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Event Notification Report for February 7, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/06/2008 - 02/07/2008

** EVENT NUMBERS **


43950 43954 43955 43964 43967 43968

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General Information or Other Event Number: 43950
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA HEALTH CARE METRO INC
Region: 3
City: MILWAUKEE State: WI
County:
License #: 79-1281-01
Agreement: Y
Docket:
NRC Notified By: JASON HUNT
HQ OPS Officer: JOE O'HARA
Notification Date: 02/01/2008
Notification Time: 11:11 [ET]
Event Date: 01/31/2008
Event Time: 12:30 [CST]
Last Update Date: 02/01/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3)
SANDRA WASTLER (FSME)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT SAFETY FAILURE

"On Thursday, January 31, 2008 during a treatment of a patient an event occurred with the licensee's Leksell Gamma Knife Stereotactic teletherapy treatment unit (Model 24001 Type C).

"The patient treatment plan called for three exposure fractions. The first fraction was initiated at 10:25 a.m., without incident. After the normal termination time of treatment, the couch retracted fully and the patient's head was withdrawn from the unit. However, the shielding doors on the unit did not close. An Authorized Medical Physicist (AMP) then entered the treatment room, walked behind the unit, and closed the shielding doors manually. The licensee estimates that the AMP received an exposure of no more than 0.0083 mrem while closing the shielding doors. The patient was removed from the treatment room and a radiation survey was conducted to verify that the shielding doors had closed completely.

"Elekta was contacted (12:30 p.m. 01/31/08) and a service representative arrived and completed an evaluation of the Gamma Knife and could find no faults in any aspect of the Gamma Knife system operation. A decision was made by the Authorized User to complete the last two exposure factions. The remaining shots were successfully completed.

"The patient did not receive a radiation dose deviating from the written directive from the shielding doors not closing. The licensee was in constant contact with DHFS throughout this incident. This event will be followed up by DHFS on the next scheduled inspection (02/19/08).

"Event Report ID No WI-08-01

"License No.: 79-1281-01

"Event Type: HFS 157.13(17)(b)2.a - 'Equipment is disabled or thus to function as designed'"

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General Information or Other Event Number: 43954
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: ALLEGHENY RODNEY
Region: 1
City: NEW BEDFORD State: MA
County:
License #: 15-7052
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/01/2008
Notification Time: 15:49 [ET]
Event Date: 02/01/2008
Event Time: 13:00 [EST]
Last Update Date: 02/01/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT OF METAL THICKNESS GAUGE MALFUNCTION

The Massachusetts Radiation Control Program (MRCP) reported that a licensee, Allegheny Rodney (metal foil manufacturer), informed the MRCP of a malfunction in a metal thickness measuring gauge. The process gauge is supplied by Integrated Industrial Systems and contains a 1000 milliCurie Am-241source (Serial #1225). The licensee stated that the gauge is not functioning for unknown reasons and a technician from Integrated Industrial Systems will be responding to investigate the problem. There is no evidence at this time of a missing or leaking source.

MRCP intends to follow-up with the licensee early next week after the cause of the gauge malfunction has been determined.

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General Information or Other Event Number: 43955
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: ISORAY
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/01/2008
Notification Time: 19:20 [ET]
Event Date: 02/01/2008
Event Time: [PST]
Last Update Date: 02/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
LARRY CAMPER (FSME)
MATT HAHN (E-MAIL) (ILTA)

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

Event Text

AGREEMENT STATE REPORT - DEPLETED CESIUM-131 SEEDS LOST FROM DAMAGED PACKAGE DURING SHIPMENT

The State provided the following information via email:

"The Licensee reported by phone that at 2:30 PST today a package of returned and depleted implant seeds containing Cs-131 with a 9.7 day half-life was found damaged upon receipt with some of the contents missing. The package was to have contained 15 seeds that were returned from a customer on the east coast. When the package arrived, the licensee upon receipt inspection noted the package had a hole in it that had been repaired with tape. The receipt inspection also detected higher than expected dose rates at slightly less than 1 mr/hr contact with the package. The package was taken to a controlled area suitable for bio-hazard work and opened by the RSO. The package was opened and discovered with loose seeds in the box. 11 seeds were recovered, 4 seeds are missing. An Isoray facility survey was performed between the receiving area and the controlled area where the package was opened. No additional seeds were located. The sender of the package is being contacted as well as the RSO for FedEx. Highest dose rate on contact with a single seed was 1 mr/hr. The seeds were reported to have aged seven half-lives as of this day and at 1/100th of original strength. The Licensee will update our office [the State of Washington] with additional information when it comes available."

The State does not know who originated the shipment or the initial strength of the CS-131 before the seven half-life decay.

Washington State Report Number: WA-08-007


* * * UPDATE FROM ARDEN SCROOGS TO BILL HUFFMAN ON 2/4/08 AT 1504 EST VIA E-MAIL * * *

The shipment originated from Geisenger Health in Danville, PA, and was shipped by FedEx.

The original strength of the seeds was nominally 4 to 5 millicuries each, or 14 to 20 for the four missing seeds. At seven half-lives, the strength would be approximately 1/100th of the original strength, or 40 to 50 microcuries.

R4DO (Mike Shannon), FSME EO (Larry Camper), ILTAB (Matt Hahn), and R1DO (Christopher Cahill) informed.


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: 43964
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DALE SHELTON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/06/2008
Notification Time: 12:56 [ET]
Event Date: 02/06/2008
Event Time: 11:33 [CST]
Last Update Date: 02/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS KOZAK (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 27 Power Operation 27 Power Operation

Event Text

FLOOD WATCH DUE TO SNOW MELT AND HEAVY RAIN

"On February 6, 2008 at 1119 hours, Clinton Lake level reached 694 feet 0 inches (mean sea level). Normal lake level is 690 feet 0 inches. Per Clinton Power Station (CPS) procedure 4303.02, 'Abnormal Lake Level,' the CPS Main Dam - Emergency Action Plan requires that a 'Flood Watch' be declared. This resulted in a notification to the DeWitt County Sheriff's Department that occurred at 1133 hours. Lake level continues to slowly rise due to the melting snow and heavy rains received in the area for the past several days. Expected peak is approximately 694 feet 6 inches. Mitigating measures are currently being instituted as a precautionary measure in the screen house, per CPS procedures.

"The NRC Resident has been notified."

High lake level only affects the plant intake structure.

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Power Reactor Event Number: 43967
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RANDY CRANE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/06/2008
Notification Time: 20:19 [ET]
Event Date: 02/06/2008
Event Time: 19:20 [EST]
Last Update Date: 02/06/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS KOZAK (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

TRAIN "A" 250 VDC CABLE PASSES THROUGH TRAIN "B" SWITCHGEAR ROOM

"On February 6, 2008 at 1920 hours, Cook Nuclear Plant Engineering personnel identified an unanalyzed condition that has the potential to degrade plant safety. Specifically, a cable routing error in the original design for safety related Train 'A' 250 VDC was discovered. A short section of Train 'A' 250 VDC was found to pass through the Train 'B' 4kV switchgear room. This routing was discovered to exist in both units. The routing of the cabling presents the possibility that a fire could disable the remote control to both 4kV switchgear trains.

"Local inspection identified no additional or supplementary fire barrier such as fire retardant wrapping.

"Compensatory measures (fire watch) have been established.

"In accordance with 10 CFR 50.72(b)(3)(ii) this condition is reportable as a condition that resulted in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43968
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: EDWEN URQUHART
HQ OPS Officer: JOE O'HARA
Notification Date: 02/07/2008
Notification Time: 05:16 [ET]
Event Date: 02/07/2008
Event Time: 03:40 [EST]
Last Update Date: 02/07/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RANDY MUSSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

OSC HVAC SYSTEM DID NOT START AS REQUIRED

"In preparation for scheduled Motor Control Center (MCC) cleaning activities, the Health Physics normal HVAC system had to be shutdown and the Health Physics emergency HVAC was to be started while the MCC that supplies power to the normal HVAC would be out of service. When the emergency HVAC system was started per the system operating procedure (34S0-Z41-006-0), the air handling unit (1Z41-B100) started, but neither compressor units (1Z41-B101) started. Maintenance has been notified and is currently working to restore the system to operable status.

"This event is reportable per 10CFR50,72 (b)(3)(xiii) as described in NUREG-1022, rev. 2 as an emergency facility (Plant Hatch Operational Support Center) is affected with the Health Physics emergency HVAC out of service.

"Update: maintenance cleaned electrical contactors and have both compressors running at 0436 hours."

The licensee notified the NRC Resident Inspector.

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