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Event Notification Report for March 28, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2008 - 03/28/2008

** EVENT NUMBERS **


43478 43942 44083 44094 44101 44102 44103

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General Information or Other Event Number: 43478
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7D-051-01
Agreement: Y
Docket:
NRC Notified By: JACK FERRUOLO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/10/2007
Notification Time: 13:40 [ET]
Event Date: 05/10/2007
Event Time: [EDT]
Last Update Date: 03/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1)
MICHELE BURGESS (FSME)

Event Text

MEDICAL AFTERLOADER-APPLICATOR PLACED IN INCORRECT LOCATION

"On 10 May 2007 it was discovered that a patient who was being treated for recurrent endometrial cancer (Paravaginal Tumor) had received a dose which differed from the prescribed dose for the fraction by greater than 50%. The intended dose to the patient was 500 cGy to the tumor. However, the dose was delivered approx 54mm from the tip of the catheter instead of 5 mm from the tip. It was noted in the misadministration report that there were no critical structures that were exposed above any threshold tolerance. Due to a physics catheter measurement error, which was entered into the treatment plan, the catheter did not go in as deeply as intended but stopped short of the target. On audit of the procedure, and remeasurement of the catheter, the chief physicist identified the error in measurement and filed a report with the RI RCA. Corrective actions in addition to re-measurement and subsequent adjustment of treatment plan included adjustment in the dose per remaining fractions to provide the correct dose to the target."

Rhode Island Report: RI-07-001

Actual initial dose was approximately 10% of expected.

Source Ir-192, 8.05 Curies

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.

* * * UPDATE FROM FLANNERY TO O'HARA VIA E-MAIL AT 0949 ON 7/11/07 * * *

"This event (EN43478) has been reviewed and determined to be a reportable medical event."

* * * UPDATE FROM FERRUOLO TO SNYDER VIA FACSIMILIE AT 1452 ON 3/27/08 * * *

The following information was received from the State via facsimilie:

"Based on preliminary information obtained per voice and e-mail: underdosing on initial fraction of treatment was due to improper measurement of the catheter. Adjustments were made in subsequent fractions. Written documentation of the incident stated that no critical structures were exposed above the threshold tolerances."

Notified R1DO (Bellamy) and FSME (McConnell).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43942
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DANIEL SEMETER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/29/2008
Notification Time: 21:50 [ET]
Event Date: 01/29/2008
Event Time: 14:41 [EST]
Last Update Date: 03/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
HAROLD GRAY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM NOT AVAILABLE FOR SAFE SHUTDOWN CAPABILITY

"The D/C power supply for the Unit 1 High Pressure Coolant Injection (HPCI) system instrumentation has failed resulting in the inability of HPCI to meet its requirement to support safely shutting down the reactor during a Station Blackout (Complete Loss of A/C Power) situation. The Emergency Core Cooling System (ECCS) function of HPCI is still available with the alternate A/C power supply."

The licensee is actively troubleshooting the power supply. The HPCI unavailability places the licensee in a 14-day Limiting Condition for Operation action statement.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM D. SEMETER TO P. SNYDER ON 3/27/08 AT 1300 * * *

"This is a retraction of the event notification made on 1/29/08 at 21:50 EST hours. This event (#43942) was initially reported as a safety system functional failure under the requirement of 10 CFR 50.72(b)(3)(v)(A). The notification stated that the D.C. power supply for the Unit 1 High Pressure Coolant Injection (HPCI) system instrumentation failed resulting in the inability of HPCI to meet its requirement to support safely shutting down the reactor during a Station Blackout (SBO) (Complete Loss of A/C Power) situation. The Emergency Core Cooling System (ECCS) function of HPCI is still available with the alternate A/C power supply.

"A review of the station's current licensing basis determined that HPCI is not credited with a safety function during a Station Blackout (SBO) event. Operating procedures direct securing HPCI early in an SBO event to minimize the discharge rate on the Class 1E batteries. The Reactor Core Isolation Cooling (RCIC) system is credited with maintaining reactor inventory during a SBO event. HPCI remained capable of completing its safety function to inject coolant into the reactor pressure vessel during a loss of coolant accident (LOCA) concurrent with loss of offsite power (LOOP) event. The Division 2 automatic initiation logic was inoperable but the Division 4 automatic initiation logic was unaffected by the Division 2 instrument power supply failure. Division 2 instrument power is required for HPCI automatic flow control and would not have been initially available during a LOOP event. However, the Division 2 instrument power would have been restored when the 480 VAC load center is re-energized approximately 13 seconds into the event. The 13 second delay in HPCl injection is offset by existing margin in HPCI's capability to meet the Technical Specification response time of 60 seconds.

"Therefore, a condition did not exist at the time of discovery that could have prevented the fulfillment of the HPCI safety function."

The licensee notified the NRC Resident Inspector. Notified R1DO (Bellamy).

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General Information or Other Event Number: 44083
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: REGAL CINEMAS
Region: 1
City: SOUTH PORTLAND State: ME
County:
License #: 05735G
Agreement: Y
Docket:
NRC Notified By: SHAWN SEELEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/20/2008
Notification Time: 13:45 [ET]
Event Date: 12/15/2007
Event Time: [EDT]
Last Update Date: 03/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL PERRY (R1)
MICHELE BURGESS (FSME)

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

Event Text

AGREEMENT STATE REPORT INVOLVING IMPROPER DISPOSAL OF TRITIUM EXIT SIGNS

In December, 2007, the Regal Cinemas complex was sold and underwent renovation by a contracting company, PM Renovations. The contractor removed and disposed of fifty (50) general licensed tritium exits signs. The signs were manufactured by Best Lighting Products, Model # SLXTU1GB20, serial #'s 115741 through 115790. Each sign contained 11.47 Curies of tritium.

The State of Maine during an inspection on 03/11/08 noticed that the signs had been removed and is pursuing discussions with PM Renovations as to their final disposition. The signs may have been taken to one of two landfills located in Norridgewock, ME or Hampden, ME or incinerated. If the signs were disposed of in a landfill, the State will perform an assessment to determine potential impact on water supply.

* * * UPDATE FROM S. SEELEY TO P. SNYDER ON 3/27/08 AT 1443 * * *

The following information was received from the State of Maine via facsimile:

"The event is not yet closed by the State. We are still trying to locate the final resting place of the missing signs. We are also working with our Dept. of Environmental Protection for further action."

Additional information received by the State from PM Renovations suggests that the signs could have gone to the Juniper Ridge landfill facility in Old Town, ME.

Notified R1DO (Bellamy) and FSME (McConnell).

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: 44094
Facility: BYRON
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICHARD WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/25/2008
Notification Time: 20:24 [ET]
Event Date: 03/25/2008
Event Time: 18:49 [CDT]
Last Update Date: 03/28/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
DAVID HILLS (R3)
JIM CALDWELL (R3 R)
JIM WIGGINS (NRR)
BRIAN McDERMOTT (IRD)
ELIOT BRENNER (PAO)
SAMSON LEE (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 99 Power Operation

Event Text

LOSS OF OFFSITE POWER DUE TO STATION AUXILIARY TRANSFORMER FAULT

"At 1835 on March 25, 2008, Unit 2 experienced a Loss of Offsite Power. At 1849, an Unusual Event was declared. Station Auxiliary Transformer (SAT) 242-2, Phase C, experienced a Phase Overcurrent. This resulted in an isolation of the SAT, a loss of offsite power, and an automatic Fire Protection deluge of the SAT. No fire was confirmed. All equipment responded as required. The appropriate abnormal operating procedure was entered for event mitigation and is in progress. The Unit 2 Emergency Diesel Generators are supplying required safety-related power. Unit 2 remains at power."

The plant is stable and all equipment is functioning as required. The licensee is assessing a cross-tie to Unit 1 which is unaffected by this event and in the refueling mode.

The licensee notified the State and local authorities and the NRC Resident Inspector. Notified DHS (Greg Ray), FEMA (Erwin Casto), DOE (Sal Morrone), USDA (Timmons), HHS (Rick Turner), EPA/NRC (Petty Officer Thompson Report #866038).

* * * UPDATE BY SCOTT PURIN TO NRC AT 2230 EDT ON 3/25/08 * * *

The emergency buses on Unit 2 have been re-energized by offsite power supply sources via Unit 1 SAT. The Unit 2 EDGs have been secured and placed back in standby. The licensee is developing a recovery plan to restore a Unit 2 SAT to supply offsite power to Unit 2 loads. This will require such things as analyzing chemistry samples of the affected SAT transformers and assessing the protective relaying. In addition, some switchyard realignment will be necessary. The licensee is currently in a 72 hour LCO under Tech Spec 3.8.1 for the current electrical alignment.

The NRC Resident Inspector is onsite and the NRC Region continues to monitor the situation.

* * * UPDATE FROM STEVE WIDOLFF TO HOWIE CROUCH AT 0022 EDT ON 3/28/08 * * *

"At 2309 [hrs. CDT] on 3/27/08, Byron Unit 2 terminated an Unusual Event that was declared at 18:49 on 3/25/08, in accordance with EAL M.U.1 due to a loss of offsite power to transformers 242-1 and 242-2.

"Transformer 242-1has been energized from offsite power and is supplying Unit 2 ESF busses 241 and 242. The entry conditions for M.U.1 are no longer met. A press release will be issued."

Transformer 242-2 is out of service and isolated for repairs.

The licensee notified the NRC Resident Inspector. Notified R3DO (Hills), NRR EO (Ross-Lee), IRD (McDermott), DHS SWO (Doyle), FEMA (Liggett), DOE (Morrone), EPA (Allison), USDA (Timmon) and HHS (Dalziel).

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Other Nuclear Material Event Number: 44101
Rep Org: HIRO MAKINO
Licensee: HIRO MAKINO
Region: 4
City: AIEA State: HI
County:
License #: 53-29263-01
Agreement: N
Docket:
NRC Notified By: RONALD FRICK
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/27/2008
Notification Time: 17:58 [ET]
Event Date: 03/27/2008
Event Time: 10:00 [HST]
Last Update Date: 03/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
20.1906(d)(2) - EXTERNAL RAD LEVELS > LIMITS
Person (Organization):
VINCENT GADDY (R4)
KEITH McCONNELL (FSME)

Event Text

PACKAGE EXTERNAL CONTAMINATION ABOVE LIMITS

At 1000 HST on 03/27/08 a package containing 3 unit doses of Tech 99 (M) was delivered by Pacific Radiopharmacy to the licensee. Wipe survey of shipping bag handle revealed 20000 dpm on a 300 square centimeter wipe. A single wipe of all three unit dose pigs revealed 14000 dpm. The delivery carrier was notified and reported that no contamination was found on the transport vehicle or the driver. The unit dose pigs were decontaminated and the shipping bag was stored for decay.

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Power Reactor Event Number: 44102
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: TOM HACKLER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/27/2008
Notification Time: 20:27 [ET]
Event Date: 03/27/2008
Event Time: 16:45 [EDT]
Last Update Date: 03/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JAY HENSON (R2)

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

Event Text

UNACCEPTABLE FLAW FOUND IN RPV CAP TO PIPE WELD

"At 1645 EDT, it was determined that an unacceptable flaw existed in reactor pressure vessel penetration N9. This penetration leads to a capped line and the flaw is in the cap-to-pipe weld. Based on manual ultrasonic examination, the flaw is 6.2 inches in length on a 5.5 inch OD pipe. Using non-qualified ultrasonic sizing techniques, the flaw is estimated to have a maximum depth of 30 percent through-wall. The flaw was discovered during in-service inspection examination of this penetration, using an improved technique compared to the technique used during a 2004 inspection. The flaw has been found unacceptable per paragraph IWB-3514.4 of the 1989 Edition of ASME Section XI Code and is therefore reportable. A weld overlay repair is being planned.

"The safety significance of this is minimal. Unit 1 is currently in a refueling outage. Repairs of the affected weld will be completed prior to startup."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44103
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MIKE TAYLOR
HQ OPS Officer: PETE SNYDER
Notification Date: 03/27/2008
Notification Time: 21:38 [ET]
Event Date: 03/27/2008
Event Time: 19:07 [EDT]
Last Update Date: 03/27/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RONALD BELLAMY (R1)
MARY JANE ROSS-LEE (NRR)
BRIAN McDERMOTT (IRD)

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

FATALITY OF LICENSEE EMPLOYEE

"OSHA was notified at 2055 on 3/17/08, under 29 CFR 1904, of the fatality of an employee caused by an apparent heart attack while at work."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012