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Event Notification Report for August 1, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/31/2007 - 08/01/2007

** EVENT NUMBERS **


43522 43530 43532 43537 43538 43541

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Hospital Event Number: 43522
Rep Org: LOUDOUN HOSPITAL
Licensee: LOUDOUN HOSPITAL
Region: 1
City: LEESBURG State: VA
County:
License #: 45-16806-01
Agreement: N
Docket:
NRC Notified By: ANNE PATTERSON
HQ OPS Officer: JASON KOZAL
Notification Date: 07/25/2007
Notification Time: 16:02 [ET]
Event Date: 07/24/2007
Event Time: 15:30 [EDT]
Last Update Date: 07/25/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PAT FINNEY (R1)
ILTAB (E-MAIL) ()
CINDY FLANNERY (FSME)

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

Event Text

LOST I-125 SEED

The licensee was performing a prostate seed case requiring 12 loose I-125 seeds with an activity of .34 mCi each. The seeds were assayed in the licensee hot lab and transported to the operating room for the procedure. After completion of the procedure only 11 seeds were accounted for. The RSO was notified. The seed was verified to not be in the patient. The licensee completed search for the material throughout the operating room and hot lab with no success. The licensee contacted the NRC Region 1 representative.


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.

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General Information or Other Event Number: 43530
Rep Org: ALABAMA RADIATION CONTROL
Licensee: VITAL INSPECTION PROFESSIONALS
Region: 1
City: ALABASTER State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CASON COAN
HQ OPS Officer: JASON KOZAL
Notification Date: 07/27/2007
Notification Time: 15:26 [ET]
Event Date: 07/26/2007
Event Time: 09:00 [CDT]
Last Update Date: 07/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1)
CINDY FLANNERY (FSME)

Event Text

AGREEMENT STATE REPORT - MALFUNCTION OF RADIOGRAPHY CAMERA SAFTEY EQUIPMENT

The State provided the following information via facsimile:

A licensee technician was performing an exposure with a INC Model IR-100 (Source: Ir-192 source strength: 41 Ci) on a test coupon in the company shooting room. When the technician attempted to retract the source the safety latch popped up to indicate that the source was in the shielded position. The technician approached the camera with a survey meter. The technician, thinking the source was retracted, turned the key to lock the camera. When the technician surveyed the front of the camera, the survey meter went off scale. The technician realized there was a malfunction exited the area and contacted the Assistant RSO (ARSO).

The ARSO and the technician determined that the source was still in front of the safety latch and not shielded. The licensee called the manufacturer for guidance. The licensee freed the source, and after several attempts was able to engage the safety latch and lock the source in the stowed position.

The camera has been taken out of service and is being shipped to the manufacturer for repair. Both the technician and the ARSO received between 2-3 mR during the event.

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General Information or Other Event Number: 43532
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: VARIAN MEDICAL SYSTEMS
Region: 1
City: CHARLOTTSVILLE State: VA
County:
License #: 45-30951-01
Agreement: N
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JASON KOZAL
Notification Date: 07/27/2007
Notification Time: 17:02 [ET]
Event Date: 07/27/2007
Event Time: 14:15 [EDT]
Last Update Date: 07/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1)
ERIC DUNCAN (R3)
DENNIS RATHBUN (FSME)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE TO RETRACT

The State provided the following information via email:

"ODH Bureau of Radiation Protection received a phone call from Varian Medical Systems at approximately 3:15 PM EDT regarding a situation which had occurred at a customer's location (St. Elizabeth Hospital in Youngstown, Ohio). The incident occurred at approximately 2:15 PM EDT. A Varian technician was performing maintenance on a Gamma Med Model 12i HDR unit, with the source extended into a shielded safe. During the maintenance action the technician disconnected a nylon tube that was part of the source wire travel path. This action caused the retract mechanism in the unit to energize, retracting the source wire from the safe, exposing approximately 8 inches of the source wire and the source end. The source is approximately 9.5 Curies of Iridium-192.

"Varian personnel believe that the disconnection of the nylon tube reduced the tension on the source wire, causing the park switch to no longer sense the presence of the wire, and energizing the retraction mechanism, which then pulled the source from the safe. The technician realized that something was not right when he heard the drive mechanism energize, and exited the treatment room immediately. Varian estimates the exposure to the technician as approximately 15 mrem, based on the activity of the source and time required to exit the room. The technician was not wearing his dosimetry at the time the incident occurred.

"Varian is sending an additional engineer to the customer location to assist with source recovery, with an estimated arrival time between 7:00 PM and 8:00 PM EDT. Varian has set-up a mock scenario at their office with the same model unit in the same configuration as what is present at the customer site. They have performed run throughs of source recovery, and have determined that the most effective method of retrieval will be to grasp the source wire with 18" forceps and then guide the source wire back into the shielded safe. They expect the evolution to take 5 - 8 seconds with an estimated whole body exposure of 25 mrem or less."

Ohio report # 2007-046

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Power Reactor Event Number: 43537
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MICHAEL REED
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/31/2007
Notification Time: 05:16 [ET]
Event Date: 07/31/2007
Event Time: 00:51 [EDT]
Last Update Date: 07/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN WHITE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"On 7/31/07 at 0051, the High Pressure Coolant Injection (HPCI) system was declared inoperable. The HPCI valve quarterly IST was in progress and the BJ-HV-8278 HPCI to Feedwater injection valve failed to respond to an open signal during stroke timing.

"Loss of the HPCI system is reportable under 10CFR50.72 (b)(3)(v) as loss of a single train safety system required to mitigate the consequences of an accident. No additional Emergency Core Cooling Systems are inoperable. The D Safety Auxiliary Cooling System (SACS) pump is inoperable for motor replacement."

The licensee is in a 14 day Hot Shutdown LCO.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43538
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIMOTHY L. SCOTT
HQ OPS Officer: JOE O'HARA
Notification Date: 07/31/2007
Notification Time: 13:39 [ET]
Event Date: 07/31/2007
Event Time: 09:30 [CDT]
Last Update Date: 07/31/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES MOORMAN (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 95 Power Operation 95 Power Operation
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO SMALL HYDRAULIC FLUID SPILL IN INTAKE BAY

"OIL SHEEN IN THE PLANT FOREBAY

"At 0930 plant personnel reported an oil sheen in the plant Forebay at the Intake Structure. The source was hydraulic oil from a small boat used to harvest and remove Milfoil [ biological plant; marine life] from the Forebay. Actions were initiated in accordance with plant procedure RWI-007, Spill Prevention Control and Countermeasures Plan. The volume of the spill was approximately one (1) gallon. The spill was stopped, contained, and clean-up efforts are in progress.

"At 1100 the National Response Center was notified of the hydraulic oil spill along with other Alabama State and local agencies.

"This event is reportable as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(xi) as an event or condition related to protection of the environment for which notification to other government agencies was made.

"The licensee has notified the NRC Senior Resident Inspector."

Specifically, the licensee notified the Alabama Department of the Environmental Management, Alabama Emergency Management Agency, and Limestone County Emergency Management Agency.

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Power Reactor Event Number: 43541
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: TONY SPRINGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 08/01/2007
Notification Time: 02:55 [ET]
Event Date: 08/01/2007
Event Time: 02:05 [EDT]
Last Update Date: 08/01/2007
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JAMES MOORMAN (R2)
BRIAN McDERMOTT (IRD)
BILL TRAVERS (R2)
JIM DYER (NRR)
PATRICK HILAND (NRR)
I. LEE (DHS)
G. CANUPP (FEMA)

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 91 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO FIRE IN PROTECTED AREA GREATER THAN 10 MINUTES

"An Unusual Event was declared based on a fire lasting > 10 minutes within the Protected Area. Fire was on a Pole Mounted Transformer located on the 230 KV Supplemental Power System in the North East corner of the Protected Area. Helper Cooling Tower Fans were lost and sequenced back on. Unit 1 maintained 100% Rated Thermal Power. Unit 2 reduced power to 91.2% due to increasing Circulating Water Temperatures per procedure. Fire was extinguished at 0213 using dry chemical fire extinguishers."

Fire was initially spotted at 0152 EDT. It is believed that a snake may have caused the transformer to arc and that the arcing caused the wood transformer pole to catch on fire. Other than the brief loss of helper cooling to the circ water, there was no other impact on the facility. No offsite assistance from the fire department was called or needed. The licensee terminated the Unusual Event at 0250 EDT.

The licensee notified local and State Authorities and the NRC Resident Inspector.

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