United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2007 > December 12

Event Notification Report for December 12, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/11/2007 - 12/12/2007

** EVENT NUMBERS **


43827 43834 43835 43836 43837

To top of page
General Information or Other Event Number: 43827
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ARIZONA ONCOLOGY ASSOCIATES
Region: 4
City: SCOTTSDALE State: AZ
County:
License #: 07161
Agreement: Y
Docket:
NRC Notified By: PATRICIA HAWORTH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/07/2007
Notification Time: 15:32 [ET]
Event Date: 12/03/2007
Event Time: [MST]
Last Update Date: 12/07/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
JOSEPH GIITTER (FSME)

Event Text

ARIZONA AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

"A leaking sealed source discovered on Monday, December 3rd 2007, at the Scottsdale Radiation Oncology Center in our hot lab.

"This seed is listed as a sealed source containing Cs-131, from the company IsoRay Medical, Inc. The activity contained inside this seed was 3.12 mCi [milli-Curies] of Cs-131. The incident occurred following a patient prostate implant. This seed had become jammed in a Mick Applicator cartridge. After the patient procedure in the hospital had finished, surveys of linen, OR [Operating Room], patient bed, and trash showed readings of background with the GM [Geiger-Mueller] survey meter. The seed, still in the cartridge, was packaged inside the container it had originally arrived in and shipped to the [Scottsdale Radiation Oncology Center].

"Upon its arrival in Scottsdale, the package was surveyed externally with a wipe test which showed no contamination on the external package. It was at [Scottsdale Radiation Oncology Center] that we ascertained that the seed had leaked into its internal container and contaminated the Mick cartridge it resided in. Our personnel that regularly loads seeds was removing it with bare hands since the outside container had been surveyed and showed no contamination. The seed was dislodged into a lead container behind a leaded shield, and the cartridge was surveyed by a GM tube. Since the GM tube responded, our personnel then placed the cartridge into a lead container and then surveyed her fingers. Upon realizing she was contaminated she informed the ARSO [Assistant Radiation Safety Officer]. She was directed to wash with soap and water. After about 15 minutes her hands showed no residual contamination with a GM and pancake probe with open face. The seeds were then placed into a capped glass container and into a marked leaded container. The original shipping box was surveyed, and the decision was to bag the entire box, and store in locked cabinet for 70 days (10 half lives). A survey will be performed to prove that the container is background before it is put back into service.

"All areas and personnel were surveyed with the GM and pancake probe open faced, to confirm no residual contamination. The area and personnel were clean and further wipe tests showed only background.

"The physician was informed of incident as well as ARRA [Arizona Radiation Regulatory Agency], and IsoRay's health physicist. A calculation showed that the 15 minutes of exposure to the personnel extremities did not exceed the regulation AAC R12-1-445 of 50 rads that is reportable.

"As a corrective action, personnel will now wear rubber gloves until all cartridges are examined following the return of any seeds."

To top of page
Power Reactor Event Number: 43834
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: GENE DAMMANN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/11/2007
Notification Time: 13:57 [ET]
Event Date: 10/15/2007
Event Time: 14:02 [CST]
Last Update Date: 12/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JOHN MADERA (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

Event Text

INADVERTENT START OF EMERGENCY DIESEL GENERATOR D2

"This notification is being made to report an invalid system actuation in accordance with 10 CFR 50.73(a)(2)(iv)(A). Prairie Island Nuclear Generating Plant (PINGP) Train B Unit 1 emergency diesel generator (D2) started due to an invalid system actuation.

"On 10/15/07, at approximately 1402 hours (CDT), with PINGP Unit 1 in MODE 1, D2 started inadvertently during an air roll.

"The inadvertent start of D2 Diesel Generator occurred while the diesel was declared inoperable (Technical Specification LCO 3.8.1 CONDITION B was entered at 0916 10/15/07 and exited at 1433 10/15/07). Normally, an air roll uses starting air to turn the engine one revolution to clear oil from the top piston of the D2 opposed piston diesel engine. The D2 control switch is to be in pullout per procedure. However, due to operator error, the D2 control switch was not in pullout during the air roll and D2 started during the attempted air roll. D2 did not automatically connect to the associated emergency bus (Bus 16), because no bus undervoltage signal was present and the supply breaker was open.

"The Train A diesel generator (D1) remained operable during this event and the Train A EDG was able to provide power to the Train A emergency bus (Bus 15), if necessary. The invalid start was entered into the PINGP corrective action program. The preliminary investigation of this event determined that the D2 start was caused by operator error - the outplant operators performing the air roll missed a step in the procedure that directed calling the control room to verify the D2 control switch in pullout prior to conducting the air roll.

"Corrective actions for this event are in progress and are being tracked via the corrective action program."

The licensee will notify the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 43835
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: JASON KOZAL
Notification Date: 12/11/2007
Notification Time: 16:20 [ET]
Event Date: 12/11/2007
Event Time: 10:19 [CST]
Last Update Date: 12/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RUSSELL BYWATER (R4)

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

LOSS OF 11 ALERT AND NOTIFICATION SIRENS DUE TO SEVERE ICE STORM

"Due to a severe winter ice storm in the area surrounding Cooper Nuclear Station, 11 of 24 Alert and Notification System Sirens were discovered to be out of service as of 1019 hours on 12/11/07. This event impacts the ability to readily notify a portion of the 10 Mile Emergency Planning Zone (EPZ) Population for Cooper Nuclear Station. This event also meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii), major loss of the off-site emergency notification system.

"Eight of the failed sirens are located in Atchison County, MO (Seven have failed directly due to loss of AC power and one has partially failed due to other aspects of the storm). One of the failed sirens is located in Richardson County, NE (due to direct loss of AC Power). The other two sirens are located in Nemaha County, NE (One has failed directly due to loss of AC power and one has partially failed due to other aspects of the storm).

"Atchison, Richardson, and Nemaha County Authorities have been notified and compensatory emergency route alerting has been discussed as an alternate means of public notification. NOAA/EAS Tone Alert Radios issued for notification of rural residents within the 10-mile emergency planning zone are available and the local NOAA radio transmitter is operable. Contact of the local power utilities has been initiated so that power restoration efforts can be monitored. The licensee also notified the NRC Resident Inspector, FEMA Region 7, Missouri State Emergency Management Agency, and the Nebraska Emergency Management Agency."

To top of page
Power Reactor Event Number: 43836
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/11/2007
Notification Time: 17:28 [ET]
Event Date: 12/11/2007
Event Time: 08:55 [CST]
Last Update Date: 12/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JOHN MADERA (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

Event Text

LOSS OF RHR ROOM COOLER

"At 08:55 on 12/11/07 the division 1 RHR room cooler, V-AC-5 would not start. At approximately 10:00, troubleshooting determined that the cause of the failure was a blown line fuse on the B phase of the 480 VAC supply breaker. In accordance with plant procedures, a loss of this room cooler requires that the associated division 1 core spray pump and both division 1 LPCI pumps be declared inoperable. The result is entry into Technical Specification 3.5.1 Condition M due to having two or more ECCS injection/spray subsystems inoperable. This requires entry into LCO 3.0.3. At 10:53 on 12/11/07 the blown line fuse was replaced, the unit was tested and operability was restored. LCO 3.0.3 was exited at this time.

"The Technical Specification bases for Technical Specification 3.5.1 Condition M states that when multiple ECCS subsystems are inoperable, as stated in Condition M, the Plant is in a condition outside of the accident analyses. As described in this bases section the plant is in an unanalyzed condition and pursuant to 10 CFR 50.72(b)(3)(ii) an 8 hour report is being made.

"At this time, the station believes there was no loss of safety function. Further review of the event is in progress at the station.

"The station has informed the NRC resident inspector of this event."

To top of page
Power Reactor Event Number: 43837
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: SUSAN GARDNER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/11/2007
Notification Time: 17:53 [ET]
Event Date: 12/11/2007
Event Time: 11:05 [PST]
Last Update Date: 12/11/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RUSSELL BYWATER (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
3 N Y 100 Power Operation 100 Power Operation

Event Text

MAJOR LOSS OF COMMUNICATIONS CAPABILITY

"On Tuesday, December 11, 2007, at approximately 1105 PST, the San Onofre Nuclear Generating Station Control Room Red Phone and commercial telephone systems became inoperable for approximately 10 minutes. Control Room Red Phone operability was confirmed by a successful call to NRC Headquarters Operation Office about 1115 PST.

"Southern California Edison is reporting this event in accordance with 10CFR50.72(b)(3)(xiii) for a condition that resulted in a major loss of offsite communications capability (Emergency Notification System and offsite notification system).

"As part of the problem solving efforts, the Red Phone may become inoperable for brief periods of time.

"At the time of this report, Unit 2 is in Mode 6 in a refueling outage and Unit 3 is in Mode 1 at 100 percent power. The NRC Senior Resident Inspector has been notified of this event and provided a copy of this report."

The licensee still had satellite phone communications capability.

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