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Event Notification Report for November 14, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/13/2007 - 11/14/2007

** EVENT NUMBERS **


43753 43774 43775 43777 43778 43780

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43753
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: BERNIE LITKETT
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2007
Notification Time: 02:12 [ET]
Event Date: 10/28/2007
Event Time: 22:03 [EDT]
Last Update Date: 11/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JOHN CARUSO (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

REFUEL FLOOR EXHAUST HI-HI RADIATION ALARMS DURING REACTOR REASSEMBLY

"On 10/28/07 at 2203 in Operational Condition 5, two of three Refuel Floor Exhaust Radiation Monitors actuated on HI-HI Radiation during the Moisture Separator lift for Reactor Pressure Vessel Reassembly. Reactor Building Ventilation was procedurally secured at the time of the actuation to minimize the potential for airborne contamination. The cause of the elevated radiation levels at the Refuel Floor Exhaust Radiation Monitors is currently attributed to the lifting of the Moisture Separator closer to the surface of the water to obtain an unobstructed underwater path to the Reactor Pressure Vessel. The resulting ESF signal yielded an automatic start of the 'A' and 'D' Station Service Water Pumps, the Filtration Recirculation and Ventilation System, and load-shed of non-1E breaker loads. All systems responded as expected. Systems and components actuated by the condition have been restored to a normal stand-by alignment as required. No other systems were affected and the plant is stable in Operational Condition 5."

The licensee will notify the NRC Resident Inspector. The licensee notified the Lower Alloways Creek Township.

* * * RETRACTION AT 1554 ON 11/13/2007 FROM MICHAEL REED TO MARK ABRAMOVITZ * * *

"Follow up investigation has revealed that the initiation of the signals was the result of radiation levels outside of the Refuel Floor Exhaust duct, and not from the in-duct activity. This would not be considered the parameter satisfying the requirements for initiation of the safety function of the system. The actual plant condition that satisfies the requirements for initiation of the safety function of the system is to detect conditions and initiate protective actions due to a release of steam or radioactive material internal to the duct that could result in the release of fission products to the environment. As a result, this is not considered a 'valid actuation' and is being retracted. Also, upon review of the refuel floor camera system, the reason for the HI-HI actuation was that during the Moisture Separator lift, the Moisture Separator broke the surface of the water by approximately 24 inches. This caused the radiation monitors to alarm on radiation shine from the moisture separator rather than airborne activity in the exhaust duct.

"This notification also provides telephone notification of an invalid actuation other than actuation of the reactor protection system instead of submitting a written LER
1. This is not considered an LER
2. This report is being made under 10 CFR 50.73(a)(2)(iv)(A).
3. The resulting ESF signal yielded an automatic start of the 'A' and 'D' Station Service Water Pumps, the Filtration, Recirculation and Ventilation System (FRVS), and load-shed of non-1E breaker loads: all systems responded as expected. This was a complete actuation. All required systems started and functioned successfully."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Holody).

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General Information or Other Event Number: 43774
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: MEDI-PHYSICS
Region: 3
City: ARLINGTON HEIGHTS State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/08/2007
Notification Time: 14:55 [ET]
Event Date: 11/01/2007
Event Time: [CST]
Last Update Date: 11/09/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
SANDRA WASTLER (FSME)
ILTAB (email) ()

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

Event Text

ILLINOIS AGREEMENT STATE REPORT - MISSING SHIPMENT OF I-125 TO SPAIN

On 7 November 2007 at 1500 CST, the licensee notified the State of Illinois of a single package of medical therapy isotopes (I-125, 97.5 millicuries total) that was scheduled for delivery to a customer in Madrid, Spain on 1 November 2007 was missing in transit. The shipment was delivered by Medi-Physics personnel to the Iberia Airlines Cargo freight office for booking on Iberia Airlines Flight 6274, nonstop from O'Hare, IL to Madrid, Spain. The licensee has information that the shipment had not cleared customs and the shipment did not get to the freight forwarder that was contracted to deliver the shipment to a hospital in Spain. The licensee is actively trying to locate the shipment.


* * * UPDATE PROVIDED BY STATE (DAREN PERRERO) TO JEFF ROTTON VIA EMAIL AT 1703 EST ON 11/09/07 * * *

The State provided the following information via email:

"[The State of Illinois] has been notified by [Deleted], radiation safety officer, of GE Healthcare/Medi-Physics (IL-01109-01) in Arlington Heights, IL. [The licensee RSO reported that they] have been advised as of 1545 CST that their package of thirteen missing I-125 seeds totaling 95 millicuries has been located by the carrier, Iberia Cargo. The package was found intact, with no apparent damage or loss at the airport in Madrid, Spain. The package will be released from customs and sent on to the intended recipient (Hospital la FE. Servicio de Braquiterapia). Written confirmation will be provided later by Iberia Cargo."

Notified R3DO (M. Phillips) and FSME (R. Lewis). Notified 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.

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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General Information or Other Event Number: 43775
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: BARD BRACHYTHERAPY, INC
Region: 3
City: CAROL STREAM State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: DARREN PARRERO
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/09/2007
Notification Time: 15:14 [ET]
Event Date: 11/09/2007
Event Time: 11:00 [CST]
Last Update Date: 11/09/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
ROBERT LEWIS (FSME)
BLAIR SPITZBERG (R4)

Event Text

ILLINOIS AGREEMENT STATE REPORT - HIGH EXTERNAL RADIATION LEVELS ON I-125 MEDICAL SEED SHIPMENT

"This afternoon [at 1330 CST, the State of Illinois] received a call from the [Deleted], the Radiation Safety Officer [RSO] for Bard Brachytherapy located in Carol Stream, IL. The RSO advised that a package of fifty one, I-125 seeds with a total activity of 38 milliCuries, had been returned to them from a client that had abnormal radiation levels associated with the package. Surface readings showed 600 mr/hr and readings at 1 meter showed 1.4 mr/hr. Their investigation quickly showed that all sources identified in the shipping papers were accounted for. However, the lid to the pig which shielded the contents had become askew during transit due to failure to secure it properly resulting in the elevated readings. The vial within the leaded container was intact with no signs of external radioactive contamination or loss of integrity. The RSO promptly notified the shipper, Virginia Mason Medical Center of Seattle, Washington as well as the courier's (Federal Express) radiation safety officer. There is no reason to suspect that there were any overexposures to transportation personnel as a result of the event considering the low level gamma radiation associated with I-125. This event has no media attention associated with it at this time, nor are there any security concerns associated with it. Given the improper preparation of the package by the shipper, no further action is expected from Bard Brachytherapy at this time save for filing the appropriate written report."

IL Event No: IL070058

See also EN #43778, Washington State Agreement State report.

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General Information or Other Event Number: 43777
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: QUALITY INSPECTION SERVICES INC
Region: 1
City: JACKSONVILLE State: FL
County:
License #: 3043-1
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/09/2007
Notification Time: 17:56 [ET]
Event Date: 11/09/2007
Event Time: 15:30 [EST]
Last Update Date: 11/09/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARIE MILLER (R1)
ROBERT LEWIS (FSME)

Event Text

AGREEMENT STATE REPORT - TRUCK TRANSPORTING A RADIOGRAPHY CAMERA OVERTURNED

The State provided the following information via facsimile:

"At approximately 1530 hours the left rear tire of the pickup truck transporting the camera blew out. Truck rolled on its side [just West of I-4/I-95 intersection on I-4]. There were no injuries and no damage to the camera. Company personnel have custody of camera and a truck is being dispatched to retrieve it. Camera will be tested for leakage and functionality before being placed back into service. No further action will be taken in this incident."

Camera: Sential Model 424-9 S/N 3688
Source: 29 Curies Ir-192

Florida Incident: FL07-174

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General Information or Other Event Number: 43778
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: VIRGINIA MASON MEDICAL CENTER
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/10/2007
Notification Time: 11:45 [ET]
Event Date: 11/09/2007
Event Time: [PST]
Last Update Date: 11/10/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
ROBERT LEWIS (FSME)
BLAIR SPITZBERG (R4)

Event Text

AGREEMENT STATE REPORT - HIGH EXTERNAL RADIATION LEVELS ON I-125 MEDICAL SEED SHIPMENT

The State provided the following information via email:

"Bard Brachytherapy, a vendor of I-125 prostate seeds based in Carol Stream Illinois, notified the Illinois Radiation Control Program that they had received a shipment of seeds from a state of Washington licensee, Virginia Mason Medical Center, which had excessive external radiation levels. The Illinois, Division of Nuclear Safety promptly notified the state of Washington, Department of Health via phone and email.

"At the surface the package was reported to be reading 600 mR/hr while readings at a meter were 1.4 mR/hr. It was determined the lid of the pig which contained the returned seeds (51 seeds total from an original shipment of 90, with an activity of 1406 MBq [38 mCi]) had shifted during transport allowing a beam of radiation to penetrate the external surface of the transport package.

"Immediately upon notification from Illinois, the shipper (Virginia Mason Medical Center) was contacted. Washington DOH staff spoke with the Authorized Medical Physicist who provided this information: This was the remainder of a shipment originally received by the licensee on 5 November 2007. It arrived with a total of 90, I-125 seeds with an average activity of 0.4 mCi/seed. Thirty-nine of the original 90 seeds were implanted and the remaining 51 were repackaged according to the manufacturer's (Bard's) instructions.

"At the time of shipment, licensee records show a dose rate at the surface of the package of 0.14 mR/hr, and a reading at one meter of 15 microR/hr.

"The licensee, upon questioning, acknowledged this shipment differed from all prior shipments from this vendor because it was a sterile shipment (all prior shipments had been non-sterile) and thus came in new/different packaging with different packaging instructions.

"The licensee firmly believes the lid of the pig was dislodged due to abuse during shipment.

"The licensee stated they had been in contact with Bard concerning this incident. Bard has agreed that on all future such shipments for clients in the state of Washington (it was unclear if corrective action would be extended to clients in other states as well) Bard will include more tape, for sealing the 'lid' of the pig, and that repackaging shipping instructions would also include steps for taping the pig closed prior to shipment."

See also EN #43775, Illinois Agreement State report.

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Power Reactor Event Number: 43780
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: BOYD
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/13/2007
Notification Time: 07:08 [ET]
Event Date: 11/13/2007
Event Time: 06:32 [EST]
Last Update Date: 11/13/2007
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MARIE MILLER (R1)
JOHN LUBINSKI (NRR)
BRIAN McDERMOTT (IRD)
SAM COLLINS (R1RA)
JIM DYER (NRR)
T. BLOOMER (EDO)
BETH HAYDEN (PAO)
B. KEELING (OCA)
M. DAPAS (DR1R)
TOM BLOUNT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

UNUSUAL EVENT DECLARED DUE TO UNEXPECTED REACTOR VESSEL WATER LEVEL CHANGE DURING A REFUELING OUTAGE WITH IRRADIATED FUEL IN THE CORE


While in a drained down condition the reactor vessel experienced an unexplained loss of reactor coolant system inventory with irradiated fuel within the vessel. Licensee entered Emergency Action Level MU-9, Unusual Event at 0632 EST. Within a few minutes after entering EAL MU-9 reactor vessel water level returned to its initial water level of 13.7 inches above the centerline of the Hot Legs of the Reactor vessel. Licensee is investigating why reactor vessel water level changed.



Chairman Klein's Comm. Assist. (Bill Orders), Comm. Jaczko's Assist (T. Hipschman), Comm. Lyons Assist (S. Baggett), R1DO (M. Miller), R2DO (M. Lesser), R3DO (M. Phillips), R4DO (V. Campbell) , DHS (A. Ackers), FEMA (Sullivan), DOE (S. Bailey), USDA (Watts), HHS (C. Harper) , EPA (NRC) Chief Brown were notified.


* * * UPDATE ON 11/13/07 AT 1025 EST FROM J. BOYD TO MACKINNON * * *

Termination of Unusual Event.

"EAL classification of MU9 is no longer applicable. Investigation of the unplanned Reactor vessel level showed no indication of leakage into any building containing RCS piping. The apparent cause of the event is due to a slight negative pressure in the RCS. When the OTSG lower manways were installed with HEPA filters fan units running, the indicated RCS level lowered and stabilized due to the HEPA units drawing air from the RCS. No actual RCS inventory loss occurred. When the HEPA units were turned off the RCS level returned to the indicated Reactor vessel level prior to the event. In accordance with station procedures this EAL event was terminated at 0929 on 11/13/07."

The licensee notified the Resident Inspector, State and Local Officials of this event update

R1DO (D. Holody), NRR EO (J. Dozier), IRD (B. McDermott) , DHS ASWO (Ed Hoisinton) and FEMA (D. Sullivan) were notified of the termination of the Unusual Event.

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Thursday, March 29, 2012