Event Notification Report for July 30, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/29/2009 - 07/30/2009
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 45237
Rep Org: MUNSON MEDICAL CENTER
Licensee: MUNSON MEDICAL CENTER
Region: 3
City: TRAVERSE CITY State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: DENNIS SZMANIA
HQ OPS Officer: DONG HWA PARK
Licensee: MUNSON MEDICAL CENTER
Region: 3
City: TRAVERSE CITY State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: DENNIS SZMANIA
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/30/2009
Notification Time: 15:15 [ET]
Event Date: 07/30/2009
Event Time: 09:00 [EDT]
Last Update Date: 12/23/2009
Notification Time: 15:15 [ET]
Event Date: 07/30/2009
Event Time: 09:00 [EDT]
Last Update Date: 12/23/2009
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):
ROBERT DALEY (R3DO)
CHRISTEPHER MCKENNEY (FSME)
ROBERT DALEY (R3DO)
CHRISTEPHER MCKENNEY (FSME)
POTENTIAL MEDICAL EVENT INVOLVING NOVOSTE BETA-CATH STRONTIUM BRACHYTHERAPY SYSTEM
The licensee reported that a patient was undergoing brachytherapy treatment of the heart. During the procedure, it was determined that the source was not in the proper position. The sources were retracted and the procedure reattempted. During the reattempt, it was determined that the sources were not going into the proper position. However, the licensee was not able to retract the sources into the Novoste device. The physician removed the catheter and device as an assembly and placed in a safe box. The licensee does not know the failure mode with any degree of certainty and is sending the device to the manufacturer for evaluation. The cardiologist believes it may have been a kink in the catheter. The patient was notified of the event, and the licensee discussed the issue with NRC Region 3(G. Warren).
The device is a Novoste Beta-Cath, Device number: 86865, and source number: ZB551.
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 FROM DENNIS SZMANIA TO VINCE KLCO ON 12/23/2009 @ 1056 EST* * *
The licensee is retracting the event because the source never entered the patient's body and the exposure to the patient was negligible.
Notified the R3DO(Kunowski) and FSME (Villamar).
The licensee reported that a patient was undergoing brachytherapy treatment of the heart. During the procedure, it was determined that the source was not in the proper position. The sources were retracted and the procedure reattempted. During the reattempt, it was determined that the sources were not going into the proper position. However, the licensee was not able to retract the sources into the Novoste device. The physician removed the catheter and device as an assembly and placed in a safe box. The licensee does not know the failure mode with any degree of certainty and is sending the device to the manufacturer for evaluation. The cardiologist believes it may have been a kink in the catheter. The patient was notified of the event, and the licensee discussed the issue with NRC Region 3(G. Warren).
The device is a Novoste Beta-Cath, Device number: 86865, and source number: ZB551.
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 FROM DENNIS SZMANIA TO VINCE KLCO ON 12/23/2009 @ 1056 EST* * *
The licensee is retracting the event because the source never entered the patient's body and the exposure to the patient was negligible.
Notified the R3DO(Kunowski) and FSME (Villamar).
Power Reactor
Event Number: 45238
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID BRAGLIA
HQ OPS Officer: VINCE KLCO
Region: 3 State: IL
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID BRAGLIA
HQ OPS Officer: VINCE KLCO
Notification Date: 07/30/2009
Notification Time: 22:55 [ET]
Event Date: 07/30/2009
Event Time: 21:08 [CDT]
Last Update Date: 08/02/2009
Notification Time: 22:55 [ET]
Event Date: 07/30/2009
Event Time: 21:08 [CDT]
Last Update Date: 08/02/2009
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ROBERT DALEY (R3DO)
BRIAN McDERMOTT (IRD)
ALLEN HOWE (NRR)
MARK SATORIUS (R3)
JIM WIGGINS (NRR)
ROBERT DALEY (R3DO)
BRIAN McDERMOTT (IRD)
ALLEN HOWE (NRR)
MARK SATORIUS (R3)
JIM WIGGINS (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
UNUSUAL EVENT DECLARED DUE TO A LOSS OF OFFSITE POWER FOR GREATER THAN 15 MINUTES
Unit 2 automatically tripped from 100% reactor power as a result of the over-current trip of the 2C Reactor Coolant Pump. Both station auxiliary transformers on Unit 2 subsequently tripped offline. All control rods fully inserted on the trip. Auxiliary feedwater auto-started and maintained Steam Generator water level. The unit is stable in Mode 3. The Emergency Diesel Generators auto started and loaded supplying both emergency busses with power. All systems functioned as required. There was no affect on Unit 1.
The licensee notified the NRC Resident Inspector.
* * * UPDATE AT 0218 ON 8/2/2009 FROM DEAN YARBROUGH TO MARK ABRAMOVITZ * * *
"At 2059 on July 30, 2009, a reactor trip of Unit 2 at Braidwood occurred. A loss of offsite power occurred and an Unusual Event was declared at 2108. NRC Headquarter Operations was notified at 2155 (ENS call # 45238).
"Power from System Auxiliary Transformer (SAT) (credited offsite power supply) 242-2 was restored to buses 241 and 242 (safety related buses) at 0036 on August 2, 2009.
"The Unusual Event was terminated at 0036 on August 2, 2009. This call is being made due to the termination of the Unusual Event declared on July 30, 2009.
"An Event Summary Report is required by Exelon procedures within 24 hours of termination of the Unusual Event and will be communicated to the Headquarter Operations later today."
The initial event was the result of the actuation of the SAT sudden pressure relay. When the transformer tripped, a slow automatic bus transfer resulted. When the RCPs [Reactor Coolant Pump] and condensate pumps were reenergized, they tripped on overcurrent causing the reactor trip. The sudden pressure relay has subsequently tripped during testing and may have caused the initial event. The licensee reported no damage to the plant. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Daley), IRD (McDermott), NRR (Howe), DHS (An), and FEMA (Biscoe).
* * * UPDATE AT 1617 ON 8/2/2009 FROM SCOTT BUTLER TO VINCE KLCO * * *
The Event Summary Report was received and documented the following technical conclusions:
"The Unusual Event declaration was caused by a sudden pressure relay on SAT 242-1 causing a lockout of both SATs followed by a trip of Unit 2 due to the 2C RCP tripping during the automatic bus transfer for bus 258. This led to a loss of offsite power to Unit 2. It is currently unknown why the sudden pressure relay on SAT 242-1 actuated. Troubleshooting on the sudden pressure relay is in progress."
The licensee will notify the NRC Resident Inspector.
Notified the R3DO (Daley). Notified the IRD (McDermott) and NRR (Howe) via e-mail.
Unit 2 automatically tripped from 100% reactor power as a result of the over-current trip of the 2C Reactor Coolant Pump. Both station auxiliary transformers on Unit 2 subsequently tripped offline. All control rods fully inserted on the trip. Auxiliary feedwater auto-started and maintained Steam Generator water level. The unit is stable in Mode 3. The Emergency Diesel Generators auto started and loaded supplying both emergency busses with power. All systems functioned as required. There was no affect on Unit 1.
The licensee notified the NRC Resident Inspector.
* * * UPDATE AT 0218 ON 8/2/2009 FROM DEAN YARBROUGH TO MARK ABRAMOVITZ * * *
"At 2059 on July 30, 2009, a reactor trip of Unit 2 at Braidwood occurred. A loss of offsite power occurred and an Unusual Event was declared at 2108. NRC Headquarter Operations was notified at 2155 (ENS call # 45238).
"Power from System Auxiliary Transformer (SAT) (credited offsite power supply) 242-2 was restored to buses 241 and 242 (safety related buses) at 0036 on August 2, 2009.
"The Unusual Event was terminated at 0036 on August 2, 2009. This call is being made due to the termination of the Unusual Event declared on July 30, 2009.
"An Event Summary Report is required by Exelon procedures within 24 hours of termination of the Unusual Event and will be communicated to the Headquarter Operations later today."
The initial event was the result of the actuation of the SAT sudden pressure relay. When the transformer tripped, a slow automatic bus transfer resulted. When the RCPs [Reactor Coolant Pump] and condensate pumps were reenergized, they tripped on overcurrent causing the reactor trip. The sudden pressure relay has subsequently tripped during testing and may have caused the initial event. The licensee reported no damage to the plant. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Daley), IRD (McDermott), NRR (Howe), DHS (An), and FEMA (Biscoe).
* * * UPDATE AT 1617 ON 8/2/2009 FROM SCOTT BUTLER TO VINCE KLCO * * *
The Event Summary Report was received and documented the following technical conclusions:
"The Unusual Event declaration was caused by a sudden pressure relay on SAT 242-1 causing a lockout of both SATs followed by a trip of Unit 2 due to the 2C RCP tripping during the automatic bus transfer for bus 258. This led to a loss of offsite power to Unit 2. It is currently unknown why the sudden pressure relay on SAT 242-1 actuated. Troubleshooting on the sudden pressure relay is in progress."
The licensee will notify the NRC Resident Inspector.
Notified the R3DO (Daley). Notified the IRD (McDermott) and NRR (Howe) via e-mail.
General Information or Other
Event Number: 45239
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: LONGVIEW FIBRE
Region: 4
City: LONGVIEW State: WA
County:
License #: WN-I090-1
Agreement: Y
Docket:
NRC Notified By: ANINE GRUMBLES
HQ OPS Officer: VINCE KLCO
Licensee: LONGVIEW FIBRE
Region: 4
City: LONGVIEW State: WA
County:
License #: WN-I090-1
Agreement: Y
Docket:
NRC Notified By: ANINE GRUMBLES
HQ OPS Officer: VINCE KLCO
Notification Date: 08/03/2009
Notification Time: 13:15 [ET]
Event Date: 07/30/2009
Event Time: 00:00 [PDT]
Last Update Date: 08/03/2009
Notification Time: 13:15 [ET]
Event Date: 07/30/2009
Event Time: 00:00 [PDT]
Last Update Date: 08/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
WAYNE WALKER (R4DO)
ANGELA MCINTOSH (FSME)
WAYNE WALKER (R4DO)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE - DAMAGED GAUGE
"On 11 Dec 2008 a generally-licensed fixed gauge (serial M3465, containing 80 millicuries Cs-137 as of 2nd quarter 1989; decayed to 50.4 millicuries in July 2009) was removed by the manufacturer from its installed location and placed in storage pending disposal. On 30 July 2009, a WA [Washington] Department of Health (DOH) materials inspector visited the fixed gauge licensee (also specific license WN-I090-1) to conduct a reciprocity inspection of the manufacturer's on-site activities. The manufacturer's representative was there to remove and package a total of 14 decommissioned gauges for disposal.
"Several of the gauges showed varying degrees of corrosion. The fixed gauge, serial M3465, showed significant corrosion and was missing a cover plate. The manufacturer's representative reported no unusual radiation measurements prior to packaging activities on 30 July 2009. During packaging, the fixed gauge was rolled over at which time the DOH materials inspector measured the dose rate at the opening as 500 milliRoentgen per hour. Immediate action was taken to control exposure.
"The manufacturer's representative adequately secured and shielded the gauge prior to shipping. Apparently the shutter and lead shielding that blocks the radiation beam was either broken or misaligned and failed to function as designed. There was no significant exposure to personnel. The WA DOH investigation continues."
The State of Washington incident number is: WA-09-055.
"On 11 Dec 2008 a generally-licensed fixed gauge (serial M3465, containing 80 millicuries Cs-137 as of 2nd quarter 1989; decayed to 50.4 millicuries in July 2009) was removed by the manufacturer from its installed location and placed in storage pending disposal. On 30 July 2009, a WA [Washington] Department of Health (DOH) materials inspector visited the fixed gauge licensee (also specific license WN-I090-1) to conduct a reciprocity inspection of the manufacturer's on-site activities. The manufacturer's representative was there to remove and package a total of 14 decommissioned gauges for disposal.
"Several of the gauges showed varying degrees of corrosion. The fixed gauge, serial M3465, showed significant corrosion and was missing a cover plate. The manufacturer's representative reported no unusual radiation measurements prior to packaging activities on 30 July 2009. During packaging, the fixed gauge was rolled over at which time the DOH materials inspector measured the dose rate at the opening as 500 milliRoentgen per hour. Immediate action was taken to control exposure.
"The manufacturer's representative adequately secured and shielded the gauge prior to shipping. Apparently the shutter and lead shielding that blocks the radiation beam was either broken or misaligned and failed to function as designed. There was no significant exposure to personnel. The WA DOH investigation continues."
The State of Washington incident number is: WA-09-055.