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Event Notification Report for April 3, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/02/2008 - 04/03/2008

** EVENT NUMBERS **


44104 44105 44109 44110

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Fuel Cycle Facility Event Number: 44104
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHAKELFORD
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/28/2008
Notification Time: 15:25 [ET]
Event Date: 03/28/2008
Event Time: 10:00 [EDT]
Last Update Date: 04/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
JAY HENSON (R2)
BRIAN SMITH (NMSS)

Event Text

FILTERS NOT SCANNED PROPERLY FOR ACTIVITY PRIOR TO PACKAGING

"Some contaminated cartridge filters were placed/packaged in two (2) 55-gallon drums based on nominal values of U-235 content as opposed to measured values (i.e., some filters were not measured by the segmented scanning system).

"The control system is the scanning of the contaminated filters [individually]. The deficiency was the failure to scan the filters [individually] prior to placing the filters into drums. [Filters packaged in drums are required to be NDA scanned prior to packaging. This is an item relied on for safety (IROFS). Not scanning some filters was a degradation of an IROFS.]

"Written instructions were issued to operations personnel to package contaminated processing cartridge filters. The instructions indicated that the filters had been previously scanned and the U mass values were listed in an attachment to the instructions. However, some of the filters were not scanned, and instead were assigned nominal U-235 mass values. Nominal values are based on process history. Nuclear Criticality Safety required each filter to be scanned prior to being loaded/packaged into drums. Approval of the instructions was based on the implication that all of the cartridge filters had been scanned.

"The two (2) drums were scanned to confirm the total U-235 mass in each drum. The activity to package the filters has been suspended until additional corrective actions can be completed.

"The criticality safety significance is low due to the low U-235 mass values for each filter in addition to the low total U-235 mass for each drum [less than 350 grams U-235 process limit]. In addition, the nominal U-235 values are based on historical records and provide a good estimate of the U-235 content.

"Initial activities to inspect the filters and the use of nominal values prevented the drum limits from being exceeded.

"There were no actual or potential safety consequences to workers, the public, or the environment."

The licensee notified the NRC Resident Inspector.

* * *UPDATE ON 4/2/2008 AT 1615 FROM R. SHAKELFORD TO M. ABRAMOVITZ * * *

NFS is preparing a press release in anticipation of inquiries from the media. The licensee will notify the NRC Resident Inspector.

Notified R2DO (Evans), NMSS (Whaley) and Fuel Cycle OUO (via e-mail).

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Hospital Event Number: 44105
Rep Org: WILLIAMSPORT HOSPITAL
Licensee: WILLIAMSPORT HOSPITAL
Region: 1
City: WILLIAMSPORT State: PA
County:
License #: 37-04185-01
Agreement: N
Docket: 03003037
NRC Notified By: JUDITH GOULDIN
HQ OPS Officer: PETE SNYDER
Notification Date: 03/28/2008
Notification Time: 15:35 [ET]
Event Date: 03/28/2008
Event Time: 13:00 [EDT]
Last Update Date: 03/28/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
RONALD BELLAMY (R1)
DUNCAN WHITE (FSME)

Event Text

UNPLANNED DOSE TO FETUS

"A written directive was completed on 3/18/08 prescribing 18 mCi of I-131 (capsule) for the treatment of hyperthyroidism on 3/28/08. The [prescribing physician] indicated on the form that pregnancy test was negative and she was not breastfeeding. The pregnancy test result was attached to the directive.

"Upon arrival the patient completed an assessment form and consent form and she indicated in writing that she was not pregnant or breastfeeding. Staff and authorized user verified patient identity (name and birth date), dose, dose calibrator setting, and route of administration. The patient received the dose as prescribed.

"Nuclear Medicine was contacted by the lab shortly after the administration with a positive pregnancy result that was done on the day of the therapy. The patient's physician was notified. The patient was notified to increase fluids and void frequently and advised to make an appointment with her OBGYN physician. [A] Health Physicist Consultant was also notified and [the hospital] is awaiting the dose calculation to the embryo."

At the time of the report, the hospital had not calculated a dose to the unborn child. The hospital will provide the calculated dose when it is available but the Radiation Safety Officer believes that the result will be less than 50 milliSieverts (< 5 rem).

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Power Reactor Event Number: 44109
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RICHARD TODD
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/31/2008
Notification Time: 17:11 [ET]
Event Date: 03/31/2008
Event Time: 13:52 [EDT]
Last Update Date: 04/02/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAY HENSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON TURBINE TRIP DURING MAINTENANCE ACTIVITIES

"Event: At 1352 hours, Unit 2 experienced a Reactor Trip due to a turbine trip. The indicated cause was low condenser vacuum. The exact cause is still under investigation but is believed to be related to a maintenance procedure in progress on the condenser vacuum instrumentation. Post-trip response was normal. Auxiliary power transferred to the start-up source (switchyard) as expected. Main Feedwater was not affected so there was no demand for Emergency Feedwater. A second High Pressure Injection pump was manually started per procedure to maintain Pressurizer level indication on scale. This is a routine action to compensate for post-trip RCS temperature and volume changes.

"In an apparently unrelated event, Keowee Hydro Units (KHU) 1 and 2 were shutdown from commercial operation at approximately 1425 hours. During the shutdown, the KHU 1 output breaker failed to open as expected and KHU 1 was manually locked out. The lockout removed both the Overhead and Underground Power Paths from service, making on-site emergency power unavailable to all three Oconee units. Per Tech Specs, a gas turbine unit at Lee Steam Station was started and used to energize the Oconee Standby Bus at 1518 hours.

"Initial Safety Significance: There is little or no safety significance to the Unit trip. The subsequent KHU 1 lockout removed both the Overhead and Underground Power Paths from service, making on-site emergency power unavailable until the Lee gas turbine was aligned. There was no demand for the Keowee emergency power function during either event.

"Corrective Action(s): Investigations are in progress as to the cause of the Reactor Trip and the KHU 1 lock out. Alignment of KHU 2 to the underground is currently on hold, pending evaluation of the problem which led to the KHU 1 lockout."

All control rods fully inserted with decay heat being removed via the turbine bypass valves.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1055 EDT ON 04/02/08 FROM COREY GRAY TO HOWIE CROUCH * * *

The licensee is retracting a portion of the original report identified under 10CFR50.72(b)(3)(v)(D) based on the following:

"Event: UPDATE:

"At 1352 hours, Unit 2 experienced a Reactor Trip due to a turbine trip. The indicated cause was low condenser vacuum. The exact cause is still under investigation but is believed to be related to a maintenance procedure in progress on the condenser vacuum instrumentation. Post-trip response was normal. Auxiliary power transferred to the start-up source (switchyard) as expected. Main Feedwater was not affected so there was no demand for Emergency Feedwater. A second High Pressure Injection pump was manually started per procedure to maintain Pressurizer level indication on scale. This is a routine action to compensate for post-trip RCS temperature and volume changes.

"In an unrelated event, Keowee Hydro Units (KHU) 1 and 2 were shutdown from commercial operation at approximately 1425 hours. During the shutdown, the KHU 1 output breaker, ACB-1, failed to open as expected and KHU 1 was manually locked out. The lockout removed KHU 1 and the Overhead Power Path from service due to the failed ACB. Because KHU 1 was the unit aligned to the Underground Power Path, Operations declared that path inoperable also.

"This condition was initially reported as making on-site emergency power unavailable to all three Oconee units. Per Tech Specs, a gas turbine unit at Lee Steam Station was started and used to energize the Oconee Standby Bus at 1518 hours. In this alignment, the Lee gas turbine provides the on-site emergency power function.

"A design feature allows a KHU to automatically align to the Underground Path when the unit originally aligned to that path has been locked out, the overhead path is locked out and an emergency start signal exists. Keowee Operations confirmed that during the lockout event the required lockout signals were present on KHU 1 such that KHU 2 would have aligned to the Underground Power Path if an emergency start demand had occurred. As a result, the Underground Power Path remained available during this event and there was no loss of safety function. Therefore the portion of the event related to 10CFR50.72(b)(3)(v)(D) is RETRACTED.

"The Underground Power Path was administratively inoperable because a surveillance (SR 3.8.1.3) to verify operability of KHU 2 to the underground path, required per TS 3.8.1 Condition C.1, could not be performed. The surveillance procedure utilizes a normal start signal, which was inhibited by the lockout on the overhead path. The surveillance procedure does not include provisions for using an emergency start signal. At 1906 hours, after the overhead lockout had been reset, KHU 2 successfully completed an Operability test aligned to the Underground Power Path.

"Investigation determined that the failure of ACB-1, the output breaker for KHU 1, was due to a terminal strip sliding link in the trip circuit being in an intermediate position. It was damaged during repair so the entire sliding link block was replaced. The unit was successfully tested connected to each power path and was declared Operable on 4-1-08 at approximately 0600 hours. At 0930 hours on 4-1-08 the standby bus was disconnected from Lee.

"Initial Safety Significance:

"There is little or no safety significance to the Unit trip. The subsequent KHU 1 lockout removed the Overhead Power Path from service. The Lee gas turbine was aligned to energize the standby bus. Operations and Engineering subsequently confirmed that on-site emergency power remained available via KHU 2 and the Underground Power Path. There was no demand for the Keowee emergency power function during either event.

"Corrective Action(s):

"Investigation as to the cause of the Reactor Trip continues. Unit 2 is now on-line at low power and is in the process of returning to full power.

"ACB-1, the output breaker for KHU 1, terminal strip sliding link has been repaired/replaced; both KHUs have been tested and declared operable; the Lee gas turbine has been secured."

The licensee informed the NRC Resident Inspector. Notified R2DO (Evans).

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General Information or Other Event Number: 44110
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: PROVIDENCE EVERETT MEDICAL CENTER
Region: 4
City: EVERETT State: WA
County:
License #: WN-M0135-1
Agreement: Y
Docket:
NRC Notified By: ARDEN C. SCROGGS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/31/2008
Notification Time: 18:19 [ET]
Event Date: 03/28/2008
Event Time: [PDT]
Last Update Date: 03/31/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4)
KEITH McCONNELL (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A PARTIAL EQUIPMENT FAILURE OF AN HDR UNIT DURING A SOURCE EXCHANGE

The following information was received from the State of Washington via email (quotations omitted for ease of reading):

STATUS: New

Licensee: Providence Everett Medical Center
City and State: Everett, WA
License Number: WN-M0135-1
Type of License: Medical
Date and time of Event: 28 March 2008
Location of Event: Everett, WA

ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention):

A Varian Medical Systems (varian) representative was attempting a routine source exchange at the licensee's facility. There were no patients or Medical Center staff involved in the source exchange process. The varian rep noted some trouble with making the "old" source enter the exchange container. After several attempts the rep realized the transfer was not proceeding as expected. The rep telephoned staff at Varian Corporate headquarters for assistance. The decision was made to cut the source wire near the source and place the source assembly into the emergency shielded source container (emergency pig). After the wire was snipped and the cut piece placed into the emergency pig, the rep performed a survey and noticed that the radiation levels were less than expected. At this time the licensee and the Varian rep both notified the Office of Radiation Protection of the event by telephone.

The room was locked and barrier tape placed across the door. A Varian recovery team was called for and arrived at the Medical Center, with the source designer, on Saturday, 29 March 2008.

An Office of Radiation Protection investigator also joined the team on Saturday to direct the onsite investigation and recovery.

The investigation determined that both the dummy wire and the source wire had tried to exit the HDR unit simultaneously. The wires become stuck in the "home switch" part of the HDR. When a wire was cut it had been the dummy wire and not the source assembly wire. The cutoff dummy wire had been placed into the emergency pig which had given lower then the expected dose rate readings.

On Saturday, the recovery team successfully retracted the source into the HDR. Testing is underway to determine why the HDR source exchange process had allowed both wires to be sent out at once. A comprehensive written report is expected from the manufacturer within the next few days.

Notification Reporting Criteria: WAC 246-220-250 Equipment Failure.

Isotope and Activity involved: HDR Sealed Source: Ir-192, approximately 185 GBq (5 Curies).

Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None

Lost, Stolen or Damaged? (mfg., model, serial number): Varian HDR source model VS2000 (not lost, not stolen, possibly damaged).

Disposition/recovery: Source recovered 29 March 2008 by Varian recovery team.

Leak test? No "official" leak test yet but several contamination wipe surveys were performed during the course of the recovery. All of these were negative.

Vehicle: N/A

Release of activity? None

Activity and pharmaceutical compound intended: N/A

Misadministered activity and/or compound received: N/A

Device (HDR, etc.) Mfg., Model; Varian VariSource iX (Trademark) HDR

Exposure (intended/actual); consequences: None to patients and the public. The highest exposure received by a recovery team member was 87 mRem.

Was patient or responsible relative notified? N/A

Was written report provided to patient? N/A

Was referring physician notified? N/A

Consultant used? No

Event Report # WA-08-020.

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