Event Notification Report for March 19, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/18/2009 - 03/19/2009
Power Reactor
Event Number: 44920
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: MARK ABRAMOVITZ
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/19/2009
Notification Time: 21:39 [ET]
Event Date: 03/19/2009
Event Time: 15:32 [CDT]
Last Update Date: 03/20/2009
Notification Time: 21:39 [ET]
Event Date: 03/19/2009
Event Time: 15:32 [CDT]
Last Update Date: 03/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARK RING (R3)
MARK RING (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNPLANNED START OF A COOLING WATER PUMP DURING TESTING
"In preparation for planned maintenance of 12 Diesel Driven Cooling Water Pump (Train A), 121 Cooling Water Pump was aligned as a safeguards replacement pump per plant procedures. Maintenance steps were then completed to a point allowing testing and 12 DDCLP was restored. The Operations procedure steps to enter the Cooling Water LCO 3.7.8 Condition A and realign 121 CL Pump away from being a safeguards replacement were missed and permission was granted to perform testing. 12 DDCLP was locally started per the PM and then tripped as directed from rated speed at 1513. The pump trip resulted in a cooling water pressure transient that automatically started 121 CLP and is reportable under 10CFR 50.72(b)(3) as an unplanned safety related system actuation. 121 CLP operated normally and there were no adverse plant effects from the transient.
"During the investigation of the automatic start, it was recognized that with 121 CLP still aligned as a safeguards replacement and 12 DDCLP running locally, a Safety Injection signal and start of 22 Diesel Driven Cooling Water Pump (Train B) would result in 121 CLP trip. LCO 3.7.8 Condition A was entered for one safeguards pump OOS and 121 CLP was returned to OPERABLE status at 1613. 121 Cooling Water Pump was shut down and returned to standby at 1936.
"Maintenance activities and testing for 12 DDCLP have been suspended pending investigation and corrective actions. 121 CLP remains aligned as a safeguards replacement and both cooling water headers have operable safeguards pumps."
The licensee notified the NRC Resident Inspector.
* * * * UPDATE AT 1700 EDT ON 03/20/09 FROM TYLER GREENFIELD TO S. SANDIN * * *
"The licensee has completed its initial investigation and corrective actions. Maintenance and testing activities for 12 Diesel Driven Cooling Water Pump has resumed.
"There was an error in the text of the initial notification, the time of the autostart of 121 Motor Driven Cooing Water Pump was 1532 not 1513."
The licensee informed the NRC Resident Inspector. Notified R3DO (Ring).
"In preparation for planned maintenance of 12 Diesel Driven Cooling Water Pump (Train A), 121 Cooling Water Pump was aligned as a safeguards replacement pump per plant procedures. Maintenance steps were then completed to a point allowing testing and 12 DDCLP was restored. The Operations procedure steps to enter the Cooling Water LCO 3.7.8 Condition A and realign 121 CL Pump away from being a safeguards replacement were missed and permission was granted to perform testing. 12 DDCLP was locally started per the PM and then tripped as directed from rated speed at 1513. The pump trip resulted in a cooling water pressure transient that automatically started 121 CLP and is reportable under 10CFR 50.72(b)(3) as an unplanned safety related system actuation. 121 CLP operated normally and there were no adverse plant effects from the transient.
"During the investigation of the automatic start, it was recognized that with 121 CLP still aligned as a safeguards replacement and 12 DDCLP running locally, a Safety Injection signal and start of 22 Diesel Driven Cooling Water Pump (Train B) would result in 121 CLP trip. LCO 3.7.8 Condition A was entered for one safeguards pump OOS and 121 CLP was returned to OPERABLE status at 1613. 121 Cooling Water Pump was shut down and returned to standby at 1936.
"Maintenance activities and testing for 12 DDCLP have been suspended pending investigation and corrective actions. 121 CLP remains aligned as a safeguards replacement and both cooling water headers have operable safeguards pumps."
The licensee notified the NRC Resident Inspector.
* * * * UPDATE AT 1700 EDT ON 03/20/09 FROM TYLER GREENFIELD TO S. SANDIN * * *
"The licensee has completed its initial investigation and corrective actions. Maintenance and testing activities for 12 Diesel Driven Cooling Water Pump has resumed.
"There was an error in the text of the initial notification, the time of the autostart of 121 Motor Driven Cooing Water Pump was 1532 not 1513."
The licensee informed the NRC Resident Inspector. Notified R3DO (Ring).
General Information or Other
Event Number: 44917
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: CHERYL K. ROGERS
HQ OPS Officer: STEVE SANDIN
Licensee: UNIVERSITY OF WISCONSIN - MADISON
Region: 3
City: MADISON State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: CHERYL K. ROGERS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/19/2009
Notification Time: 12:57 [ET]
Event Date: 03/19/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/20/2009
Notification Time: 12:57 [ET]
Event Date: 03/19/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK RING (R3)
ANGELA McINTOSH (FSME)
MARK RING (R3)
ANGELA McINTOSH (FSME)
AGREEMENT STATE REPORT INVOLVING IMPROPERLY PACKAGED MATERIAL
The following information was received from the State of Wisconsin via fax:
"On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Officer, but was shipped directly to the University calibration lab on March 18, 2009 and received about 3:30 pm. Alarms went off at the loading dock and the calibration lab when the package was delivered. The [transportation index] TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The licensee wipe tested the package and found no removable contamination. The package has been placed in a secured area and has not been opened.
"The RSO has contacted the shipper's contact person at LAC + USC and the courier. The package is approximately 10 inches x 10 inches x 10 inches in size. The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public dose limit may have been exceeded."
Wisconsin Event Report ID No.: WI09004
* * * UPDATE AT 1646 EDT ON 03/20/09 FROM CHERYL K. ROGERS TO S. SANDIN * * *
The following information was provided as an update via fax:
"On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Office as required, but was shipped directly to the University Calibration Lab on March 18, 2009. It was received and signed for at the Wisconsin Institute for Medical Research (WIMR) loading dock at around 9:00 am and delivered to the calibration lab at 9:52 am. An area monitor in the lab shipping/receiving room alarmed when the package was delivered. A student worker immediately notified the Technical Director of the UW Calibration Lab.
"The Director used a meter to identity the package and noted that the exposure rate on one package exceeded 50 mR/hr on contact. The package was placed on a cart and transported to a secure location. The TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The package was approximately 10 inches x 10 inches x 10 inches in size. The licensee conducted a thorough wipe test and confirmed that there was no removable contamination on the outside of the package. He then left a message for UW Safety.
"The call was returned about noon and the Safety Office staff arrived around 2 pm. The RSO and Assistant RSO concluded that the two sealed sources were outside of the lead shielded container due to the high radiation readings on contact with the package. The RSO called the shipper's contact person named on the shipping papers at LA County, University of Southern California and the courier. The individual who had prepared the package stated that the package must have been opened either in transport or by the Calibration Lab. The UW-Madison RSO emphatically stated that the package had not been opened.
"The State of Wisconsin was notified on the morning of March 19, 2009 and made an immediate notification to the NRC Operations Center. Contact was established with the California jurisdiction for the shipper/licensee in order to facilitate contact with the licensee's radiation safety office. The State of Wisconsin inspector made arrangements to be present on the morning of March 20, 2009 to monitor and video the package opening.
"On March 20, 2009, the Director of the UW Radiation Calibration Laboratory carefully opened the package and conducted multiple wipe tests to assure there was no contamination inside the package. The package contained an open lead pig. The sources were loose in the box. One source was located under the bottom of the styrofoam tray and one source was stuck in the styrofoam tray. There were multiple problems with the packaging, markings and shipping paperwork. The main problems were that the lead pig was not adequately taped shut and the inner packaging was not sufficient to hold the pig in place, thus, the pig moved about in the package. It does not appear that this was an approved shipping container. The sealed sources were wipe tested and were not leaking, however, the Director would like to take a closer look at the sources to assure that they were not damaged.
"The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public close limit may have been exceeded."
Notified R3DO (Ring) and FSME (Camper).
The following information was received from the State of Wisconsin via fax:
"On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Officer, but was shipped directly to the University calibration lab on March 18, 2009 and received about 3:30 pm. Alarms went off at the loading dock and the calibration lab when the package was delivered. The [transportation index] TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The licensee wipe tested the package and found no removable contamination. The package has been placed in a secured area and has not been opened.
"The RSO has contacted the shipper's contact person at LAC + USC and the courier. The package is approximately 10 inches x 10 inches x 10 inches in size. The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public dose limit may have been exceeded."
Wisconsin Event Report ID No.: WI09004
* * * UPDATE AT 1646 EDT ON 03/20/09 FROM CHERYL K. ROGERS TO S. SANDIN * * *
The following information was provided as an update via fax:
"On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Office as required, but was shipped directly to the University Calibration Lab on March 18, 2009. It was received and signed for at the Wisconsin Institute for Medical Research (WIMR) loading dock at around 9:00 am and delivered to the calibration lab at 9:52 am. An area monitor in the lab shipping/receiving room alarmed when the package was delivered. A student worker immediately notified the Technical Director of the UW Calibration Lab.
"The Director used a meter to identity the package and noted that the exposure rate on one package exceeded 50 mR/hr on contact. The package was placed on a cart and transported to a secure location. The TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The package was approximately 10 inches x 10 inches x 10 inches in size. The licensee conducted a thorough wipe test and confirmed that there was no removable contamination on the outside of the package. He then left a message for UW Safety.
"The call was returned about noon and the Safety Office staff arrived around 2 pm. The RSO and Assistant RSO concluded that the two sealed sources were outside of the lead shielded container due to the high radiation readings on contact with the package. The RSO called the shipper's contact person named on the shipping papers at LA County, University of Southern California and the courier. The individual who had prepared the package stated that the package must have been opened either in transport or by the Calibration Lab. The UW-Madison RSO emphatically stated that the package had not been opened.
"The State of Wisconsin was notified on the morning of March 19, 2009 and made an immediate notification to the NRC Operations Center. Contact was established with the California jurisdiction for the shipper/licensee in order to facilitate contact with the licensee's radiation safety office. The State of Wisconsin inspector made arrangements to be present on the morning of March 20, 2009 to monitor and video the package opening.
"On March 20, 2009, the Director of the UW Radiation Calibration Laboratory carefully opened the package and conducted multiple wipe tests to assure there was no contamination inside the package. The package contained an open lead pig. The sources were loose in the box. One source was located under the bottom of the styrofoam tray and one source was stuck in the styrofoam tray. There were multiple problems with the packaging, markings and shipping paperwork. The main problems were that the lead pig was not adequately taped shut and the inner packaging was not sufficient to hold the pig in place, thus, the pig moved about in the package. It does not appear that this was an approved shipping container. The sealed sources were wipe tested and were not leaking, however, the Director would like to take a closer look at the sources to assure that they were not damaged.
"The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public close limit may have been exceeded."
Notified R3DO (Ring) and FSME (Camper).
Hospital
Event Number: 44918
Rep Org: VIRTUA HEALTH SYSTEM
Licensee: VIRTUA HEALTH SYSTEM
Region: 1
City: MARLTON State: NJ
County:
License #: 29-01862
Agreement: N
Docket:
NRC Notified By: DAN JANUSESKI
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: VIRTUA HEALTH SYSTEM
Region: 1
City: MARLTON State: NJ
County:
License #: 29-01862
Agreement: N
Docket:
NRC Notified By: DAN JANUSESKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/19/2009
Notification Time: 17:01 [ET]
Event Date: 03/19/2009
Event Time: 14:15 [EDT]
Last Update Date: 03/20/2009
Notification Time: 17:01 [ET]
Event Date: 03/19/2009
Event Time: 14:15 [EDT]
Last Update Date: 03/20/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANNE DEFRANCISCO (R1)
LARRY CAMPER (FSME)
ANNE DEFRANCISCO (R1)
LARRY CAMPER (FSME)
MEDICAL BRACHYTHERAPY TO UNINTENDED SITE
"At approx. 1415 hrs. [3/19/09] the physicist was performing a post operative dosimetry analysis of the Iodine-125 prostate seed brachytherapy implant for [the patient] when it was discovered that none of the implanted seeds made it to their intended destination, and were, in fact, implanted outside the target organ. The seeds retained their planned pattern grouping, with the superior end of the seed cloud being about 2 cm from the apex of the prostate gland. A dosimetric analysis of the CT image revealed all 93 seeds accounted for, and a calculated dose to 90% of the target organ (prescription line) being 2.24 Gy. The prescribed dose in the Written Directive was 145 Gy.
"As the seeds appear distal to the target organ, the dose appears to be maximally confined to soft tissue including muscle and subcutaneous fat. A complete analysis was requested of the Radiation Oncologist who was immediately informed. A preliminary dose report was printed for review.
"Actions Taken: The attending Radiation Oncologist was immediately notified. It was also noted by the physicist/RSO that this event was reportable as a Medical Event under 10CFR35. [The] License Administrator, was notified at approximately 3:00 PM as was the Nuclear Medicine Manager. The preliminary dosimetry report was printed at 1632 hrs and the NRC Operations Center was notified at 1701 hrs by telephone. A follow-up notice will be emailed to the Ops Center within 1 hr.
"The involved individuals were notified of the NRC contact and a request was made for an investigation. Marlton Risk Management will also be informed."
Incident Number: 2009-03-19
A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.
"At approx. 1415 hrs. [3/19/09] the physicist was performing a post operative dosimetry analysis of the Iodine-125 prostate seed brachytherapy implant for [the patient] when it was discovered that none of the implanted seeds made it to their intended destination, and were, in fact, implanted outside the target organ. The seeds retained their planned pattern grouping, with the superior end of the seed cloud being about 2 cm from the apex of the prostate gland. A dosimetric analysis of the CT image revealed all 93 seeds accounted for, and a calculated dose to 90% of the target organ (prescription line) being 2.24 Gy. The prescribed dose in the Written Directive was 145 Gy.
"As the seeds appear distal to the target organ, the dose appears to be maximally confined to soft tissue including muscle and subcutaneous fat. A complete analysis was requested of the Radiation Oncologist who was immediately informed. A preliminary dose report was printed for review.
"Actions Taken: The attending Radiation Oncologist was immediately notified. It was also noted by the physicist/RSO that this event was reportable as a Medical Event under 10CFR35. [The] License Administrator, was notified at approximately 3:00 PM as was the Nuclear Medicine Manager. The preliminary dosimetry report was printed at 1632 hrs and the NRC Operations Center was notified at 1701 hrs by telephone. A follow-up notice will be emailed to the Ops Center within 1 hr.
"The involved individuals were notified of the NRC contact and a request was made for an investigation. Marlton Risk Management will also be informed."
Incident Number: 2009-03-19
A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.