breached cooling coil represents an inoperable containment boundary.

"In accordance with Technical Specification (T.S.) 3.6.1.B1&2, a shutdown was initiated at 1805 hours EST, following expiration of the completion time of 1 hour for restoring containment to operable per T.S. 3.6.1.A.1."

The licensee anticipates having the unit in mode 3 Hot Standby by 2205 hours EST, at which time an evaluation involving extent of condition for the required repairs will be performed. The leak is characterized at this time as 300 ml/minute.

The licensee informed the NRC Resident Inspector.

UNIT 2 DECLARED AN UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER TO THE 4KV EMERGENCY BUSES

At 1823 EST, Unit 2 was manually scrammed due to a loss of offsite power from the Startup Auxiliary Transformer to both 4KV Emergency (E) buses. Both Emergency Diesel Generators (EDGs) 3&4 autostarted and re-energized the affected electrical buses. At 1823 EST, an Unusual Event was declared based on EAL 06.01.01, "Inability to power either 4KV E bus from offsite power."

Unit 2 is currently stable in mode 3, Hot Shutdown, with MSIVs closed and HPCI controlling pressure and RPV Water Level. All control rods fully inserted following the manual reactor scram. The licensee determined that no emergency facilities will be activated and that no offsite assistance is needed at this time.

The licensee informed both state and local agencies and will inform the NRC Resident Inspector.

* * * UPDATE PROVIDED BY JOEL LEVINER TO JEFF ROTTON AT 2214 EST ON 11/01/06 * * *

"On 11/01/06 at approximately 18:23 (EST) Brunswick Unit 2 experienced a loss of the unit's Startup Auxiliary Transformer and a loss of reactor forced circulation. A manual reactor scram was performed as required by station Abnormal Operating Procedures. Due to the loss of the Startup Auxiliary Transformer and subsequent manual reactor scram, a loss of Offsite Power resulted to the unit's power buses when unit shutdown was completed. All control rods properly inserted when the manual reactor scram was performed. All four site emergency diesels started and diesels 3 and 4 are supplying the Unit 2 emergency buses. Reactor water level reached low level 1 (LL1) and low level 2 (LL2) as result of the reactor scram and loss of offsite power. The LL1 signal resulted in Group 2 (floor and equipment drain isolation valves), Group 6 (monitoring and sampling isolation valves) and Group 8 (shutdown cooling isolation valves) isolation signals. All low level 1 isolations occurred as designed. The LL2 resulted in a Reactor Core Isolation Cooling (RCIC) system actuation, High Pressure Coolant Injection (HPCI) system actuation, Group 3 (reactor water cleanup valves) isolation signal, a secondary containment isolation signal, a Standby Gas Treatment (SBGT) initiation signal, a Control Room Emergency Ventilation (CREV) initiation signal, and an Alternate Rod Insertion (ARI) actuation signal. All isolation and actuations occurred as designed with the exception the CREV initiation and ARI actuation. CREV initiation and ARI actuations were performed by manual actions. The failure of the CREV and ARI initiation/actuations are under investigation. The RCIC and HPCI systems were used to restore reactor water level to the normal operation band. Reactor vessel pressure is being controlled in the normal band with manual operation of Safety Relief Valves (SRV), and HPCI/RCIC in pressure control mode. The Main Steam Isolation Valves (MSIVs) (Group 1) and the drywell pneumatic isolation valves (Group 10) closed on the loss of power. The plant is a stable condition. Troubleshooting activities are in progress to determine the cause of the event.

"At 1910, the NRC was previously notified of the Unusual Event declaration.

"Initial Safety Significance Evaluation: The safety significance of this event is minimal and Unit 2 is in a stable condition. All control rods properly inserted when the manual scram was performed. Plant safety systems responded as required with the exception of the CREV and ARI systems which did not automatically initiate but functioned properly when manually actuated. All four emergency diesels started and Unit 2 diesels 3 and 4 are supplying the Unit 2 emergency buses. Reactor pressure and level are being controlled per procedure, with HPCI and RCIC. Actions are in progress to re-establish off site power supply to emergency buses 3 and 4 via backfeed through the Unit Auxiliary Transformer (UAT).

"Corrective Actions: Actions are in progress to re-establish offsite power supply to emergency buses 3 and 4 via backfeed through the UAT. Investigations are in progress to determine the cause of the SAT failure and the failure of CREV and ARI to auto-initiate."

The licensee has notified the NRC Resident Inspector and the State and local emergency agencies.

Update provided also added the following reportable notifications due to the event: 10CFR50.72(b)(2) (iv)(A) and(iv)(B) and 10CFR50.72(b)(3)(iv)(A). Notified R2DO (Evans).

* * * UPDATE PROVIDED BY MARK SCHALL TO JEFF ROTTON AT 1805 EST ON 11/02/06 * * *

Licensee reported that the Unusual Event was terminated at 1745 EST on 11/02/06 after Offsite power was restored to both 4 KV E Buses from the Unit Auxiliary Transformer (UAT) on Unit 2. The #3 and #4 EDGs have been secured and are in Standby. #1 EDG remains inoperable and #2 EDG is presently being Load Tested.

The licensee will be notifying the NRC Resident Inspector and the State and local emergency agencies.

Notified R2DO (Evans), NRREO (Richards), IRD Manager (Leach), DHS (Barnes), and FEMA (Kuzia).

LOST TRITIUM FOIL SOURCE

A licensee representative reported that a 600 milliCurie tritium foil source (SSDR IL8138D802S) has been lost from a static measuring device (Tritium Static Wand). The source was discovered to be missing when the device was determined to not be operating correctly. The licensee is uncertain how the tritium source may have fallen out of the device. When the source is missing the device continues to operate providing a low static reading such that it would not be obvious that the source was no longer present or that the device is not functioning properly. The device is not routinely calibrated. The device was shipped to the facility about 2 months ago from the 3-M St. Paul, MN, facility and was verified to contain the source when shipped. The licensee has searched likely facility locations where the source could be located including trash and scrap.

The licensee plans on notifying the State of Indiana and the Region 3 Inspector.

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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

AGREEMENT STATE - PERSONNEL UNDEREXPOSURE

The State was notified by the licensee's RSO that a patient had an underexposure by 24%. The State will provide updates as licensee information is received.

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.

* * * RETRACTION PROVIDED BY K. SIEBERT TO KOZAL ON 3/14/07 AT 1333 EDT * * *

After review of the event by the licensee and the State, the material involved in this event (Palladium -103) is accelerator produced and is not regulated by the NRC. Therefore, this event is not reportable and is retracted.

Notified R4DO (Shannon) and FSME (G. Morell)

LOSS OF UNIT-2 AUX TRANSFORMER CAUSED UNIT-1 SYSTEM ISOLATIONS AND ACTUATIONS

"This report is being made in accordance with 50.73 (a)(1), which states, in part, 'In the case of an invalid actuation reported under 50.73 (a)(2)(iv), other than actuation of the reactor protection system (RPS) when the reactor is critical, the licensee may, at its option, provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER.' These invalid actuations are being reported under 50.73 (a)(2)(iv)(A), NUREG-1022, Rev. 2, states that the report should provide the following information:

The specific train(s) and system(s) that were actuated
Whether each train actuation was complete or partial
Whether or not the system started and functioned successfully.

"On November 1, 2006, with Unit 1 operating at 100% of rated thermal power, the loss of the Unit 2 Startup Auxiliary Transformer resulted in loss of power to the isolation logic associated with the common main stack radiation monitor resulting in actuations normally associated with a high radiation signal. This invalid signal resulted in actuation of the Unit 1 Primary Containment Isolation System (PCIS) Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems) valves, a Unit 1 Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation) and the automatic start of both Unit 1 Standby Gas Treatment (SGT) System trains A and B. The actuations of PCIS Group 6 valves and Reactor Building Ventilation System isolation were complete and the affected equipment responded as designed to the invalid signal (i.e., the valves and dampers that were open, at the time of the event, closed). Additionally, SGT System trains A and B started and functioned successfully.

"Discussion of the causes and corrective actions associated with this event are documented in the corrective action program in Nuclear Condition Report (i.e., NCR) 211237. The resident inspector will be notified."

The System Engineer (Leo Kauffel) verified that the Unit 2 actuations resulting from this event were previously submitted in LER 2-2006-001 and are not stated in this event report.