Event Notification Report for September 11, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/10/2013 - 09/11/2013
Non-Agreement State
Event Number: 49350
Rep Org: KALISPELL REGIONAL MEDICAL CENTER
Licensee: KALISPELL REGIONAL MEDICAL CENTER
Region: 4
City: KALISPELL State: MT
County:
License #: 25-15463-01
Agreement: N
Docket:
NRC Notified By: ANDREA VANTERPOOL
HQ OPS Officer: JOHN SHOEMAKER
Licensee: KALISPELL REGIONAL MEDICAL CENTER
Region: 4
City: KALISPELL State: MT
County:
License #: 25-15463-01
Agreement: N
Docket:
NRC Notified By: ANDREA VANTERPOOL
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/16/2013
Notification Time: 16:50 [ET]
Event Date: 09/11/2013
Event Time: 14:00 [MDT]
Last Update Date: 09/16/2013
Notification Time: 16:50 [ET]
Event Date: 09/11/2013
Event Time: 14:00 [MDT]
Last Update Date: 09/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)
LOST BRACHYTHERAPY MEDICAL SOURCE
The licensee reported that a brachytherapy source/seed was lost after completion of a medical procedure. After the seed was removed from the patient, the device was improperly placed in the rack for sterilization and cleaning and it is believed the seed was lost as part of this cleaning process. Normally, the device would have been placed in a surgical bowl and moved to a flash chamber for seed recovery. The seed was a Best Double Walled I-125 seed with a 204 microcurie source, model #2301.
There was no harm to the patient or exposures to other personnel. The licensee is continuing their investigation and will provide additional information when it becomes available.
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The licensee reported that a brachytherapy source/seed was lost after completion of a medical procedure. After the seed was removed from the patient, the device was improperly placed in the rack for sterilization and cleaning and it is believed the seed was lost as part of this cleaning process. Normally, the device would have been placed in a surgical bowl and moved to a flash chamber for seed recovery. The seed was a Best Double Walled I-125 seed with a 204 microcurie source, model #2301.
There was no harm to the patient or exposures to other personnel. The licensee is continuing their investigation and will provide additional information when it becomes available.
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 49338
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: FROEHLING & ROBERTSON
Region: 1
City: SUTHERLAND State: VA
County: DINWIDDIE
License #: VA-760-096-02
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: DONALD NORWOOD
Licensee: FROEHLING & ROBERTSON
Region: 1
City: SUTHERLAND State: VA
County: DINWIDDIE
License #: VA-760-096-02
Agreement: Y
Docket:
NRC Notified By: MICHAEL WELLING
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/11/2013
Notification Time: 17:24 [ET]
Event Date: 09/11/2013
Event Time: 00:00 [EDT]
Last Update Date: 09/12/2013
Notification Time: 17:24 [ET]
Event Date: 09/11/2013
Event Time: 00:00 [EDT]
Last Update Date: 09/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
FSME EVENTS RESOURCE (E-MA)
ILTAB (E-MA)
CHRISTOPHER CAHILL (R1DO)
FSME EVENTS RESOURCE (E-MA)
ILTAB (E-MA)
AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following information was received via facsimile:
"A Troxler model 3411 gauge was stolen from the licensee's truck while at a temporary jobsite. The authorized user placed the gauge in the back of the truck and stepped away to perform other work. When he returned, he found the gauge was gone. He contacted his RSO. The Dinwiddie Sheriff's office was notified and a report filed. The licensee searched the near area but did not find the gauge.
"A press release is being issued by VDH [Virginia Department of Health] utilizing the Richmond and Petersburg area media outlets."
Virginia Report Number: VA-13-08
* * * UPDATE FROM MIKE WELLING TO JOHN SHOEMAKER AT 1605 EDT ON 9/12/13 * * *
"On September 12, 2013, a member of the public returned the gauge to a local business who then contacted the local authorities. The [Virginia] RMP (Radiation Materials Program) was notified and a staff member was dispatched to ascertain the gauge condition. A survey was performed and all readings were found to be within expected dose rates. A wipe test of the gauge was performed and no contamination was found. The licensee was notified and arrived on scene. The gauge was returned to the licensee and an observation was made of the gauge being blocked and braced and secured with cables in the vehicle. An investigation is being performed by RMP."
Notified R1DO (Cahill), FSME Events Resource (via email), and ILTAB (via email).
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was received via facsimile:
"A Troxler model 3411 gauge was stolen from the licensee's truck while at a temporary jobsite. The authorized user placed the gauge in the back of the truck and stepped away to perform other work. When he returned, he found the gauge was gone. He contacted his RSO. The Dinwiddie Sheriff's office was notified and a report filed. The licensee searched the near area but did not find the gauge.
"A press release is being issued by VDH [Virginia Department of Health] utilizing the Richmond and Petersburg area media outlets."
Virginia Report Number: VA-13-08
* * * UPDATE FROM MIKE WELLING TO JOHN SHOEMAKER AT 1605 EDT ON 9/12/13 * * *
"On September 12, 2013, a member of the public returned the gauge to a local business who then contacted the local authorities. The [Virginia] RMP (Radiation Materials Program) was notified and a staff member was dispatched to ascertain the gauge condition. A survey was performed and all readings were found to be within expected dose rates. A wipe test of the gauge was performed and no contamination was found. The licensee was notified and arrived on scene. The gauge was returned to the licensee and an observation was made of the gauge being blocked and braced and secured with cables in the vehicle. An investigation is being performed by RMP."
Notified R1DO (Cahill), FSME Events Resource (via email), and ILTAB (via email).
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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Power Reactor
Event Number: 49339
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARCY BLOW
HQ OPS Officer: MARK ABRAMOVITZ
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARCY BLOW
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/11/2013
Notification Time: 20:37 [ET]
Event Date: 09/11/2013
Event Time: 17:31 [CDT]
Last Update Date: 09/12/2013
Notification Time: 20:37 [ET]
Event Date: 09/11/2013
Event Time: 17:31 [CDT]
Last Update Date: 09/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MICHAEL HAY (R4DO)
MICHAEL HAY (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 50 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO LOSS OF COOLING TO SWITCHGEAR ROOMS
"Wolf Creek has commenced a plant shutdown in accordance with Technical Specifications. The A Train Class 1E Electrical Equipment Air Conditioning unit was declared non-functional due to a possible failed compressor cylinder, as indicated by increased vibration. This failure could prevent the unit from performing its required function over its required mission time, as required by Technical Specifications 3.8.4, 3.8.7, and 3.8.9. The following safety related electrical equipment was declared inoperable: 4.16KV Bus NB01; 480 Volt AC buses NG01 and NG03; 120 Volt Instrument AC inverters and buses NN11, NN13, NN01 and NN03; 125 VDC chargers and buses NK11, NK13, NN01 and NN03.
"Technical Specification 3.0.3 was entered at 1645 CDT on 9/11/2013 from Technical Specification 3.8.7 due to two out of four 120 VAC inverters (NN11 and NN13) being inoperable. Plant shutdown to Mode 5 commenced at 1731 CDT. The unit is currently at approximately 50% power.
"All electrical systems listed above remain available but are declared inoperable due to inadequate room cooling capability.
"No major equipment is out of service.
"The NRC Resident Inspector has been notified."
No switchgear room temperature limits were challenged.
See EN #49008 (May 6, 2013) and EN #49126 (June 17, 2013) for similar events.
* * * UPDATE ON 9/12/13 AT 0215 EDT FROM MARCY BLOW TO HUFFMAN * * *
"At 00:36 CDT 9/12/13, Wolf Creek had an Auxiliary Feedwater Actuation during a plant shutdown in accordance with Technical Specifications. The plant was in Mode 3, all control rods inserted, with reactor trip breakers closed when low steam generator levels prompted a manual reactor trip. A Valid Auxiliary Feed Actuation signal was received due to low steam generator levels. All Auxiliary Feedwater pumps started and operated as expected."
The licensee has informed the NRC Resident Inspector. R4DO (Hay) notified.
"Wolf Creek has commenced a plant shutdown in accordance with Technical Specifications. The A Train Class 1E Electrical Equipment Air Conditioning unit was declared non-functional due to a possible failed compressor cylinder, as indicated by increased vibration. This failure could prevent the unit from performing its required function over its required mission time, as required by Technical Specifications 3.8.4, 3.8.7, and 3.8.9. The following safety related electrical equipment was declared inoperable: 4.16KV Bus NB01; 480 Volt AC buses NG01 and NG03; 120 Volt Instrument AC inverters and buses NN11, NN13, NN01 and NN03; 125 VDC chargers and buses NK11, NK13, NN01 and NN03.
"Technical Specification 3.0.3 was entered at 1645 CDT on 9/11/2013 from Technical Specification 3.8.7 due to two out of four 120 VAC inverters (NN11 and NN13) being inoperable. Plant shutdown to Mode 5 commenced at 1731 CDT. The unit is currently at approximately 50% power.
"All electrical systems listed above remain available but are declared inoperable due to inadequate room cooling capability.
"No major equipment is out of service.
"The NRC Resident Inspector has been notified."
No switchgear room temperature limits were challenged.
See EN #49008 (May 6, 2013) and EN #49126 (June 17, 2013) for similar events.
* * * UPDATE ON 9/12/13 AT 0215 EDT FROM MARCY BLOW TO HUFFMAN * * *
"At 00:36 CDT 9/12/13, Wolf Creek had an Auxiliary Feedwater Actuation during a plant shutdown in accordance with Technical Specifications. The plant was in Mode 3, all control rods inserted, with reactor trip breakers closed when low steam generator levels prompted a manual reactor trip. A Valid Auxiliary Feed Actuation signal was received due to low steam generator levels. All Auxiliary Feedwater pumps started and operated as expected."
The licensee has informed the NRC Resident Inspector. R4DO (Hay) notified.