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Event Notification Report for June 6, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/05/2007 - 06/06/2007

** EVENT NUMBERS **


43398 43399 43401 43404 43406 43407

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General Information or Other Event Number: 43398
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA ST. LUKE'S MEDICAL CENTER
Region: 3
City: MILWAUKEE State: WI
County:
License #: 079-1281-01
Agreement: Y
Docket:
NRC Notified By: SEAN MATYAS
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/01/2007
Notification Time: 10:15 [ET]
Event Date: 05/31/2007
Event Time: [CDT]
Last Update Date: 06/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH O'BRIEN (R3)
CYNTHIA FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT OF A MEDICAL EVENT INVOLVING AN UNDERDOSE

The following information was received via email from the State of Wisconsin:

"Event Report ID No.: WI070011

"License No.: 079-1281-01
"Licensee: Aurora St. Luke's Medical Center

"Event Location: Aurora St. Luke's Medical Center, Milwaukee, WI

"Event Type: Medical Event
"Notifications: RSO called DHFS 5/31/2007

"Event description: On the morning of 5/31/2007 a Y-90 TheraSphere procedure was attempted. 1.05 GBq (28.3 mCi) was prescribed by the authorized user's written directive to deliver 123 Gy to the patient tumor. The activity in the dose vial was in agreement with this written directive. The TheraSphere Delivery Device (TDD) was appropriately set up by the radiopharmacist and the RSO, following the check list provided by the TheraSphere manufacturer, MDS Nordion. The interventional radiologist prepared the patient under fluoroscopy and positioned the catheter to fit his desired treatment site. This was completed at 9:30 a.m. At 9:40 the TDD was attached to the catheter. The TheraSphere injection was then started by the authorized user. The RSO was monitoring the radiation exposure in the room and did not see the normally-expected rise in exposure rate as the TheraSpheres enter the catheter and then the patient. After a few moments (after the injection of about half the balloon-inflator/syringe) the injection was stopped to evaluate what had happened. The authorized user and RSO then noticed that the blue stopcock was in the wrong position, directing the TheraSpheres into the waste vial and not into the patient.

"A radiation survey revealed that most of the radioactivity was now in the waste vial, very little (if any) in the patient, and some possibly remaining in the dose vial. It was decided to complete the normal four flushes of the dose vial into the patient, and to estimate the administered dose based on the activity in the waste vial.

"After the procedure the activity in the waste vial was measured in the dose calibrator in nuclear medicine. 25.9 mCi Y-90 was measured at 10:40 a.m. This constitutes approximately 94% of the activity that was originally in the dose vial (accounting for decay).

"The RSO estimates the dose delivered to the target volume in the patient liver is 6% of the intended dose, or 7 Gy.

"At 11:00 a.m. the RSO measured the exposure rate at the surface of the patient to be 0.00 mR/hr with a GM survey meter and 0.0 mR/hr with an ionization survey meter. Therefore, very little of the activity was injected into the patient. The waste vial is now being held for decay-in-storage. All personnel in the procedure, the TDD, and the room were surveyed and found to be free of contamination.

"The patient will be scheduled for re-treatment in the next few weeks.

"The licensee is evaluating the checklist provided by the manufacturer. DHFS will review the licensee's 15-day report and evaluate the licensee's proposed corrective actions.

"Media attention: None"

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.

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General Information or Other Event Number: 43399
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SEATTLE IRON AND METALS
Region: 4
City: SEATTLE State: WA
County:
License #: WN-R1180
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JASON KOZAL
Notification Date: 06/01/2007
Notification Time: 13:25 [ET]
Event Date: 05/17/2007
Event Time: [PDT]
Last Update Date: 06/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - NITON DEVICE SHUTTER MALFUNCTION

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

"The licensee's radiation contact individual notified Washington Department of Health (DOH) on 18 May 2007 that their Niton XLp 818 device's [used for metal composition identification] shutter mechanism malfunctioned. It contains a 30-millicurie americium-241 sealed source.

"On the morning of May 17, 2007 when the licensee attempted to start their analyzer, it failed to start properly. They called the manufacturer who was unable rectify the problem over the phone. They performed a shutter test using a Ludlum Model 19 survey meter; the reading was approximately 90 microR per hour which was greater than expected. As instructed by the manufacturer's service representative, the analyzer was packaged, properly labeled and shipped back to the manufacturer's location in Rhode Island via Federal Express. The manufacturer will repair the malfunction and perform shutter and device leak tests.

"DOH verified with the manufacturer's technical contact that the proper packaging included lead shielding adequate to completely shield the source and shutter, even if the shutter was stuck full open.

"No DOH on-site investigation. No known media attention.

"Notification Reporting Criteria:

"Per WAC 246-233-020 General License - Certain measuring, gauging or controlling devices.

"Isotope and Activity involved: one 30-millicurie americium-241 sealed source.

"Overexposures? Unknown but most likely not. The unit was functioning properly on 16 May 2007, but first thing in the morning on 17 May 2007 the unit would not start up properly. It was then the malfunction was discovered. No workers were exposed. The RCI (radiation contact individual) and one supervisor were the only people to handle this instrument after it had failed.

"Lost, Stolen or Damaged? (mfg., model, serial number): No loss or stolen. No obvious damage. It did not appear that it was dropped or anything happened to it between shut down on 16 May 2007 and start up on 17 May 2007.

"Leak test? Shutter tests have been performed and documented every six months. Most recent leak test was 13 December 2005 (no contamination, < 0.000002 microcuries)."

WA report number : WA-07-048

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General Information or Other Event Number: 43401
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: PEPG ENGINEERING, LLC
Region: 4
City: EAGLE MOUNTAIN State: UT
County:
License #: UT 1800447
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: PETE SNYDER
Notification Date: 06/01/2007
Notification Time: 14:59 [ET]
Event Date: 05/31/2007
Event Time: 10:00 [MST]
Last Update Date: 06/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4)
WILLIAM RULAND (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER

This event took place in the Southmoor Subdivision, Phase 2, Eagle Mountain, UT.

"This event involved Troxler, model 3440, serial number 28420, containing 8 [millicuries] of Cs-137 and 40 mCi of Am-241:Be. The technician was testing sidewalk compaction ahead of the cement crew and was trying to keep ahead of the concrete truck. To do so, the technician would put the gauge in the back of his truck and drive about 200 feet along to the next test site. The gauge was not put in the transportation box nor was it secured. The technician drove off the asphalted road onto a 'roughed in' dirt road. When the truck hit the bump, the Troxler gauge slid or bounced out of the truck and hit the asphalt. The technician realized very quickly that the gauge was no longer in the truck and could see it approximately 200 feet behind the vehicle. Initially, the source rod remained in the safe shielded position, but the technician tried to lift the gauge by the handle and the source rod totally detached from the remaining portion of the gauge.

"The Am-241:Be source was not damaged and remained in place."

UT Event Report ID No.: UT-07-006

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Power Reactor Event Number: 43404
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: WILLIAM BODIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/04/2007
Notification Time: 17:28 [ET]
Event Date: 06/04/2007
Event Time: 16:00 [CDT]
Last Update Date: 06/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MONTE PHILLIPS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION DUE TO IDENTIFIED NON COMPLIANT FIRE PROTECTION MANUAL OPERATOR ACTIONS

"During performance of NFPA-805 Transition Project Task SUP-1, 'Manual Action Compliance,' it was determined there were 5 non-compliant manual operator actions that were being performed to achieve and maintain hot safe shutdown in Fire Area 29, Admin Building Electrical & Piping Room 1. These manual actions were being performed in an Appendix R Section III.G.1/G.2 fire area, however, they do not meet the criteria for allowable manual actions specified in RIS 2006-10, 'Regulatory Expectations with Appendix R Paragraph III.G.2 Operator Manual Actions.'

"The discovery of these non-compliant manual actions is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii). The alternate compensatory measure for Fire Area 29 is to perform the manual action. An extent of condition review has been initiated that will encompass the remainder of the safe shutdown areas in both Prairie Island Nuclear Generating Plant (PINGP) units. The results of the extent of condition will be documented in the site's corrective action program with compensatory measures being established as appropriate. The 60-day licensee event report, submitted to the Commission in accordance with 10 CFR 50.73(a)(2)(ii), will provide the results of the manual action compliance review and follow-up corrective actions."

The licensee will notify the NRC Resident Inspector.

* * * UPDATE FROM W. BODIN TO P. SNYDER AT 1643 ON 6/5/07 * * *

"During performance of NFPA-805 Transition Project Task SUP-1, 'Manual Action Compliance,' it was determined that non compliant manual operator actions are credited to achieve and maintain hot safe shutdown for a fire. The following actions were identified during the extent of condition reviews conducted subsequent to EN 43404 report."

Numbers of Non-compliant Actions and Fire Areas Affected:
"2 actions for Fire Area 2, Ventilation Fan Room, Unit 1;
"2 actions for Fire Area 10, Train A Event Monitoring Equipment Room;
"6 actions for Fire Area 20, Unit 1 4.16 KV Safeguards Switchgear (Bus 16);
"2 actions for Fire Area 22, 480V Safeguards Switchgear (Bus 121);
"1 action for Fire Area 23, Unit 2, 4.16 KV Normal Switchgear (Bus 23, 24);
"2 actions for Fire Area 30, Administration Building Electrical & Piping Room #2;
"1 action for Fire Area 33, Battery Room 11;
"1 action for Fire Area 34, Battery Room 12;
"6 actions for Fire Area 37, Unit 1 480V Normal Switchgear Room;
"4 actions for Fire Area 41A, Screenhouse (DDCWP Rooms);
"6 actions for Fire Area 41B, Screenhouse Basement;
"10 actions for Fire Area 58 and 73, [Auxiliary] Building Ground Floor Unit 1 & 2;
"2 actions for Fire Area 59, [Auxiliary] Building Mezzanine Level Unit 1;
"1 action for Fire Area 80, 480V Safeguard Switchgear Room (Bus 112); and
"4 actions for Fire Area 81, 4.16 KV Safeguard Switchgear Room (Bus 15).

"These manual actions are credited for safe shutdown in an Appendix R Section III.G.1/G.2 fire area; however, they do not meet the criteria for allowable manual actions specified in RIS 2006-10, 'Regulatory Expectations with Appendix R Paragraph III.G-2 Operator Manual Actions.'

"The discovery or these non-compliant manual actions is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii). The manual actions have been determined to be feasible and will be treated as alternate compensatory measures for Fire Areas 2, 10, 20, 22, 23, 30, 33, 34, 37, 41A, 41B, 58, 59, 73, 80, and 81. An extent of condition review is continuing that will encompass the remainder of the safe shutdown areas in both Prairie Island Nuclear Generating Plant (PINGP) Units."

The licensee notified the NRC Resident Inspector. Notified R3DO (M. Phillips).

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Other Nuclear Material Event Number: 43406
Rep Org: MEADWESTVACO VIRGINIA CORP.
Licensee: MEADWESTVACO VIRGINIA CORP.
Region: 1
City: COVINGTON State: VA
County:
License #: 45-01568-01
Agreement: N
Docket:
NRC Notified By: RIDGE HUNDLEY
HQ OPS Officer: PETE SNYDER
Notification Date: 06/05/2007
Notification Time: 15:50 [ET]
Event Date: 06/05/2007
Event Time: 14:58 [EDT]
Last Update Date: 06/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RICHARD BARKLEY (R1)
GREG MORELL (NMSS)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

THREE LOST TRITIUM EXIT SIGNS

The licensee reported that after a thorough search of their facility in Covington, VA they cannot account for three (3) tritium exit signs. The licensee had decided to return all of their tritium exit signs to the manufacturer, SRB Technologies. They were able to return 136 of their 139 signs.

The activity of two of the signs was originally 20 Curies each on October 1990 for one sign and July of 1992 for the other sign. Because of decay the activity of the signs now is estimated to be 7.8 Curies and 8.6 Curies respectively. The activity of the third sign is estimated to be in the same range.

The licensee is not sure when the signs were lost but two were installed above an old door in the facility that was replaced with a new door in a remodel some time ago so they may have ended up in a land fill.

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.

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Power Reactor Event Number: 43407
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RYAN RODE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 06/05/2007
Notification Time: 20:03 [ET]
Event Date: 06/05/2007
Event Time: 15:17 [CDT]
Last Update Date: 06/05/2007
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):
MONTE PHILLIPS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP AFTER FEEDWATER VALVE FAILURE

"On 06/05/07 at 1512 hours CDT, operators observed that the Unit 1 main feedwater regulating valve (1 FD-476B) was going full open to full shut and entered abnormal operating procedure (AOP) 2B for a feedwater system malfunction. An immediate inspection of the valve determined that the valve positioner arm was disconnected, with the positioner arm locknut found on the floor adjacent to the valve. Operators manually tripped the Unit 1 reactor at 1517 hours CDT in response to the loss of 'B' train main feedwater control. During the trip, the auxiliary feedwater system actuated due to low level in the 'B' steam generator and an actuation of the ATWS mitigating system (AMSAC).

"Plant systems and equipment functioned properly following the manual trip with the following exceptions: A switchyard bus section 2 lockout occurred, resulting in loss of 345 Kv Line 121; 1FD-2603 bleeder trip valve (1 HX-22A moisture reheater drain) stuck open; and 1 P-129A turbine bearing oil lift pump did not automatically start, but was successfully started manually.

"Troubleshooting and additional investigations are continuing. The affected equipment has been quarantined. Unit 1 is in MODE 3 and is stable. Unit 2 was unaffected by the Unit 1 manual trip."

All control rods fully inserted on the trip. No safety or relief valves lifted from the trip. Reactor pressure and temperature are being maintained with main feedwater and steaming to the main condenser. Emergency Diesel Generator GO-1 (two EDGs per train) and one Service Water Pump are out of service for replacement.

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012